Overview 

In today's rapidly developing healthcare community, pain management has become a vitally important aspect, which is not only focused on reducing the potential risk factors that can cause pain but also focuses on improving the overall quality of life of the patients. A commonly encountered painful condition that could make a person's life more difficult is peroneal tendonitis. A comprehensive approach is considered when managing peroneal tendonitis that could give patients quick relief and long-term rehabilitation strategies to manage recurrent bouts of pain. Let's get a quick overview of what exactly peroneal tendonitis is. 

What is peroneal tendonitis? 

Peroneal tendonitis is an acute or chronic condition caused by irritations and inflammation of both or one peroneal tendon in the lower extremities. It is mainly associated with inflammatory and degenerative changes. It is most commonly seen in running athletes, dancers, skaters, and sports involving frequent jumping or twisting such as basketball and skiing.¹ Additionally, it is seen in manual workers working long hours on their feet or with improper footwear. 

Peroneal tendinopathy is an umbrella term given to pain, inflammation or injury to the peroneal tendons, which encompasses different conditions including peroneal tendonitis. However, some practitioners use the terms tendonitis and tendinopathy interchangeably which can be a source of confusion.

The causes can be diverse, including:

• Tight calf muscles 
• Poor foot and leg biomechanics 
• Excessive eversion or over-pronation of the foot (ankle turning inwards)
• Muscle weakness (mainly of the peroneus longus) 
• Recurrent ankle sprains
• A direct blow or trauma to the ankle or foot
• Fractures of the ankle etc^1,2

Who is at risk?

The chances of getting peroneal tendonitis are high among people involved in sports. However, others can also develop peroneal tendonitis if they:

• Are diabetic, or are suffering from gout, osteoarthritis, or rheumatoid arthritis 
• Have high arches 
• Are obese 
• Smoke 
• Are over the age of 40 years
• Had previous untreated injuries 
• Have tight tendons³

What are the signs and symptoms of peroneal tendonitis? 

People usually have acute inflammatory signs such as pain, swelling, and a rise in temperature commonly on the back or side of the ankle. Common symptoms include: 

• Pain that diminishes with rest
• Pain while pushing a ball or when walking up and down the stairs
• People with peroneal tendonitis can develop pain along the whole length of the tendon and usually complain that the pain is aggravated by any physical activity.³

How is peroneal tendonitis diagnosed?

It is not an easy task to diagnose peroneal tendonitis because the symptoms are very similar to other ankle problems such as fractures and sprains. 

The healthcare provider must conduct a thorough examination and appropriate testing and measures to confirm the diagnosis of peroneal tendonitis. This may include: 

• Physical examination focuses on the assessment of painful areas, testing the range of motion of involved joints, and palpating swelling
• Plain radiographs or X-rays are taken to exclude the possibility of fractures, arthritis and certain soft tissue abnormalities such as tissue tears 
• The diagnosis is confirmed with MRI imaging and ultrasound investigation⁴

Role of physical therapy in peroneal tendonitis

Physical therapy (PT) plays an important role in treating peroneal tendonitis. Effective management is crucial in restoring mobility and alleviating discomfort in patients. A multifaceted approach is often used to:

• Reduce pain
• Improve range of motion
• Provide stability to prevent re-injuries

A physical therapist usually makes a treatment plan that includes strength training, stretching exercises, and a variety of electrical modalities to ease the pain and inflammation. Additionally, a physical therapist has a responsibility to educate patients about their condition and inform them regarding progression.

Initial assessment 

A thorough initial examination plays a crucial role in achieving the correct diagnosis. The therapist starts by observing the overall posture and alignment of the leg and foot. Secondly, skilled palpation of the affected area looking particularly for swellings over the posterolateral aspect of the ankle is carried out. This also includes feeling for tenderness along the length of the tendon. Finally, active, passive and resisted movement and orthopaedic tests of the ankle to provoke any pain symptoms are used to yield further information.^{5, 6}

Stretching exercises

Your therapist may teach you stretching techniques that would help to facilitate the mobility and flexibility of the ankle joint. The calf stretch, Achilles tendon stretch, and peroneal muscle stretch would help minimise the pain and improve biomechanics.¹

Strengthening exercises

To regain the same previous strength, the physical therapist may teach you resistance exercises with physio bands, weights, sandbags, or dumbbells. Utilising these tools while doing a regular range of motion exercises aims to strengthen your calf muscles, ankle, foot, and lower muscles. Resisted calf raises, ankle dorsiflexion, eversion, and inversion help in stabilising the joint. 

Pain management with modalities

A variety of modalities could be used such as ice therapy to reduce inflammation and swelling, ultrasonic therapy and electrical stimulation may be used to reduce pain. Electrotherapy can be utilised by an experienced professional – effective implementation can help management of pain symptoms and promote tissue healing decreasing recovery time in appropriate patients. Interferential current (IFC) is where a therapeutic current is induced within the affected area to increase the healing by increasing blood flow. 

Manual therapy

Manual therapy techniques such as soft tissue mobilisation, joint mobilisation and manipulation, and tender point treatment can help gradually loosen the tightened structures of the lower leg, promote healthy blood circulation, and relieve excessive muscle tension. These techniques may also help to drain off the fluid in the swelling. However, in a systematic review, there is only limited formal evidence available to support the use of manipulation and mobilization in providing relief.⁷

Bracing 

If the patient is facing severe symptoms, immobilisation should be given for at least 10 days. In the most severe cases when there's a fracture along with a peroneal tear, a plaster of Paris cast is applied. Ankle braces can help support and stabilise the ankle. It is recommended that the patient should wear an ankle brace during particular movements such as running or jumping. In a systematic review, there is insufficient formal evidence to make a general case for or against the use of bracing but it is recommended for specific appropriate patients.⁷

Functional training

As the symptoms improve, functional exercises that incorporate real-life movements are implemented to restore the functional movements. Exercises would also be implemented by your therapist to improve your sport-specific movements.⁸

Balance training and biomechanical correction

Different exercises should be incorporated within the exercise plan to improve balance, proprioception, and coordination. These are the vital points involved in rehabilitation training. Training involves physioball exercises, balance board, single and double leg exercises, cue training, etc. To achieve normal gait patterns, your therapist may recommend proper footwear and would also initiate gait training sessions.^1,8

How can peroneal tendonitis be prevented?

A physical therapist is responsible for educating patients about the dos and don'ts during and after the recovery. Patient education is a vital aspect of the recovery period. By following directions given by the therapist, you may prevent any relapse of the injury. You may consider: 

• Following the appropriate home plan (e.g strengthening and stretching exercises guided by the PT)
• Choosing the proper footwear for activities like running, jumping, or walking
• Modifying daily life activities to your needs
• Gradually increasing distances run and slowly adding uneven surface training 
• Supporting the ankle by wearing braces while doing vigorous activities^7,8

Prognosis

The prognosis for peroneal tendonitis is fairly good. Most people recover fully from this condition in about a month if they are following the appropriate course of management. However, in some cases where the patient requires surgery, it may take another 6 to 8 weeks after surgery to recover fully. They might need walking aids such as crutches in the early stages but a PT will suggest when to fully bear weight on the limbs.³

Summary

Peroneal tendonitis is an inflammatory condition that occurs due to prolonged or repetitive stress on your peroneal tendons. Physical therapy plays an important role by focusing on pain management, improving strength and flexibility, and targeting biomechanical concerns, thereby promoting functional recovery. By involving a combination of different treatment techniques such as electrical therapy, manual therapy, exercises, and patient education, physical therapy aims to restore the optimal functional level of individuals and ensure their safe return to activities.