Physical activity and exercise are great for one’s physical and mental health. However, in certain scenarios where proper maintenance of the muscle, joints and tendons isn’t done, tears and sprains, breaks and other injuries can occur. Excessive physical activity that most enjoy that to peroneal tendonitis, including: running, jumping, football, basketball, high-intensity training, skiing, etc.  Excessive activity leads to pain and inflammation of the outer area of the foot. The specific location of the pain is known as peroneal tendonitis. Before the pain becomes chronic, early symptoms should be recognised, diagnosed and appropriate measures taken to treat, rehab and restore the tendon, so that physical activities may continue without pain. Peroneal tendonitis is treatable and manageable, and requires patience and rehab consistency, more than anything.

Introduction

Definition of peroneal tendonitis

It is associated with pain and inflammation of the peroneal tendons, which are tendons that run from the outside of the lower leg and around the ankle. This condition can often be debilitating and associated with repetitive injury/stress of the tendon.

Importance of understanding overuse

Overuse of the tendon is associated with specific activities and is common in athletes who use that tendon in sports or activities like:

• Horse riding 
• Sprinting
• Basketball
• Cycling
• Skiing

Even incorrect footwear and poor foot formation can contribute to poor movement (biomechanics), ankle sprains or breaks, and other injuries, which can also lead to peroneal tendonitis. Tendonitis, by definition, occurs when proper rest and rehabilitation have not been taken to allow the tendon to heal and be appropriately strengthened before continued use of the activity.

Anatomy and function of the peroneal tendons

•  Location and Role
  • The peroneal tendons are two tendons known as the Peroneus longus and peroneus brevis tendons, which are located on the outside of the ankle
• Function in Movement and Stability
  • The role of these tendons is ankle stability and proper ‘placement’ of the foot on the ground

Mechanisms of overuse

• Repetitive Strain
  • Strenuous repetitive movements, such as running, jumping or continued walking on uneven surfaces, can cause strains or even breaks
•  Sudden Increase in Activity
  • Rapid changes in the length, frequency, and intensity of certain activities, as mentioned above, can cause damage to the tendons. This is caused by not allowing the tendons to strengthen over time for the increase in length, frequency and duration of that specific activity, which compromises the tendon
• Poor Biomechanics or Technique
  • Footwear contributes to the formation of the foot, and improper footwear may affect the biomechanics of the foot (the way the foot moves and weight distribution). Physical problems such as high arches or flat feet can also be causes of peroneal tendonitis

Pathophysiology of inflammation

1.  Small tears in Tendon Fibres
   • Repetitive stress can cause tears in the tendon and compromise the fibres, leading to pain and inflammation²
2. Inflammation
   • Compromises in the tissue structure naturally lead to an inflammatory response as the body tries to resolve the damage. Inflammation causes swelling, pain, and, if left untreated, can lead to tendon dysfunction
3. Chronic Inflammation Risk
   • Tendon degeneration can be caused by long-term damage without reparations in the tendon where the fibres have been torn or are under mechanical stress. This can lead to consistent inflammation in the tendon and also tendinitis. Tendinosis is a condition where the collagen in the tendon degenerates due to overuse

Symptoms and diagnosis

Common symptoms

• Pain
• Inflammation (swelling of the ankle)
• Instability as balancing becomes painful 
• Weakness in the ankle, which may initially present as sprains in the ankle

 Diagnostic methods

• MRI and ultrasounds to physically diagnose the problem 
• Physical examination of the foot by an appropriate professional

Risk factors related to overuse

1.  Athletes
   • Football players, dancers, runners, skiers, and individuals engaging in high-intensity interval training and other activities that require rapid, prolonged, and intense movement of the ankle.
2. Occupational Risks
   • Occupational hazards that require long periods of standing, walking or other strenuous activity on uneven surfaces that cause overuse of the tendon⁴
3.  Insufficient rest and rehabilitation that delays recovery

Prevention and management

• Activity Modification - this can involve going back to basics (such as physiotherapy) to slowly and steadily strengthen the tendon through alternative exercises
• Biomechanical Corrections - physical therapy, to learn proper movements and correct the movement of the ankle
• Rest and Rehabilitation
  • Anti-inflammatory medication, ice packs to reduce swelling and other therapy to prevent pressure on a healing tendon. This may include using crutches to avoid putting weight on an initially swollen ankle as the swelling reduces
  • In addition, exercises to increase mobility, strengthen the muscles and balance exercises can also assist in restoring the tendon
  • RICE - rest, ice, compression and elevation is a common acronym for how to treat tendonitis pain

Conclusion

Peroneal tendonitis is a painful condition that is treatable and manageable if proper rest and rehabilitation are undertaken. As the name suggests, any tendonitis is caused by overuse and stress of the tendon, as well as collagen loss within the tendon itself. Proper nutrition and diet should also be considered, as the body requires materials to repair and restore compromised tendon fibres. Continuous stress for lengthy periods of time, if intense and frequent, would cause any mechanic to fail; thus, biomechanical compromise of the ankle is no different. Care should be taken to ensure that the tendon is healed correctly before continuing intense activities.

Importance of early intervention

Acute conditions should be treated immediately and not left to develop, and the condition should not degenerate to the point of becoming a chronic inflammatory condition or cause more severe conditions requiring surgery.⁵

Final thoughts

As with any physical activity, a balance needs to be maintained as the tendon is used. Use, rest and recovery are important mantras to remember in preventing chronic conditions and maintaining good health.