Hi guys! This video is about peroneal tendinopathy and what you can do to treat it,
as well as why it sometimes may not get better. So, my name is Maryke, I'm the physiotherapist
from sports-injury-physio.com, where you can get online treatment for your injuries. If you've got
any questions about that, check out the comments; I've put a link to my website in the description
of this video. Good! So, what am I going to look at today? We're gonna look at the anatomy of the
peroneal muscles – where they run, where the tendons run – and then we're gonna look at the
symptoms of peroneal tendinopathy or tendonitis – remember, both terms mean the same thing – and
how you can basically be sure that you've got it, or very likely that you have it. We're gonna also
look at what causes it, because if you can understand the cause of your tendinopathy,
then you can prevent it from happening again, and you can avoid those things, that it can get
better. And then lastly, we're going to look at the different treatment options available for you,
because as usual, there's not one size fits all; you've got to kind of choose between the things
what works best for you. Good! So, let's move on to anatomy then. Now, if you look at that picture,
your peroneal muscles run down the outside of your leg. There're actually three peroneal muscles,
but I'm gonna … There's a little one that kind of comes over the front of the ankle, but I'm
only going to focus on the two that run down the side, because they are the main ones that develop
the tendinopathy. You've got the peroneal longus and brevis. Now, it's exactly as the name says:
longus is longer and the brevis is shorter. Your peroneus longus starts from just underneath the
knobbly bit there, where you can see … If you feel on your leg, you'll feel just below the knee, you
can feel a knobbly bit there, and that's actually the head of your fibula. And your peroneus longus
starts just underneath that and runs down the side of your leg … Peroneus brevis lies underneath it,
and starts round about at this level, okay? Now, both their tendons come around the outside or the
back of the outside of the ankle bone. So, you can see that in the picture – I've put a green circle
around that. Your brevis tendon runs close to the bone, and the longus one just slightly behind it.
Now, peroneus brevis attaches to this knobbly bit on the side of your foot, okay? That's the base of
your fifth metatarsal. Whereas the longus, it's tendon runs behind that and comes underneath the
foot and eventually attaches around about in this area. Good! So, their main function is to turn
your foot out and also they help point it down, but it's mainly to do that outwards movement. And
they are extremely important for stability around your ankle. And if you think of it, when you
sprain your ankle, like with a normal sprain where you … Let me just get my foot into the picture.
Normally, when you roll your ankle, you turn it in like that. So, you're running along, and it turns
in. Because of where those tendons run, they can resist that turning in and stop it from going over
fully. So, they play a really important role in stability. But because of that, that's also one
of the main ways that it gets injured, and we'll get to that in a minute. So, if we move on to the
symptoms of your … Actually I … You know what, I'm going to mix it up a bit. I'm gonna go to
causes first, because that actually follows very nicely. So, if we think of the fact that those
tendons run on the outside of the foot, and they control how much your foot turns in, and they pull
your foot back out, then, if you go over on your ankle, you can give them quite a severe stretch
injury there. And if you don't rehabilitate your ankle sprain properly, that can lead to
a tendinopathy. 'Cause remember, a tendinopathy is when the tendon doesn't heal, and you get that the
tendon structure changes – your fibres of your collagen separate a little bit, you've got more
ground substance in there, the cells change shape. So, if you get an injury like an ankle sprain and
you don't rehabilitate the ankle properly, then those muscles can go into this disrepair state,
or the tendons. The second is if you have an instability in the ankle. Because when you have a
chronic instability in the ankle, it's gonna want to turn; you won't have proper control over it.
So, those muscles will have to work a lot harder all the time to stop your ankle from rolling in,
and that can cause them to overwork and over-strain and cause the tendinopathy to develop.
Most ... You get two types of ankle instability: You get a structural one, which is usually when
the ligaments have been torn when you sprain your ankle, but we're talking about a Grade 3 tear,
where they're fully separate it, and they haven't healed properly. You can often improve that by
strengthening all the muscles around it, but sometimes you need a bit of surgery there;
it depends on your ankle. The second type of instability is a functional instability,
and that's where the ligaments are there and they are strong and healthy, but actually your muscles
are too weak and they're not controlling the ankle properly. Again, this often happens when somebody
rolls their ankle and then doesn't do the right exercises to strengthen all the stability muscles
up, and then the poor peroneal muscles have to overwork to try and provide that stability.
The third cause of peroneal tendinopathy is soft shoes or really flexible shoes, and just because
that will make your foot wobble with every step you take. Now, some people are absolutely fine
with that if they have stiffer ankles or stiffer ligaments. But if you're on the more flexible side
of the spectrum, then that may actually cause your peroneal muscles to over-strain because they've
got to work so hard. So, it's always better to have more supportive shoes in those cases.
If I have to think of a typical trainer that I often see causing trouble with this – especially
in kids – they don't get tendinopathy, they get other type of overuse injuries there – is Nike,
Nike shoes; they can be extremely flexible. So, if you're able to twist your trainer all the way
around, it's probably not the right shoe for you. And then also, running on a cambered surface. We
live down in the South of England, and we've got the South Downs, which means that a lot of the
time, if you're running in the countryside, you add an angle like that or like that,
and it can be miles and miles and miles that you kind of run at the same angle. Now,
if you think of it, can you see that the foot at the bottom, which would be this one at the moment,
would have to restrain that turning in force all the way that you're running. So, those muscles,
the peroneals, will have to work really hard for all the miles you’re running there. So, that can
cause them to over-strain even with just one run and cause the tendinopathy to develop if you don't
treat it properly. Good! So, let's go back then to symptoms of peroneal tendinopathy. Now, the first
one is quite obvious, and I'm gonna show my lovely foot again. Maybe if I sit the other way around,
you'll be able to see … Yes, that's better. Okay, so if we think of where the tendons run: They come
right round the back there and one attaching there is the one coming down and under the foot to the
front where the toe is. The pain you get from a peroneal tendinopathy is usually along the … where
the tendon runs. So, it's in that area or on that bone, or just a little bit underneath. Also, if
you press on the tendons, they should be tender. Now, some people have really … If they're really,
really super aggravated, they can be really painful, and you can even see swelling in that
area. But you don't always see swelling; sometimes if it's been going on for a long time, you can see
that it's all thickened and sore there. So, it has to be tender pressing on those tendons. Then,
turning the foot in and stretching them like that is often uncomfortable. Again, depending
on how aggravated yours is, it could be really uncomfortable or it can be just be a little bit
uncomfortable, but it's got to be uncomfortable in the area where the tendons run, okay? And I'll
explain to you in a minute why that's important. Then, the last one is if you contract your … if
you resist the movement that those muscles do. Remember the peroneal turns your foot out. So,
if you do a resisted movement, that can cause pain in the tendon. But I find this one's quite tricky
sometimes, because you've gotta … I sometimes have to put it in quite a stretch position and
get somebody to press against me there or resist them so much that they do an eccentric movement
before it hurts. So, that one isn’t always sore, depending on how flared up it is. Quite often,
in the early stages especially, it can get a lot worse with activity and it feels better with rest.
So, those are the main characteristics of this pain. But now remember, if you've rolled your
ankle, you wouldn't have just injured the tendons there – you have likely injured your ligaments on
this side. There's a little nerve that runs there that you can give a stretch injury. So, it's quite
important to make sure that the pain is truly coming from the tendons and not from something
else. For instance, somebody mentioned in the Sports Injury group that she's getting sharp,
like electric shock, pains in that area when she's swimming. Now, two things about that: One,
sharp electric shock sensations is usually not a tendinopathy, that tends to be … I'm thinking
more, could it be nerve, could it be that she's torn something there? I'm leaning towards nerve
irritation with that type of electric type of pain. And the second, swimming shouldn't really
be aggravating your peroneals, because you're not really using them that much. So, again, I would
not suspect a tendinopathy to cause that type of pain; I would want to look towards other things
that could be a problem. Also, it's not just peroneal tendinopathy you can have in that area;
it can be that you actually tore your tendon. So, it can be a complete tear, which you don't often
get. More often, you get like a partial rupture, where you get like a split in the tendon, or a
part of the tendon tears. And you can usually tell that that may have been the case if, for instance,
when you rolled your ankle, you felt a sharp pain in that position when you did it immediately,
or if you were walking along and the pain came on suddenly; a tendinopathy tends to develop
more over several days. So, it can be painful after you've sprained it, but it's not that
sharp pain that you get immediately and wants to make you hobble, if that makes sense. Okay,
so it's really important to distinguish between these different things, because otherwise you
can follow the treatment for a tendinopathy for months and months and months and not really see
improvement because it's not the right type of treatment for the condition you have. So,
if we look … We've covered causes. That brings us on to treatment. Now remember,
the peroneal muscles are in charge of, or plays a big part, role, in stability around the ankle,
so it stops it from turning in too much when you're walking. It's not the only muscles that
should be doing or should be contributing to stability; your soleus plays an important role,
all the muscles in the foot, your tib post, your tib ant, but then also higher up in the body,
if you think of your glutes for instance – they control how much your knee moves in and out when
you're running and stuff. So, if they are weak, they will force the foot to turn in and out more.
So, you have to look at all the muscles up and down the chain and make sure that you strengthen
all of the other muscles around the ankle to help support these muscles, otherwise they will
chronically be overworked the whole time. Yes, strengthening the peroneal muscles themselves
with exercises, that you turn the foot out slowly against resistance, is important. But be careful
at the beginning, because you can overdo that as well. If they're really sensitive, you may
have to start with really low-grade exercises for them. And to be honest, it's different for every
patient. So, it may be worth seeing somebody to get guidance as to where you should start with
that. Proprioception – it's a big word, but all it means is, it's the same as position sense. And
basically, what it means is, if you close your eyes, you know where your toes, your fingers,
everything in your body is. That is because there are little sensors in your ligaments,
your tendons, your muscles, everything that keeps on feeding back to the brain about where the body
parts are. And if you think about it, running and walking are actually really complex movements;
your brain has to calculate every single joint’s position – how far a muscle and how strongly a
muscle should contract, its gotta calculate how far it is to the floor. I mean, so many things
at the same time. So, it really heavily relies on the feedback from the senses. Now, the problem is,
when you injure your ligaments or your joints or your tendons, that message gets a bit fuddled up,
and you have to retrain it, because otherwise you may end up with a chronic instability,
where you keep on turning the ankle when in fact there's no other reason for it except that the
brain doesn't know where it is. Really easy to retrain, and it's any exercise that challenges
your balance on one leg. So, the simplest place to start is just balancing on one leg and looking in
a straight line. Now, once you can do that while having a cup of tea, basically, then you need to
make it more difficult. So, you're thinking of doing things like, ‘Okay, can I balance and then
turn my head from side to side and still maintain stability?’ It doesn't count if you look like
that when you're doing it; you have to basically look as if you're comfortable there, and there's
no wobble in the foot or anything like that. Once you're good with balancing on the floor, then it's
worth getting onto balance boards and stuff. But honestly, there's no use in getting onto unstable
surfaces before you've mastered balancing properly on the floor, okay? So, don't waste your time and
getting onto those things before you've done the simplest of things first. Then, relative rest.
I'm always going on about relative rest, that you can basically sort most injuries through applying
that in the correct way. Relative rest means that you don't cut out all activity, because that's not
useful. Because if you rest totally, you lose the capacity and the muscle strength of the
tendons and everything. You only cut out the most aggravating things. So, what I've seen in the past
is that some runners could continue training with this type of injury if they stuck to the right
side of the road. So, if we think of running on a camber in this direction, this foot will really
work the peroneals hard. So, if you want to run, I would run the other … Say this is … Say this is
your injured leg. You really don't want to run it at the bottom of the camber, but you'd rather want
to put it at the front, because then actually the camber itself is offloading the peroneal tendons,
because it's going to make it want to … the foot to turn the opposite way, okay? So,
it's going to protect it. So, you may even be able to play with things like that to still be able to
run. Sometimes you have to skip running totally for a few weeks and actually get on to cycling
or something else that doesn't irritate it. Just be careful if you clip your feet into your bike;
that action of getting the clip – you know where you twist your ankle to get the clip out – that
can often annoy the peroneals as well. So, just take note that you don't go and do an activity
that actually also uses the peroneals, okay? Shoes and orthotics can make a big difference.
I’ve spoken about why really flexible shoes are really not great during the causes, because it
makes the perennials work so much harder. So, this is definitely a case of where you want more stable
shoes. They don't have to be heavy stability. That is just if you take them, they shouldn't be
able to fold double. They should be nice and firm shoes, okay? Orthotics – sometimes it helps if you
can get a little bit of a wedge on the outside of your foot that just stops it from turning out too
much. And some people tend to run on the outsides of their feet. That predisposes them to this type
of injury to an extent. But again, orthotics and things like that is my last resort normally,
because once you start messing with that, it's not easy to come back from that. So ... And
especially if you've been able to run for years and years and years without this type of injury,
then I would go for … Make sure you've got stable shoes, strengthen everything else up first,
and do your relative rest to the right amount. And if it's still a problem, then I'll start looking
at orthotics, but that's definitely a last resort for me with this type of injury. Excellent! So,
let me know if you've got any questions. If you want more help with your injury,
then you're welcome to consult me via ... online via video call. The nice thing about video calls
is that I can assess your body and your strength and everything like I would do in a clinic,
because I can see you move. And then that allows me to create a treatment program for you that's
right for your specific injury. Have a look – I've popped the link to the website in the
comments ... in the description of this video. Now, if you've got any questions, feel free to
ask them in the comments, and if you can tag me in the post, it means that I'm more likely to see it.