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Peroneal tendon injuries – diagnosis and treatment in elite cross country athletes

What a cross country training regimen can tell you about peroneal tendinitis, peroneal tendon tears and peroneal tendon subluxationJogging

When you meet with your doctor, there’s an unwritten script that your doc is using to guide his/her decision making.  Past medical history, social history, family history and your medications all make up sections of that script.  The clinical exam and testing such as labs of x-rays are also important.  But sometimes the best answers come from simply talking.  We call it taking a history.  “Tell me about yourself Mr. Smith?  What do you do for a living?  When does your foot hurt?  Where does it hurt” and so on.

Athletes, and in particular elite athletes who dedicate their lives to training are often some of the most interesting patients to speak with.  I met today with collegiate cross country runner.  This athlete is ranked within the top three runners in our state.  He described his primary symptom as right lateral ankle pain.  The pain was transient and depended to a great degree on the type of activity he did.  Not the duration or intensity of training but more so specific activities.

The athlete’s clinical exam was consistent with peroneal tendinitis or perhaps a peroneal tendon tear of the right ankle.  Two particular activities seemed to bother him the most –

  • Running counter clockwise on a track
  • Running with traffic on the road

When I asked him these questions, he looked at me in dismay stating, “How did you know?  Those are the two activities that bother me most.”  We proceeded to have a long conversation regarding the function of the peroneal tendons.  Ironically, reversing the two activities - running clockwise around the track and running against traffic had no impact on his ankle pain.

The peroneal muscles (the peroneus brevis and peroneus longus) are found in the outer leg and descend to the ankle where they pass behind the outer ankle bone (fibula) to insert on the lateral (outside) foot and bottom (plantar) foot.  Both tendons resist the force of inversion (think ankle sprain).  I think you can see how the history identified two salient activities that seem to confirm the diagnosis of peroneal tendinitis.

Treatment of peroneal tendinitis in runners

Treating tendinitis, whether it be tennis elbow or peroneal tendinitis, depends upon changing the mechanical load applied to the tendon.  In cases of tennis elbow, you need to use a lighter racket or choke up on the handle to have less load applied to the arm.

Lateral Sole Wedge InsertTreatment of peroneal tendinitis is similar in that loads that are generated like to two activities described above (running on the track and road) are mitigated.  I recommended use of a Lateral Sole Wedge Insert in this athlete’s case.  The Lateral Sole Wedge Insert will significantly decrease load applied to the peroneal tendons.  It’s almost as if the use of the Lateral Sole Wedge Insert levels the road berm or straightens the track.  Balancing the foot and decreasing inversion will off-load the peroneal tendons.  Although each case may vary, I recommended that this athlete continue his schedule, focus on trail running and stay off the track and road.

Treatment of peroneal tendon tears or peroneal tendon subluxation in runners

With an accurate clinical exam and history, many cases of peroneal tendon pathology can be caught in an early stage (tendinitis) prior to tearing of the tendon.  Acute peroneal tendon injuries, that include lateral ankle sprains that do not respond to conservative care, should be evaluated with an MRI for tendon tear or rupture of the peroneal retinaculum that may contribute to subluxation at the lateral ankle.  In the case of a peroneal tendon tear or subluxation, surgical correction is usually indicated.  I’ve seen success post operatively with the use of a Lateral Sole Wedge Insert to off-load the two peroneal tendons during the healing phase following surgery.


Dr. Jeffrey Oster
Jeffrey A. Oster, DPM

Medical Advisor

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