In 2022, my new book on treatment of lower extremity injuries will be based on mechanical treatments. The following summary is from that book entitled “Practical Biomechanics for the Podiatrist”.
Common Mechanical Changes with Peroneal Tendon Problems
Cam Walker with or without Crutches for Immobilization Phase
Ankle Braces galore!!
High Topped Boots
Valgus Wedges
OTC Inserts Customized to Stability Needed
Arch Taping
J Strap with Leukotape for Supination Support
Peroneus Longus and Brevis Strengthening Program
Metatarsal Doming and Single Leg Balancing
Mechanical Changes to Avoid Excessive Supination in Sports
Orthotic Modifications for Supination Support
Cam Walker with or without Crutches for Immobilization Phase is of course based on the severity of the injury presented to you. What will it take quickly to get the presenting injury to 0-2 on the pain scale. Will that take getting off the foot with crutches? Will a Cam Walker below the knee in length for peroneal problems be needed? How is the patient in terms of limping, black and blue, swelling, or feelings of functional instability? All of these will help your decision.
Ankle Braces galore abound in the marketplace. I like braces that are adjustable in tightness, so that if you swell more than normal, you can still use them. I also like braces that the patients can make tighter or looser depending on the need. Simple slip on braces have no purpose other than some slight compression for swelling. The goal of the braces or boots below is to rest the peroneals which have an injury.
High Topped Boots can be an immediate fix for instability, or mechanical compression of the injury. Many patients have a peroneal injury and get incredible comfort from a fashionable boot, or men with cowboy or hunting boots.
Valgus Wedges can be stand alone inserts, typically ¼ inch high, or attached to the shoe insole, midsole, or outer sole. A valgus wedge is rarely to pronate (rarely), and normally to place enough force on the lateral side of the subtalar joint axis to prevent supination at heel contact (also called lateral instability). The lateral instability, which may be due to structures like plantar flexed first rays or tibial varum, can be the cause of the peroneal strain in the first place, and the reason the peroneal tendons remain sore if not eliminated.
OTC Inserts Customized to Stability Needed in my practice are typically Sole or PowerStep. I love them since I can customize based on the biomechanics of the patient. The ones I use have no plastic making customization easy. If lateral instability or excessive pronation, or both in my medial-lateral instability patients (everted forefoot deformities in some), is the apparent cause of the peroneal strain then I attempt to fix it with these inserts and some customization of wedges, etc.
Arch Taping works for peroneal strain when an unstable cuboid is causing the peroneal tendons to strain, but it could be that you're anchoring the peroneal tendons down some, and giving them stability. I prefer the circumferential wrap with Kinesiotape or RockTape over the low dye for this function, but both may work fine.
J Strap with Leukotape for Supination Support is the opposite version we discussed for pronation support. It is typically used for ankle instability (pre-surgery, post-surgery poor result, in the early stages of a great re-strengthening program) when you want the tape to do the job of the lateral ankle ligaments. The peroneal tendons are straining to do the most they can do, so the tape should help the peroneals relax. The coverall is applied first from under the medial malleolus, and then under the heel, finally up the lateral side of the heel to about 14-18 inches above the ankle. Then, the slightly narrower Leukotape is applied with no tension medial heel and plantar heel. As you pull the Leukotape up the leg on the lateral side of the foot and ankle, you place the ankle slightly everted to the subtalar joint neutral position. The higher up the leg, the more the stress is taken off the ankle and peroneal tendons.
Peroneus Longus and Brevis Strengthening Program is typically a resistance band program that will be discussed later. You can start on your first visit with a peroneal active range of motion or peroneal isometrics. There should not be pain with these either during or after. The progression of strengthening can be a 6 month endeavor with monthly follow up visits. Until the patient is doing 2 sets of 25 at Level 6 of the resistance bands, they need either bracing or taping during a high risk activity (like return to basketball).
Metatarsal Doming and Single Leg Balancing can be found on the blog easily.
Mechanical Changes to Avoid Excessive Supination in Sports should be in place until their injury is healed, you have mechanical devices in place in terms of wedges or orthotic devices, and until the peroneal strength is great. For a golfer, it may be avoiding the uphill lays in the back foot injuries. For a tennis player, it may be the extremes of the side to side volleying. For a basketball player, it may be leaving their feet on a drive that has to be avoided. For a ballet dancer, the mechanics of their en pointe work should be evaluated. This list goes on looking for the signs that the peroneals could be overly stressed.
Orthotic Modifications for Supination Support are many and take awhile to know what to add to the mix. If the patient is an over supinator or just has marked lateral ligament laxity or severe peroneal weakness, and this patient has peroneal problems, you want to add to your orthotic prescriptions the normal ingredients to stop over supination: high lateral heel cups (25 mm or more), lateral phalanges, Denton modifications, any forefoot valgus support captured in the cast, and even 2-3 degree everted pouring when the force is severe.
