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Sunday, May 11, 2014

Peroneal Tendonitis: Email Advice

Hello Dr. Blake,

     I have had severe peroneal tendonitis in my left foot for over a year now. MRIs and Xrays were normal. After failing conservative treatment, we chalked it up to psoriatic arthritis and I've used a walking boot and crutches to get around in. Started meds for arthritis that have helped joint pain everywhere else, but foot pain still bad.
Dr Blake's comment: With negative MRI, and negative response to anti-inflammatory meds, you need to think nerve injury or mechanical (over pronation or over supination). 

     Now, recently (in January 2014), I started getting the exact same type of pain, this time in the right foot. This time around, the pain is accompanied by a loud snapping sound behind the outer ankle.
Dr Blake's comment: This definitely sounds like mechanical inflammation of the peroneal tendons. The peroneal tendons are easily irritated by limping. If you are favoring your left foot, you typically place more weight on your right foot on the outside, with only the peroneal tendons to protect and stabilize you. 

    The pain gets worse and worse each day when I try to walk and snaps almost constantly. Went to ortho doc and was diagnosed with intrasheath peroneal subluxation. He said the tendons are snapping over each other. He wants me to do physical therapy. 
Dr Blake's comment: Physical therapy sounds great. The therapist should focus on your mechanics---use an EvenUp on the right when you wear a boot/walker on the left, correct for any over pronation or over supination tendencies, and work to avoid over stressing your right foot. The PT will also help you with peroneal strengthening and anti-inflammatory measures. 

     I'm 25 and have officially lost my ability to walk, as it is too painful. I don't leave my house. I was a straight A nursing student and very athletic a year ago, I don't understand how a person can lose the ability to walk that fast. I don't understand how physical therapy will make the tendons stop snapping over one another? It hasn't worked so far.
Dr Blake's comment: I am sorry for problem. And, you should definitely get an MRI to get a baseline on what the area looks like. There can always be surprises. So, why do the peroneal tendons sublux? Typically, they hypertrophy from the overuse of limping and the tighter tendons snap on each other as they move across. If they dislocate anteriorly out of their normal groove behind the outside ankle bone, then we are talking surgery. But, typically then stay in their place. Hopefully you are experimenting with braces to stabilize the ankle. A back doc should also evaluate you for possible low disc central disc bulge which can cause bilatteral peroneal spasms/pain/snapping.

    Neither have custom orthotics helped me due to the fact that I also have type two accessory naviculars and taking pressure off peroneal tendons puts pressure on the tibial tendons and has been causing arch pain. 
Dr Blake's comment: In biomechanics, we call this Medial/Lateral Instability. It requires orthotics/shoes/braces that carefully help both tendencies---pronation tendencies and supination tendencies. You need someone skilled at addressing both in the same person!! The Fettig Modication of the Inverted Orthotic Technique is one version of an orthotic device that tries to address both motions.

    I went to another ortho person to see if he could do a groove deepening procedure that I've heard about, and he feels that it's "too aggressive."
Dr Blake's comment: Thank you to God that that doctor cared about you. You do not have surgery for subluxation. It can be fixed conservatively. I know when you are in pain, disabled, surgery can seem like a way out, but I would not do any procedure on you unless 2 doctors said you needed it, and a top notch physical therapist (with no financial ties to the surgery). 

    I've gotten so depressed from not being able to leave my house that I've considered suicide as an option, as I've lost my ability to walk and don't know what else to do anymore. I don't know why they wouldn't want to do surgery to fix a problem that's obviously not responding to conservative treatment.
Dr Blake's comment: Wow!! Please listen to yourself, this has only been going on since January (4 months). Check the AAPSM website for local sports medicine podiatrists in your area. Have your low back evaluated. Consider a brace for your better left side and a boot/walker for your right side now. See one or two physical therapists and see if they can point you in the right direction. Definitely see a psychologist to help you focus correctly. Nothing you have said waves red flags suggesting permanent disability. This is run of the mill stuff in a sports medicine practice, although there are many things I have no clue of regarding your case. 

    I'm also curious as to whether or not the subluxation in the right could have caused the pain in the left side as well, although the left side never made a snapping sound. Any advice would be greatly appreciated. I don't need both feet to work again-I just want the right one to stop snapping so I can go some places in crutches again or with an aircast. I've never been this worried before in my life :( Why wouldn't they want to do surgery to fix the subluxation when nothing else is working?
Dr Blake's comment: I hope my comments above have been helpful. Get the MRI, go to PT, back doc, consider a RollaBout for getting a round little. Email me when you have more info. See if a Flector Patch can be prescribed since you can wear 24/7 for a few weeks. We need someone to give you an old fashion muscle test to rule out peroneal spasm and grade your overall peroneal strengthen. You need to constantly work on the orthotic devices to get them right. Good luck. Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.