Peroneal Tendinitis: Email Advice

Hi Dr. Blake,

I developed bilateral peroneal tendinitis from overuse earlier this year (lots of walking). Despite a reduction in sports and addition of light physical therapy, the tendinopathy slowly worsened to the point where I couldn't walk without significant pain. This happened over several months. The pain was mostly behind my lateral ankles, sometimes extending up into my calves.

I finally took off a couple of weeks from work, saw a podiatrist, and was referred to physical therapy for more aggressive treatment, including mobility and functional exercises, stretches, and ASTYM. During this time I was able to start walking every other day with only mild pain on rest days. I'm not sure if the PT was helping, but the rest days definitely were.

On my first day back at work I had soreness in my feet and intense pain behind my left lateral malleolus that night, which had never happened before (typically I had no pain when in bed). The next two days at work were similar, though not quite as bad. I then took off another week and was recovered on my first day off, followed by having no pain at all when I returned to work days later.

However, I relapsed after a few days. I was still performing my physical therapy exercises and increased my previously band-assisted heel raises to bodyweight. This had aggravated my tendons before, and I think this was what precipitated the relapse. By the end of every day, I was incredibly sore in my lower legs and feet and had trouble performing ADLs (activities of daily living) at home. I could barely rest and recover on weekends for each following week.

I continued to work for another month with minimal walking (less than a mile/day total) and standing. During this time I started developing early PTTD (posterior tibial tendon dysfunction) in my right foot, probably from compensating for peroneal pain by overpronating.

Finally, I took a full month off work. Most of the pain subsided within a few days. I gradually started resistance band inversion/eversion exercises every other day with some walking and seated heel raises. I've been off for three weeks now. My lateral ankles have been feeling pretty good, but my right posterior tibialis is now limiting me. It seems to get easily irritated by very short walks or from standing. Custom orthotics are uncomfortable and seem to provide too much support, which stresses my peroneals. I'm also still getting dull aches/soreness in my ankles and lower legs following any physical therapy exercise. I'm not sure if this is from becoming weak from minimal walking, or some kind of sensitization?

I'll be following up with my podiatrist next week and will also see an orthopedic surgeon for a second opinion later in the month. Until then I'm really not sure of the best course of action in terms of rest and strengthening.

Thank you for reading! It's been over 6 months since this all started, and writing this out is somewhat cathartic. It takes a lot to stave off a feeling of complete hopelessness.

Dr. Blake's comment: Please do not lose hope as the universe is not picking on you. This is an all too common scenario of injury, inadequate rehabilitation, progressive weakness with new pains developing, and improper timing of events. First of all, I am going to any pain like the PTTD that is not along the course of the peroneal tendons is just compensation and will get better. What do you do at work? Is there something that forces you to use the outside of your foot a lot (called supination)? Rest for weeks and months does not normally help unless you are using the time off work to get the 5 treatments below accomplished. 
     Any tendinitis has to be treated concurrently with 5 treatments. The mnemonic is BRISS--biomechanics, rest or activity modification, ice or anti-inflammatory, strengthen, and stretch or flexibility work. For the peroneal tendons, the number one biomechanical task is to control supination (movement to the outside), and number two is to overall stabilize the ankle with braces, boots, taping, high top boots. There are a lot of options in getting achieve this stability. From the sound of things, you have to get in an orthotic that is stable and does not supinate you. You can find my video of orthotic modifications for the supinator, although I am not sure you supinate normally or only with high arched orthotics. But, you can not get better if you supinate. 
     Rest is activity modification since rest in general in these cases can really work against us in allowing weakness, nerve sensitivities, and tightness to settle in. You have to keep your body strong if you have to limit walking to elliptical, swimming, cycling, floor programs. This is even if you have to do it with tape, orthotics, braces, or boots. Typically straight rest is a killer if you get my point. We are trying to get the pain down to consistent 0-2 while we slowly increase activities, and gradually get stronger. The sad fact is one day off normal activities, especially physical activities at work, after one month can take 2 days to regain that strength. 
     Ice or anti-inflammatory is to be used after activities if you flare them up, but physical therapists have a lot of tricks to cool tissues down, as do acupuncturists. Oral NSAIDS like Advil are used after workouts not before to allow you to workout. 
     Strengthen is key. You want some activities to mimic work related, most functional, but also isolate the peroneal tendons. My blog has peroneal tendon theraband exercises to isolate the peroneus brevis vs longus, since one may be more involved. 
     Stretch is achilles mainly. The achilles, when tight, is a powerful supinator as you lift your heel. You have to check with the physical therapist or podiatrist to see if you are tight, but I would start doing normal achilles stretches three times a day. 
     I hope this helps. You have your work cut out for you, but you seem to respond to things well and should get over this. Keep strong, but do not push through the pain.