Injury Highlight: Peroneal Tendinopathy - What It Is and How to Fix It

Persistent discomfort along the outside of the ankle can be a real problem for runners, especially those who log high mileage on uneven terrain. This pain might be peroneal tendinopathy, an overuse injury involving the peroneal tendons, which are crucial for stabilizing the foot during running. Without proper management, peroneal tendinopathy can cause compensations in gait, increase the risk of other injuries, and keep you off the road longer than you’d like.

What Are the Peroneal Tendons, and What Do They Do?

The peroneal tendons, located behind the lateral malleolus (outer ankle bone), connect the peroneus longus and peroneus brevis muscles to the foot. These tendons are responsible for everting the foot (turning the sole outward) and stabilizing the ankle during weight-bearing activities like running. They also assist in absorbing impact forces when your foot hits the ground​​.

During repetitive motion, such as running, these tendons endure significant stress, especially when running on trails, cambered roads, or while making sharp turns. Over time, excessive strain can lead to microtears, irritation, and tendon degeneration. Biomechanical imbalances like excessive valgus knee positioning or pelvic drop during running have also been correlated with increased risk for peroneal tendon injuries​​.

What Does Peroneal Tendinopathy Feel Like?

Common symptoms include:

• Pain on the outer ankle or foot, especially during or after running.

• Swelling or tenderness around the lateral malleolus.

• A feeling of instability, particularly when running on uneven ground.

• Discomfort during eversion or plantar flexion of the ankle (e.g., when pushing off).

  
  

Some runners develop peroneal tendinopathy after a severe ankle sprain, where the tendons can also be strained or injured​.

How to Treat and Prevent Peroneal Tendinopathy

The key to managing peroneal tendinopathy is early intervention, which focuses on reducing pain, improving strength, and preventing recurrence. Here’s what to do:

1. Take a Break and Modify Your Activity

Completely stopping isn’t always necessary, but scaling back your mileage and avoiding uneven terrain can help reduce stress on the tendons. During this time, cross-train with activities like cycling or swimming that don’t load the ankle as much.

2. Strengthen the Supporting Muscles

Strengthening the peroneal muscles, glutes, and core can help prevent overloading the tendons in the future. There are so many exercises you can do, just make sure you are incorporating single leg strength, core, hip strength, rotational control and foot/ankle stability.

3. Stretch and Mobilize

Maintaining flexibility in the calves and improving ankle mobility can prevent further irritation. You may also need to mobilize your hips, hamstrings and thoracic spine. Just avoid overstretching the peroneal tendons themselves.

4. Choose Proper Footwear

Wearing shoes that provide adequate lateral support can help protect the tendons. Make sure your shoes aren’t too worn out, as old shoes can lose stability and cushioning, increasing the risk of injury. However, don't switch your shoes just because of the injury. Research is clear that if your shoe is comfortable then it is likely the right shoe for you.

Look for Our Peroneal Tendon Injury Program in March

Dealing with peroneal tendon pain or want to stay ahead of it? Our RUNsource app will release a peroneal tendon injury recovery program in March, designed to guide you through strengthening, mobility, and gradual return-to-running routines. With expert advice and carefully tailored exercises, you’ll have all the tools to get back to pain-free running. Until then you can still check out the App for mobility, strength, mental fitness and expert advice.

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Citations

1. Tingan AS, Bowen A, Salas-Tam C, et al. Current concepts in the evaluation, management, and prevention of common foot and ankle injuries in the runner. Curr Phys Med Rehabil Rep. 2024;12(200-209):doi:10.1007/s40141-024-00437-7​.

2. Kakouris N, Yener N, Fong DTP. A systematic review of running-related musculoskeletal injuries in runners. J Sport Health Sci. 2021;10:513-522. doi:10.1016/j.jshs.2021.04.001​.

3. Deu RS, Coslick AM, Dreher G. Tendinopathies of the foot and ankle. Am Fam Physician. 2022;105(5):479-486​.

4. Bittar CK, Alves Jr WM, Rodrigues VM, et al. Biomechanical analysis of running: correlation between main frontal findings and foot and ankle injuries in amateur runners. Braz J Case Rep. 2024;4(3):3-11. doi:10.52600/2763-583X.bjcr.2024.4.3.3-11​.