What are the peroneal tendons?

The peroneal tendons are located on the outside of the lower leg and ankle.

There are two main peroneal tendons:

• Peroneus longus

• Peroneus brevis

They originate from muscles on the outside of the lower leg and pass behind the outer ankle bone, known as the lateral malleolus, before attaching to the foot.

The peroneal tendons help with:

• Turning the foot outwards

• Stabilising the ankle

• Controlling the foot during walking and running

• Supporting the foot during weight-bearing

• Providing dynamic stability when changing direction

Because they work continuously to control the ankle and foot, they can be exposed to substantial repetitive loading.

What is peroneal tendinopathy?

Peroneal tendinopathy occurs when the peroneal tendons become painful and less tolerant of load.

The condition may develop gradually following repeated loading or occur after an ankle injury, particularly an ankle sprain.

Peroneal tendinopathy is sometimes called peroneal tendonitis, although tendinopathy is generally a more appropriate term for persistent tendon problems.

The tendons can become painful during activities such as running, walking on uneven surfaces or repeated single-leg loading.

What causes peroneal tendinopathy?

Peroneal tendon pain often develops when the amount or intensity of loading increases faster than the tendon's ability to tolerate it.

Potential contributing factors include:

• Increasing running mileage

• Introducing hills

• Increasing running speed

• Sudden increases in training

• Repeated ankle sprains

• Running on uneven surfaces

• Changes in footwear

• Changes in training surface

• Weakness of the calf or ankle muscles

• Reduced ankle control

• Repetitive jumping or cutting

• Returning to sport after a period of reduced activity

Peroneal tendon problems can also develop following an ankle inversion injury.

Symptoms of Peroneal Tendinopathy

Typical symptoms include:

• Pain around the outside of the ankle

• Pain behind or below the outer ankle bone

• Tenderness along the peroneal tendons

• Pain during or after running

• Pain when walking on uneven ground

• Pain when turning the foot outwards

• Pain during single-leg activities

• Swelling around the outside of the ankle

• Weakness when pushing the foot outwards

• A feeling of ankle instability

Symptoms may initially only appear after exercise but can become more persistent if the tendon continues to be overloaded.

Where does peroneal tendon pain occur?

The location of pain can provide useful information.

Peroneal tendon pain is commonly felt:

• Behind the lateral malleolus

• Along the outside of the ankle

• Below the lateral malleolus

• Along the outside of the foot

Pain can sometimes extend further up the outside of the lower leg.

The exact location and behaviour of the pain can help distinguish peroneal tendinopathy from other causes of lateral ankle pain.

Peroneal Tendinopathy Assessment

A physiotherapy assessment will look at more than just the painful tendon.

Your physiotherapist may assess:

• The location and behaviour of your symptoms

• Tenderness along the peroneal tendons

• Ankle movement

• Calf strength

• Peroneal strength

• Single-leg calf raises

• Foot and ankle control

• Balance and proprioception

• Hopping and landing

• Running technique where appropriate

• Recent changes in training or activity

• Previous ankle injuries

The aim is to understand why the tendon is struggling to tolerate your current level of activity and identify the most appropriate way to rebuild its capacity.

Does Peroneal Tendinopathy Need an MRI or Ultrasound?

Imaging is not always required to diagnose peroneal tendinopathy.

A clinical assessment can often provide enough information to guide treatment.

However, imaging may be considered when symptoms are persistent, severe or unusual, or when there is concern about another condition.

Ultrasound can be useful for assessing the peroneal tendons dynamically and identifying abnormalities such as tendon thickening or tears.

MRI can provide more detailed information about the tendons, surrounding structures and the ankle joint.

Imaging findings should always be interpreted alongside your symptoms and clinical examination.

Peroneal Tendon Tear

Peroneal tendon tears can sometimes occur alongside tendinopathy.

A tear may develop following an acute ankle injury or gradually through repetitive loading.

Symptoms can include:

• Persistent pain despite rehabilitation

• Significant weakness

• Swelling

• Pain with resisted eversion

• A sensation of snapping around the outside of the ankle

• Difficulty with running or single-leg activities

If a tendon tear is suspected, further assessment and potentially imaging may be appropriate.

Peroneal Tendon Subluxation

The peroneal tendons normally run behind the lateral malleolus within a groove and are held in position by a structure called the superior peroneal retinaculum.

Following certain ankle injuries, the tendons can move abnormally over the outer ankle bone.

This is known as peroneal tendon subluxation or dislocation.

A characteristic symptom is a snapping or popping sensation behind the lateral malleolus, particularly during ankle movement or sport.

Persistent or recurrent tendon subluxation may require assessment by an orthopaedic specialist.

Peroneal Tendinopathy Treatment

Treatment is usually based around progressively increasing the tendon's ability to tolerate load.

Rather than simply resting the tendon indefinitely, rehabilitation aims to gradually expose it to increasing levels of resistance and functional activity.

Load Management

Initially, it may be necessary to modify activities that significantly aggravate the tendon.

This might include temporarily reducing:

• Running

• Hill running

• Long walks

• Jumping

• Rapid changes of direction

• Uneven-ground activities

The goal is not necessarily complete rest.

Instead, we aim to find an appropriate level of activity that allows the tendon to recover while maintaining as much normal movement and fitness as possible.

Peroneal Tendon Strengthening

Progressive strengthening is a key part of rehabilitation.

Exercises may include:

• Resisted ankle eversion

• Resistance-band exercises

• Calf raises

• Single-leg calf raises

• Seated calf strengthening

• Single-leg strengthening

• Balance exercises

• Hopping and landing exercises

The exercises are progressed as your strength and tolerance improve.

Calf Strength

The calf and peroneal muscles work together to control the ankle during weight-bearing.

Following an ankle injury or period of reduced activity, calf strength can become reduced.

Rebuilding calf strength can therefore be an important part of returning to running and sport.

Balance and Ankle Stability

Peroneal tendons play an important role in dynamic ankle stability.

Rehabilitation may therefore include progressively challenging balance exercises.

These can progress from:

Double-leg balance → single-leg balance → reaching → unstable surfaces → hopping → sport-specific movements

The goal is to improve the ankle's ability to respond to unexpected movements and changes in load.

Return to Running

If you are a runner, rehabilitation should eventually reproduce the demands of running.

Running can be gradually reintroduced once your symptoms, strength and functional capacity allow.

A typical progression may involve:

Walking → jogging → continuous running → increased mileage → hills → faster running → intervals

The exact progression will depend on your symptoms and goals.

Trying to return to your previous running volume too quickly can overload the tendon again.

Peroneal Tendinopathy and Running

Runners can be particularly susceptible to peroneal tendon problems because of the repetitive loading placed through the ankle.

Training changes are often important to consider.

For example, symptoms may appear after:

• Increasing weekly mileage

• Adding hill sessions

• Introducing speed work

• Increasing long-run distance

• Changing running surfaces

• Returning to running after injury

Your physiotherapist can help identify whether your recent training load may have exceeded your current tendon capacity.

How Long Does Peroneal Tendinopathy Take to Recover?

Recovery time varies depending on the severity and duration of symptoms.

A relatively recent problem may improve over several weeks with appropriate load management and strengthening.

Long-standing peroneal tendon pain can take several months to fully rehabilitate, particularly when there is significant weakness, recurrent ankle instability or an associated tendon injury.

Progress should be based on improvements in strength, function and tolerance to activity, rather than expecting pain to disappear immediately.

Can You Run With Peroneal Tendinopathy?

You may be able to continue running with a mild case of peroneal tendinopathy, depending on your symptoms.

However, running may need to be modified if it causes significant pain or leads to a substantial increase in symptoms afterwards.

Your physiotherapist can help determine:

• Whether you can continue running

• How much running is appropriate

• Whether hills or speed work should be reduced

• How to progress your mileage

• When to reintroduce higher-intensity running

Peroneal Tendinopathy vs Ankle Sprain

Peroneal tendon pain and ankle sprains can have similar symptoms, particularly following an inversion injury.

An ankle sprain primarily affects the ligaments, while peroneal tendinopathy affects the tendons on the outside of the ankle.

Following an ankle sprain, the peroneal tendons can also become overloaded as they work harder to stabilise the ankle.

Persistent pain behind or below the outer ankle following a sprain should therefore be assessed if it is not improving as expected.

When Should I See a Physiotherapist?

Consider physiotherapy assessment if:

• Your ankle pain has persisted for several weeks

• Pain is limiting your running or sport

• You have recurrent ankle sprains

• Your ankle feels weak or unstable

• You have persistent swelling

• You have pain behind the outer ankle following an ankle sprain

• You experience snapping around the outside of the ankle

• Your symptoms are not improving despite reducing activity

Early assessment can help identify the cause of your symptoms and establish an appropriate rehabilitation plan.

Frequently Asked Questions

What is the fastest way to recover from peroneal tendinopathy?

There is no single treatment that immediately heals peroneal tendinopathy. The most important component is usually appropriately progressed loading.

Reducing aggravating activities initially and then progressively strengthening the tendon can help improve its capacity over time.

Should I rest with peroneal tendinopathy?

Complete rest is not usually necessary.

Temporarily reducing activities that significantly aggravate your symptoms can be useful, but the tendon generally needs progressive loading to rebuild strength and capacity.

Can I run with peroneal tendinopathy?

Possibly. Mild symptoms may allow you to continue running with modifications.

However, if running significantly increases pain or causes a prolonged flare-up, your running load may need to be reduced temporarily while you build strength.

What exercises are best for peroneal tendinopathy?

There is no single best exercise.

Rehabilitation commonly includes progressive resisted eversion, calf strengthening, single-leg exercises and balance work. Later stages may include hopping, jumping and sport-specific exercises.

The appropriate starting point depends on your current strength and symptoms.

Why does my ankle hurt behind the outside ankle bone?

Pain behind the lateral malleolus can be associated with the peroneal tendons, although several other conditions can cause pain in this area.

A physiotherapy assessment can help determine whether the peroneal tendons are the likely source of your symptoms.

Can an ankle sprain cause peroneal tendinopathy?

Yes. Following an ankle sprain, the peroneal muscles and tendons may work harder to stabilise the ankle.

Persistent pain around the peroneal tendons after an ankle sprain should be assessed if it is not resolving.

Do I need an MRI for peroneal tendinopathy?

Not necessarily. Many cases can be diagnosed clinically.

Ultrasound or MRI may be recommended when symptoms are persistent, the diagnosis is uncertain or there is concern about a tendon tear or another underlying problem.

What happens if peroneal tendinopathy does not improve?

If symptoms persist despite appropriate rehabilitation, your diagnosis and contributing factors should be reassessed.

Further assessment or imaging may be appropriate to investigate conditions such as a peroneal tendon tear, tendon subluxation, ankle instability or another source of lateral ankle pain.

Peroneal Tendinopathy Physiotherapy in Newcastle

At NE Physio, we provide assessment and rehabilitation for peroneal tendinopathy and other causes of lateral ankle pain in Newcastle.

Whether your symptoms developed gradually through running or followed an ankle injury, we can assess your ankle, identify the factors contributing to your symptoms and develop a progressive rehabilitation programme.

Our aim is to help you reduce pain, rebuild strength and return to running, sport and everyday activities with confidence.

Book Your Assessment

If you have persistent pain around the outside of your ankle or suspect peroneal tendinopathy, book an assessment with NE Physio in Newcastle.