Kevin Kirby, DPM has posted a biomechanical description of the orthotic modifications he uses when treating chronic peroneal tendinopathy. They mesh well with what we’ve presented here and Kevin provides an excellent diagram along with his description. Be sure to read his post.
Peroneal Tendon Complex: Injury and Rehabilitation
By Stephen M. Pribut, DPM
While ankle sprains are the most common musculoskeletal athletic injury,(1) the peroneal tendon complex (PTC) is often injured concurrently. Injury to the PTC has become widely recognized as an acute injury and a significant source of lingering pain and disability. These injuries are frequently correlated with inversion ankle sprains and chronic ankle instability (CAI).
The peroneal tendon complex (PTC) includes the peroneus longus and brevis tendons, the os peroneum, and their restraining components (Figure 1). We will discuss the anatomy, clinical significance and conservative treatment of injury to the PTC.
Peroneal Muscles and Tendons
The peroneus longus and brevis muscles are located within the lateral compartment of the leg. The vascular supply is primarily from the posterior peroneal artery. Innervation of the peroneals is from the superficial peroneal nerve. The well positioned constraints which serve to maintain proper anatomical position of the PTC include the superior peroneal retinaculum, the retromalleolar groove, the shared tendon sheath, the individual tendon sheaths, the peroneal tubercle, the inferior peroneal retinaculum, and the peroneal groove below the cuboid (Table 1).
The origin of the peroneus longus muscle is from the head and upper two-thirds of the lateral surface of the fibular body and from the intermuscular septa adjacent to the muscles of the anterior and posterior leg. The musculotendinous junction occurs proximal to the lateral malleolus. The peroneus longus along with the peroneus brevis enters the fibular fibro-osseous tunnel behind the fibular malleolus and shares a common synovial sheath. The peroneus longus tendon changes direction three times in the foot: at the lateral malleolus, the peroneal tubercle, and at the cuboid notch. A hypertrophied tubercle may be a cause of injury of the PLT.(2)
An ossified os peroneum is found in approximately 20% of individuals at the cuboid notch (Figure 2).(3). The tendon runs below the cuboid and crosses obliquely to insert into the base of the first and second metatarsal and the lateral facet of the medial cuneiform bone.
The peroneus brevis muscle originates at the distal two thirds of the lateral
aspect of the body of the fibular and the adjacent intermuscular septa. It passesbehind the fibula where it lies adjacent to the fibula and deep to the peroneus longus while passing through the fibro-osseous tunnel. The insertion is at the tuberosity of the base of the fifth metatarsal bone. An os vesalianum is found near the insertion in less than 1% of people.(4)
The peroneus tertius muscle is found in approximately 90% of people and begins at the distal third of the anterior fibula. The muscle is usually confluent with the extensor digitorum muscle and ends before the inferior extensor retinaculum. The peroneus quartus is an anomalous muscle found in 6.6% to 22% of individuals. It begins at the peroneus brevis and inserts into the peroneal tubercle after travelling through the shared peroneal tendon sheath. (5)
Biomechanics and Injury
Peroneal tendon injures are a direct result of their anatomy and biomechanics. (5) The peroneal muscles are multi-joint muscles. Early in stance, the PTC is subject to passive stretch as the gastrosoleus acts proximally as a tibial decelerator. Late in stance phase, the PTC acts as a weak plantar flexor at the ankle joint.
At the subtalar joint (STJ), the peroneals act as pronators and are antagonists to the tibialis anterior and tibialis posterior muscles. Additionally, the peroneus longus muscle (PLM) plantarflexes the first ray and is a pronator at the midtarsal joint. The peroneals are most active in mid- and terminal stance, functioning to stabilize the foot. (6,7) Recent studies have demonstrated weakness of functional evertor strength in CAI. (8)
The PTC is subject to strain forces when the foot is inverted or supinated about the STJ. A sudden inversion force or chronic overuse may injure the PTC or the lateral ankle. The most frequent injuries to the PTC are traumatic tendinopathy, a tear, or a subluxation of the peroneal tendons. (9) Tendon subluxation is believed to occur with the foot in a dorsiflexed position and the peroneal tendons contracting strongly. (10)
Risk factors associated with peroneal tendon injuries may be seen in Table 2. (11, 12) Multi-directional sports, such as soccer, tennis, and basketball, are associated with these injuries. While peroneus brevis injuries are frequently suspected at the level of the lateral malleolus, injury to the distal peroneus longus is often undetected. Additional associated injuries include injury to the cuboid, the os peroneum, or fifth metatarsal. (3, 13) Differential diagnoses are listed in Table 3.
Peroneal tendon complex injury is considered a risk factor and contributor to CAI. (14, 9) A recent study showed that a brief bout of pain posterior to the lateral malleolus preceding an inversion ankle injury was associated with MRI evidence of peroneal tendinosis in 95% of cases. (13) Up to 75% of those suffering inversion ankle injuries may have a recurrence of injury or are subject to ongoing symptoms related to chronic ankle instability (CAI). (15, 16) Examination at the time of surgery for recalcitrant CAI often demonstrates injury. A retrospective review of 136 patients who underwent a Broström-Gould ankle reconstruction found that 53.3% required operative intervention for peroneal tendon pathology. (14)
Examination of sixty-four consecutive acute ankle inversion injuries by MRI revealed that 30% of the subjects suffered an associated tendon injury. (17) These injuries, when unrecognized, may contribute to ongoing symptoms. Estimates range from 30% to 70% of inversion ankle injuries may recur or have lasting symptoms. These ongoing symptoms diminish sensorimotor functioning and lead to decreased physical activity and concomitantly a diminished quality of life (18). It has been reported that 32% of ankle inversion injuries are still symptomatic seven years after the injury. (19)
Painful Os Peroneum Syndrome (POPS)
The os peroneum (OP) is a sesamoid bone found within the peroneus longus tendon (PLT) of most people. It is usually located just proximal to the cuboid tunnel. The OP is frequently fibrocartilaginous, often bipartite, and is only visible on x-ray 6–20% of the time (Figure 3).
The OP is subject to both fracture and contusion. Bone callus formation during healing can lead to tendinopathy of the peroneus longus tendon and it may also play a role in tears of the tendon. When the OP is injured, the MRI may show fluid around the PLT and bone marrow edema of the cuboid. (20)
A history and physical examination will reveal the cause of many injuries. While the inversion movement which causes the injury occurs rapidly, the full effects may not be obvious for several hours. The lag between injury and effect will lead many patients to forget the inversion event. The history may reveal previous ankle sprain, fracture, or other lateral foot injury. Peroneal subluxation may be associated with a sensation of painful clicking.
A methodical physical examination follows the principles of look, touch, and move. Examine for swelling, color, general alignment, structure, and symmetry. Thoroughly palpate the lateral foot and ankle and explore the peroneal tendons through their entire course. Peroneus brevis tears often occur behind the fibula, while peroneus longus injury may occur at the cuboid groove or more distally. Note the strength of the peroneal tendons and pain during resisted ankle eversion. Also note pain in response to dorsiflexion of the first ray or an inability to resist the dorsiflexion. (5) Be sure to check the ankle for ligamentous disruption.
Peroneal subluxation may be tested by flexing the knee and asking the patient to actively dorsiflex the ankle with resisted eversion. The test is positive if the peroneal tendons are seen to subluxate anterior to the fibular malleolus. Intra-sheath subluxation is suspected if their position translates relative to each other. (5) The peroneal compression test suggests peroneus brevis tendinopathy. To perform this test, evert and dorsiflex the foot while compressing the fibular groove.(20)
The Ottawa protocol outlined in Table 4 should only be used for acute ankle injuries and not for late injury evaluation. On x-ray, carefully evaluate all the lateral boney structures. Figure 4 shows a hairline Jones fracture that went undetected the previous night at an urgent care center (Figure 4). A visible fleck of bone at the fibula indicates possible subluxation of the peroneal tendons from the fibular groove. A Harris view assists in assessing the peroneal tubercle and the retromalleolar groove. (21, 22) Be on guard for a fracture of the os peroneum or distraction of multipartite fragments (Figure 5). Fractures of the os peroneum may best be assessed using a CT scan which better reveals the border of the ossicle.
Ultrasound can be useful to detect peritendinous fluid, or partial or complete rupture, but it requires an experienced examiner.
Magnetic resonance imaging (MRI) shows the anatomy in best detail. Fluid surrounding the tendons are best seen on T2-weighted or short tau inversion recovery (STIR) images. These images are useful to assess subtle injury to the cuboid and base of the fifth metatarsal. The MRI finds more pathology than is clinically relevant in some cases while it may miss other pathology. (23) MRI has a positive predictive value of less than 50%. (24, 25)
Outline of Treatment
High level evidence-based medicine is the goal we seek to attain. However, there are times when the evidence is weak, contrary, wrong, or lacking. There is only scant material written on rehabilitation for PTC injury. Researching the rehabilitation of ankle injuries is a reasonable place to begin crafting a program for the PTC. (26) Most recent overviews have come to realize the flaw of not using adequate protection during the earliest stage of therapy. (16, 27)
The most consistently recommended therapy for rehabilitation of an acute ankle sprain, CAI, and for prevention to reduce the risk of future re-injury is balance training. (27, 28, 29, 30)
Proposed Functional Rehabilitation of PTC Injury
Phase I: Protection, rest, ice, compression, and elevation.
Initial therapy requires protection of the injured area. A removable pneumatic cast boot serves as both protection and compression and may be removed for exercise and evaluation. (21) An ankle brace alone is not effective since the stabilization achieved is inadequate. The tendons must be protected from forces that place them under stretch, including dorsiflexion moments applied to the foot. It is helpful to protect the mid-foot, mid-tarsal joint, and first ray from forces which translate into strain forces on the peroneal tendons. The removable cast boot is used for one to four weeks depending upon the severity of the injury.
Ice may be applied for 20 minutes on/40 minutes off for three to six times per day for the first 48 hours. Ibuprofen or another NSAID may be helpful.
Phase II: Motion
Do not rush the patient into vigorous muscle and strength exercises. This has been part of chronically failing regimens previously used for the ankle. Gentle range of motion exercises may be performed.
Phase III: Neuromotor
Proprioception, balance, and muscle strength are keys to successful recovery. The most efficacious tool to accomplish these goals is the 20” wobble board. This appears to reach optimal angular relationships at maximum excursion to train the neuro-facilitative responses needed in gait.
Other proprioception and balance exercises may also be used. The most popular are Romberg one leg balance exercises and the simplified STAR excursion exercises. (31, 32)
Muscular strength exercises may be augmented using exercise band therapy. Recent evidence has shown more proximal muscle training may also assist in recovery.
Limitation of dorsiflexion and equinus may be addressed by posterior muscle group stretching and active exercises such as the heel roll-up. Toe crunches strengthening the intrinsic muscles are also helpful to stabilize the mid-tarsal joint and decrease PTC forces needed for this stabilization.
Gentle foam rolling of the calf muscles may help mobilize the ankle.
Phase IV: Return to Activity
The balance and proprioceptive exercises from Phase III should all be continued for at least three months. Specific training for a return to activity may begin.
Preparation for return to full activity includes beginning with walking, progressing to running, cutting, and sideways movements needed for sport. It generally requires four to six weeks to return to most sports but occasionally twelve weeks may be needed.
Evidence has pointed to orthotics as being helpful in treating CAI. Orthotics are also helpful in treating PTC injuries. Orthotic modifications to reduce the strain on the peroneal tendons and lateral foot structures are important components of treatment. Research also indicates that orthotics produce proprioceptive and balance improvements. (33)
Feet that suffer these injuries often have a lateral shift of the STJ location, which increases the supinatory moment of ground reaction forces. The orthotic modifications I use are designed to alter these moments and allow the peroneals to function optimally. These modifications include a 0/0 rearfoot post with “no lateral bevel” (Figure 6). This makes the orthotic less prone to cause excessive supination. You may use a low level of cast inversion and medial skive depending upon the foot type. In addition, you may use about 3 degrees of lateral forefoot valgus wedging to the sulcus, especially for patients who do not contact with the rear foot. Additional modifications seen in Table 6 are based on Richard Blake’s suggestions for excessive supination. (34)
We have briefly reviewed the anatomy, injuries, and rehabilitation for injuries to the PTC (Table 7). There is much to research and write about this topic. Don’t stop learning. Your patients benefit from your knowledge.
Outline of Therapeutic Treatment for Peroneal Tendon Injuries
Figure 1. Know your anatomy. Tablet-based apps help demonstrate the anatomy to your patients. (Image courtesy 3d4Medical Ltd. “Essential Anatomy 5”)
Figure 2. Normal os peroneum.
Figure 4. Hairline Jones fracture. Tender to touch and visible on x-ray.
Figure 5. Fragmented os peroneum. Healing bone callus visible.
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Bio: Dr. Pribut is a Clinical Assistant Professor of Surgery at George Washington University Medical School. He serves on the Runner’s World Board of Advisors. He is a past president of the American Academy of Podiatric Sports Medicine. Dr. Pribut is in private practice in Washington, DC.
A new study – online at the J Applied Physiology (August 31, 2017) – was performed to measure beneficial impact on collagen production in chronic tendinopathy. The study evaluated mRNA (and ribosomal RNA) and more along with determining the impact on gene activity.
The study showed that one week of 1800 mg per day of Ibuprofen seemed to not have a measurable impact. The authors propose that the impact in vivo and in vitro may be dramatically different for one of several reasons. The tendon cells may not be sensitive to ibuprofen or they may not be exposed to a high level of ibuprofen in the body
The study did demonstrate that there was a decrease in pain compared to placebo and suggested that the pain reduction pathway may work in ways not yet well described.
The best news was that although it may not have a dramatic impact on chronic Achilles tendinopathy (which we suspected and perhaps knew all along), it did not destroy tendon cells.
Those two recommended set of injections at $6,000 per series for your Achilles tendinitis hasn’t sounded very good for the past few years. Ever since a controlled, prospective comparison study demonstrated there was absolutely no difference in the efficacy of PRP over saline injected in the same manner, there has been doubt about the use of PRP in the office. But instead of falling by the wayside, like a bad political candidate, it has spread by meme and scheme far and wide and even infiltrated some of the best offices in the country and world.
The British Medical Journal has recently posted an article strongly recommending against the in office use of PRP (platelet rich plasma) outside of established studies.
The article was titled: “How effective are platelet rich plasma injections in treating musculoskeletal soft tissue injuries?” The answer, at this time, seems to lie somewhere between “we have no clue” and “not very”. This study mentions a previous review by the Cochrane review (2014) which examined 19 studies and found insufficient evidence of the usefulness of PRP. This study reviews 10 additional studies and reaches the same conclusion.
The article is readily available and worth a read:
Two articles currently up on the Runner’s World news and blog areas take opposite approaches to Achilles tendon problems. One cites a study of normal individuals who were asymptomatic and measured “load” in the Achilles tendon and concluded that there would probably be no help given by a heel lift. This was not a clinical study of treatment however and it has no validity regarding statements made about treatment. In fact the least helpful part of many studies is in the “discussion” part of the study where the authors speculate about what their study means, but which their study did not show. Please beware of author speculation. There are only a few who are accurate in their speculations. And some of them win Nobel prizes.
The other article is a blog by a coach who noted that her runners seemed to be having an inordinate amount of calf and Achilles problems. These are clinical and coaching observations and not a published study. But, there truly may be wisdom in systematic observations. Over the past 6 months she noted that this injury seemed to have surged and become a trend. The calf and Achilles problems were often seen among runners who had thought they were purchasing the same shoe they had run in for years only to find that the “heel drop” (heel to forefoot height differential) had dramatically decreased. Initially I was going to post on Coach Jenny’s blog article but I’ll just link to it and make my remarks here. I believe she is right on top of things in her blog.
Over the past 3 years many manufacturers have attempted to “minimize” nearly their entire product line. A shoe which had a 12 mm heel drop, now has 8 mm. And of course zero to 2 mm are often touted as the ideal. But the reality is that not everyone responds well or even the same to changes.
As George Sheehan said “we are all an experiment of one”. And the modern reality is that studies, trends, and memes are aggregate while injuries happen to individuals. And individuals need tailored solutions that are not always the trendy advice making the rounds.
So in spite of some “nay-sayers”, who adamantly disagree, I side with Coach Jenny. Often returning those 4 mm or so back as a heel lift, can make the difference between comfort and pain. Instead of a soft gel or foam heel lift, I prefer a solid heel lift made of firm layered plastic film, hard rubber, or leather. You may find that after months of icing, foam rolling, massage and even lower heel drop shoes, this may be your answer. But if you’ve had the pain that long, you may need to check in with your sports doc. (And hope the advice is different from what has failed during your experiments!)
This is still not the entire answer for many individuals and there are other things to analyze. Shoe changes, training changes, terrain, and recent racing history along with individual biomechanics all come into play for a more complete analysis of the causes and the likely solutions. YMMV
Perhaps one day I’ll break this up into 5 slideshares and 5 articles. But for now, here are the slides from a lecture presented at the Sports Medicine Section of the American Podiatric Medical Associations Annual Scientific Conference.
I believe that basic science and research is an important component for advances clinical medicine. This lecture highlights some of that research from barebones systems biology to mechanotransduction. Cell mechanics, structure and biology are where the action is.
Point / Counter Point: The Truth is Out There Somewhere (or maybe here)
Every now and then the “Fear Factor” comes to the Internet. And if you travel the running blogosphere, you’ll discover that sometimes it takes the form of a red alert for heel lifts for Achilles tendonitis. It seems that some would rather have you run in pain or give up because of the pain for fear that a 1/8″, 1/4″ or 3/8″ lift which alleviates the pain could cause a tendon to “pop”. There is evidence that the sound of a tendon popping may come after an indiscriminate intratendinous injection of steroid though.
The truth is one should pay attention to what your body is telling you. Running in pain which causes an alteration in form is not good. It will most likely lead to both your original injury not improving, and a few additional injuries because of your altered gait.
With the knowledge that medicine is an art and a science, it is probably best to avoid dogmatic opinions such as “no, no ,no” to a heel lift. While some will be helped with shoe and surface corrections, orthotics, stretching and strengthening alone, the addition of a 1/8 – 3/8″ heel lift can often make the difference in both comfort and eventual healing of this condition. The lift is used on both sides to avoid creating a longer leg and altering the gait in such a manner that could create low back pain, hip pain or other problems in the absence of the affected leg being a short limb. The lift is best made of a non-compressible material. It is extremely important to avoid compressible materials which will lead to continued slow stretch movement which could add to either activating the stretch reflex of the achilles tendon or allow for eccentric contraction of the muscle-tendinous complex. This may work to inhibit the healing of the tendon, and stop the individual from being able to run without pain. We certainly, and the ladies among us, especially, will vary our heels by much more than this over the course of a week. A slight change in the heel contact and foot angle should not put your Achilles tendon at greater risk of injury.
While there are flaws in evidence based medicine and in the ability of us to accurately predict those most likely to become injured, there is no evidence that 1/8 to 3/8 ” lifts cause ruptured Achilles tendons. Not even the slightest hint that muscles and tendons would be ruined by such a lift or adapted so much that you’ll never be the same. I do not know of any study that shows a 1/4″ lift used for a limited amount of time each day could shorten the muscle/tendon complex. There is adequate time spent in other shoes, barefoot, and even doing stretching exercises.
Running in pain without a heel lift, or more dramatically running on a soft surfacer with a mushy, over cushioned shoe or a racing flat is far more likely to lead to chronic pain and disability. Proper orthotics are a must, along with avoiding over cushioned running shoes to prevent the tendon while functioning from being over stretched and causing eccentric working of the muscle-tendon complex . There seems to be no reason to avoid a heel lift, but it is not the be all and end all of a program to treat Achilles tendonitis.
I wasn’t sure what I’d find in the texts, but thought it would be interesting to see what other minds have come up with on this issue. I did not think that Noakes would agree with the heel lift, but he did. I do not know what is the scientific basis or aggregate clinical experience to imply that heel lifts are the worst possible therapy for this problem.
Alfredson, H. and Cook, J. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 32 “Pain in the Achilles Region” p. 606 “A heel lift worn inside both shoes (0.5 – 1.0 cm, .25-0.5 “) is a good practical way of unloading the region.
Alfredson is famous for his self termed “painful” eccentric stretching for non-insertional Achilles tendinopathy. He has published numerous articles on Achilles tendon problems and on the treatment of them. I am not convinced that eccentric stretching is appropriate in as many cases it is recommended. If you find something isn’t working, including the eccentric work is not helping, you need to change the approach. Measurements have shown that the calf is often weak in eccentric strength when one has Achilles tendonitis. One approach is to work on strengthening that (which can be painful). The other is to diminish the pain by lessening stresses which add to the eccentric contraction strength required. Both approaches and sometimes a combination may be appropriate for different patients and at different times for a specific patient. I continue to read Alfredson’s articles with interest. (And in actuality will recommend his exercises in a manner and when it can be done without causing pain. 2012)
Bradshaw, C. and Hislop, M. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 31 “Calf Pain” Since the calf includes the muscles which create the Achilles tendon, we’ll look at comments in this chapter also. “A heel raise should be used on the injured and uninjured side”.
Title, C. and Schon, L. “Achilles tendon disorders including tendinosis and tears” in Baxter’s The Foot and Ankle In Sport, Second Edition. Mosby Elsevier. Eds. Porter, D. and Schon, L. 2008. “The initial treatment for Achilles tendinitis is nonoperative. The majority of symptoms respond to rest; activity modification; improved training techniques; stretching and at times, shoe modifications and heel lifts. Initial treatment should include …At times, a heel lift (one fourth to three eights inch)….”
Noakes “The Lore of Running, Fourth Edition” Human Kinetics Press. 2003. Noakes feels a shoe with a heel height of higher than 12 – 15 mm and says “most authorities agree that a 7 to 15 mm heel-raise should be added to the running shoes”.
Update: The results are still controversial and contradictory on PRP and Achilles tendinopathy. This is a repost of a blog from 2010. (The primary reason for the repost is moving material of archival interest to a site which functions better.)
A study published in the Journal of the American Medical Association, Jan. 13, 2010 gave disappointing results in using plasma rich protein to treat non-insertional Achilles tendinopathy. It showed no difference between using a sham injection of saline and combining it with a painful eccentric stretching protocol in comparison with an injection of plasma rich protein injection along with the standard painful eccentric stretching protocol.
The authors note that previous studies did not have good control groups. In this small study, 27 patients were in the placebo group and 27 in the treatment group. The VISA-A score was used to assess improvement. Both groups improved somewhat without a significant difference between the two groups.
The study was called a “preliminary communication” which is often done with small studies. Other studies on similar topics with fewer than 30 individuals studies have also been billed as “preliminary studies”, but when they are talked up afterward, the “preliminary study” status is usually forgotten. As far as study design goes, the design, blinding, and performance of the study seems just right. I am not entirely convinced of the efficacy of the painful eccentric stretching protocol and would have not minded another study group omitting that treatment. Apparently it is not a panacea (or there would not be studies looking to add to the results), although the initial preliminary study made it sound as though it would be. Follow up journal articles by the primary author of the first study have been positive and are referenced below. Others have expressed reservations on the methodology. (see Woodley et. al. 2007 and Kingma et. al. 2006) Eccentric stretching and overload for tendinopathy has mixed results at best in other body areas.
Note: VISA-A is the Victorian Institute of Sports Assessment-Achilles
Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy: A Randomized Controlled Trial
Robert J. de Vos; Adam Weir; Hans T. M. van Schie; et al. JAMA. 2010;303(2):144-149 (doi:10.1001/jama.2009.1986)
Alfredson H. Chronic midportion Achilles tendinopathy: an update on research and treatment. Clin Sports Med. 2003;22(4):727-741.
Alfredson H and Cook J (2007), A treatment algorithm for managing Achilles tendinopathy, new treatment options, British Journal of Sports Medicine, 41, 4, 211.
J J Kingma, R de Knikker, H M Wittink, T Takken. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. Br J Sports Med 2007;41:e3 (http://www.bjsportmed.com/cgi/content/full/41/6/e3). doi: 10.1136/bjsm.2006.030916 (concludes: Studies on the effectiveness of eccentric overload training in patients with Achilles tendinopathy show many methodological shortcomings)
Woodley, B.L., R.J. Newsham- West, and D.B. Baxter, Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med, 2007. 41: p. 188-199.