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Peroneal Tendonitis?

by Cheryl
(Cleveland)

Hello,

First, please let me compliment you on having such an informative website!

The past Winter I was plagued with some health problems (diverticulitis) that kept me bedridden for months. (I didn't take any form of fluoroquinolone, but Augmentin instead) One this lengthy health problem resolved in late Spring, I was left with quite a bit of muscle atrophy due to inactivity. It also doesn't help that I'm in my early 50's, I'm noticing that ailments don't heal as quickly as when I was younger.

I immediately began (big mistake) cleaning my attic, while sitting on both feet cleaning out boxes for hours. I had some stiffness and mild swelling in my ankles, but it dissipated. I also began going on nightly walks to increase my activity level. After arriving home from my second or third walk, within 30 minutes I had developed pain in my ankles, hips and back. Fortunately the pain was gone by the next morning.

Over the coming weeks my left ankle began to cause me pain but I couldn't pinpoint exactly where. (I've never had the repeat episode of hip or back pain again) I had been to the ER twice to no avail, an urgent care clinic in which I was told that I sprained my ankle and given a boot. (No imaging was done) Shortly thereafter I had seen an Orthopedic twice. On the first occasion he took an x-ray of my foot and said that everything looked good, took me out of the boot and gave me some sort of ankle wrap which didn't help. As time progressed, so did the pain.

As for my pain patterns, it seems to come from around the lateral ankle and travel up into the side of my lateral calf. The pain in the lateral calf seems to be the worst. By evening, I have mild swelling around the lateral area of the ankle. Upon my research over the months, my best guess is Peroneal Tendonitis. I haven't been doing anything physical since this pain started and have been in bed 90% of the day with my foot elevated. In the morning, the pain isn't very bad but increases throughout the day with evening being the worst. I assume this is due to having to walk around briefly throughout the day.

With that being said, over the past few weeks, I've noticed the same dull and nagging pain beginning in the right ankle with the same pain pattern. I recently saw a Podiatrist who examined me, looked at my gait and said that I had a problem with over-pronation. He said it was more severe in the left ankle than the right. I have no problem with ROM. I'm currently waiting on a pair of Orthotics to be made that he feels will correct this mechanical imbalance.

I was in physical therapy for a brief period, but he thought it would be wise to save my visits for after I receive the Orthotics. No MRI was ever done, as my insurance company denied one.

While I understand that it can be complicated offering help without being hands on, would you tend to agree with the Podiatrist? Upon my research, I haven't come across many people that have Peroneal Tendonitis in both ankles and I seem to come across so many failed Peroneal Tendon surgeries that frighten me. While waiting for my Orthotics, I use ice nightly.

Thank you for any insight you may have to offer, it would be much appreciated.


RESPONSE

Hi Cheryl,

Thanks for the kind words regarding my site; I try. It sounds like you may have peroneal tendonitis as I see a lot of it and in most cases it appears to come from over pronation, in an otherwise healthy individual.

The pain you describe as originating on the outside (lateral) side of the ankle and going up the lateral side of your calf, follows the course of the peroneal tendons.

Since your podiatrist determined that you excessively pronate then I agree with the notion of orthotics. Why not try and alleviate the problem from the source?

Since prescription orthotics can take a few weeks to be made, I am surprised that your doctor did not suggest you try a pair of store bought arch supports. Any thing that reduces the pronation, even ever so slightly with the store orthotics, should relieve some of your discomfort.

treatment for peroneal tendonitis until your orthotics arrive


If icing helps then keep icing, try and limit your activity to necessary tasks until you get your orthotics. Because of your diverticulitis you cannot take nsaids, so you are limited there. If it is more then ten days from now before you expect to receive your orthotics then go out and buy a pair of arch supports, ones which will raise your arch the most. Try and wear them exclusively in sneakers which also tend to have a built in arch which will further reduce your pronation.

Marc Mitnick DPM
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Oct 22, 2017
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Pictures Requested
by: Cheryl

Hello Mitnick,

Thank you kindly for taking the time to offer your thoughts on my on-going problem. You've offered more assistance and advice than anyone I've seen thus far!

To answer your questions, I'm 5'6, 119 lbs and 51 years of age. My chronic pain is bilateral with the left foot/ankle being the worse.

I'm currently wearing my Powersteps in a pair of Nike Air Zoom Vomero 12 (Size 8.5) which is a neutral shoe. I can feel the arch support while in these shoes in the right arch but not as much in the left arch. Prior to this problem, I've always worn a size 8 in tennis shoes but have had to size-up due to the Powersteps and modifications made.

A week ago, I thought perhaps I needed to try the Powersteps in another pair of shoes and purchased a pair of Saucony Echelon 6 (Size 9) which again are a neutral shoe. In this pair of shoes, I felt no arch support in either arch and essentially felt like I was walking on the ground. Within 4 days, I had to go back to the Nikes as my posterior tibial tendon (along the inside ankle) was beginning to hurt on both feet. As you might imagine, my podiatrist hasn't been much help in choosing the proper shoes.

Since wearing these Powersteps for at least 3 months now, with additional modifications being made to them and seeing no relief, I have to wonder if I'm still pronating excessively while in the Powersteps. I assume if they were reducing pronation, I would have some relief but unfortunately that hasn't been the case.

I believe that I need rigid orthotics for my condition however; my podiatrist wants me in the Powersteps until he sees a reduction in pain. I don't understand his logic. At this point, I've already made an appt. with a new podiatrist and don't plan on returning to the previous one.

I don't believe he ever checked me for tarsal coalition but I did a "heel-tip test" for this in which I found on Medscape and was able to do it. My husband messages my calves and feet daily and said that I don't have a tight heel cord. I usually have tightness in my outer calves on both legs, though.

Attached are the pictures you requested, including one with my knees.

https:https://preview.ibb.co/npO8km/IMG_0274.jpg

//preview.ibb.co/f6kXBR/IMG_0275.jpg

https://preview.ibb.co/cTeQWR/IMG_0276.jpg

https://image.ibb.co/jHOkWR/IMG_0277.jpg

https://image.ibb.co/iGQM5m/IMG_0278.jpg

https://image.ibb.co/fpserR/IMG_0279.jpg

Again, I sincerely appreciate your thoughts on my chronic pain issues. Your site is a wealth of knowledge and I wish that I had a podiatrist such as yourself closer to my home. You offer an invaluable service to those in pain who can't seem to find the proper help or guidance. Thank you.

Best,
Cheryl
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Hi Cheryl,

Thanks for the kind words. I looked at all your pics and do not see anything that jumps out at me.

Your left foot, at least in the pictures, appears more pronated and of significance pronation to possibly be an issue.

Normally when I see severe peroneal tendonitis there will be swelling on the outside of the ankle, I do not see that in your pictures, so even though there is pain on the outside of the ankle I would be more inclined to think sinus tarsi issues or even lateral ankle ligament issues both from a "jamming" effect of the foot from pronation.

I cannot offer much more from your pictures and of course without examining you I am limited.

I am glad you are seeing another podiatrist and as I mentioned earlier, I would like your Achilles tendons checked as well as your ability to invert and evert your rearfoot (subtalar motion).

Hopefully with a fresh set of eyes on your feet, you will get some answers.

Marc Mitnick DPM



Oct 21, 2017
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Updated
by: Cheryl

Hello Mitnick,

I thought I'd update since it's been well over two months. Perhaps, this
could help someone in the future with similar issues.

Since my last post, I've had an ultrasound of all my
tendons/ligaments. It came back clear with the previous tendinopathy
being resolved.

I've since seen the current podiatrist that I've been working with
(who is still modifying the Powerstep Pro's) at least 25 times, if not
more since my last post. Keep in mind that these are not "custom
orthotics" but modified PowerStep Pro's. In any case, my pain remains
(peroneal tendons, posterior tibial tendons, pain in sinus tarsi area,
midfoot pain and now swelling on either side of the achilles on each
heel...not sure if tendonitis or bursitis) The podiatrist seems to
have no answers yet keeps making "adjustments." He keeps telling me in 2 weeks that I'll be pain-free.

I've seen my primary physician again who thinks it's ridiculous that
no one has been able to give me a clear-cut diagnoses in 6 months and
referred me to a certified foot and ankle surgeon, a vascular surgeon
and a neurologist.

The foot and ankle ortho. said that my bone structure is great, as are
my tendons, ligaments, etc. He examined me, I can do a single heel
raise on either foot and told me that I had a biomechanical problem
and to continue with my current podiatrist. He suggested seeing a PT.
(problem is I can't walk more than 10 minutes or do stairs without
pain without pain) I've spent 95% of the day sitting as of late, still in pain yet
to a lesser degree while sitting. I'm often awakened at night due to
my calves/ankles/feet hurting.

I've also seen a vascular surgeon for possible PAD in my legs and this
was clear with no issues. I have a neurology appt. next week in
which I don't foresee any issues.

While my podiatrist "claims" to specialize in biomechanics, I've decided
to see another podiatrist who is a runner with 35 years experience and specializes in biomechanics.

I'll attach a picture of my current "modified" Powerstep Pro's in case
you/anyone is interested. I'm not sure if they're over-correcting me or they're
just a mess. Judging by pictures of custom orthotics that I've
seen online, I'd have to say both.

I hate to keep asking your opinion but would be thrilled to be active again with no pain. Am I in need of a "decent" set of orthotics? (I hope you can see the pictures)

Thank you so much for your time and I really like your updated website!

Best,
Cheryl

https://image.ibb.co/k69okm/IMG_0272.jpg
https://image.ibb.co/edGerR/IMG_0273.jpg


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Hi Cheryl,

Have someone take a picture of your feet at ground level,while standing barefoot, both front and back and send them to me. Stop going to the podiatrist who has seen you 25 times and essentially has accomplished nothing. You do not need to be his annuity.
Does your weight have anything to do with this? Please give me your height and weight.
What type of shoe do you wear your Powersteps in?

You may ultimately need custom orthotics but only if you find the over the counter orthotics are of some value and so far they do not appear to be.

Peroneal tendonitis and sinus tarsi syndrome, as well as tibialis posterior tendonitis are usually both caused by too much pronation, or, over flattening of the foot. Generally adding any type of orthotic to your shoe should give you some, if not remarkable relief, assuming the orthotic actually supports the foot and is not just a "foot cushion". Powersteps generally are supportive.

Another key issue here is whether or not the orthotics actually reduce your pronation. Have you been checked for what is known as a "tarsal coalition" which is a fusion of your bones in the hindfoot which does not allow the foot to be moved into supination (the reverse of pronation). If you cannot reduce the pronation you will never resolve your pain.

I would also like to know if you suffer from an equinus or tight heel cord. A tight heel cord is accommodated by excess pronation. Maybe, your new podiatrist will check for these two conditions.

I saw your pictures but they do not give me much information.

That it for now.
Marc Mitnick DPM





Aug 19, 2017
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Update
by: Cheryl

Hello Dr. Mitnick,

I thought I'd give an update (perhaps this may help someone else) as well as to ask for your opinion once again. You've been very helpful and I appreciate it.

I did receive my custom orthotics from my Podiatrist a few weeks ago but unfortunately they seemed to make my pain worse. They were very rigid with no "give." I began experiencing pain around the Posterior Tibial tendons on both ankles, Peroneal tendons, as well as pain in other areas. I only made it wearing these for 2 hours a day for 5 days.

My Podiatrist then suggested an MRI of the worse (left) ankle. The basics of the results are:

1) No fracture or marrow edema. No discrete OCD lesion.
2) Small joint effusion of the tibiotalar joint and subtalar joint without a discrete focal chondral defect.
3) Peroneus brevis and longus tendons are morphologically normal without tear or tenosynovitis.
4) Low-grade posterior tibial tendinopathy in the inframalleolar portion without tenosynovitis or discrete tear.
5) Minimal fluid distending the extensor retinacular bursa.

I have read that tears can't always be picked up on MRI. Would an ultrasound be better or is an MRI the gold standard?

My Podiatrist gave me a diagnosis of "navicular drop" with secondary (mild) PTTD. He feels that custom orthotics will help me with both issues.

He's currently making me another pair of orthotics out of cork, as he said that would "give" more. He suggested Voltaren and wants me to come in twice a week for three weeks for Anodyne (Infrared) treatments.

While waiting for the custom orthotics, he gave me a pair of Powerstep Pro's in which he added some wedging in the left side to tide me over. He feels that I'm going to have to gradually work my way into the orthotics as they cause quite a bit of pain for me bilaterally. He suggested 25 minutes the first day and adding a little more time each day.

I wore them yesterday in my shoes and walked around for about 25 minutes. They felt fine, but I'm assuming that having never worn orthotics before that I'm going to have to get used to them. About 2 hours after taking them off, all of my pain increased two-fold. Is this normal? I took an Aleve last night which helped through the night.

I must say that this all has me concerned about wearing them again today. My Podiatrist said that they would bother me at first, thus going into using them slowly due to muscle memory. Does all of this sound accurate to you? I'm concerned about the Posterior Tibial tendon worsening as I certainly don't want to end up having to have surgery. (It's strange how this initially presented as Peroneal tendonitis)

Perhaps I'm expecting a miracle overnight. This all started approximately 4 months ago and I've just gotten a diagnosis after seeing a plethora of physicians. I'm becoming depressed over this issue. I long to be back to the days of walking around the block or just doing some household chores on my feet without dealing with pain a few hours later. Instead, I spend a great deal of the day sitting.

Thank you for any insight/advice you have to offer.
Best,
Cheryl

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Hi Cheryl,

The initial treatment for peroneal tendonitis or tibialis posterior dysfunction is the use of an orthotic, it is just a question of finding the right orthotic for a given patient.
I doubt the Powersteps caused pain two hours after removing them, but rather the pain occurred because you took them out and your feet reverted back to being to "flat". I cannot give any advice here, that's what your Podiatrist is for. I suggest you call him and get further guidance.

Marc Mitnick DPM

Jul 25, 2017
Rating
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Thank you
by: Cheryl

Dr. Mitnick,

Thank you for your fast response. My Podiatrist actually did make me temporary arch supports using elastikon tape and a felt wedge to prop up my arch. These were to serve as a temporary measure as I await for the custom Orthotics to be completed. They're due to be ready on Monday.

On a side note, I was diagnosed with Benign Fasciculation Syndrome approximately 3 years ago which has seemed to increased over the past 6 months or so. (fasciculations in arches of both feet and lower legs, 24/7) I can't seem to find a correlation online between BFS and PT, so I'm not sure they're related.

Oddly enough, when I bathe in hot water, it really seems to increase the PT pain. This is without any pressure on the ankle. The only thing that I can think of is an increase in inflammation. Is this common?

Thank you for your help and advice and again for your time dedicated to your website helping others.
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I do not think there is a connection between BFS and your peroneal tendonitis.

The warm bath may just be causing more swelling in the area and so it exacerbates your symptoms.

Marc Mitnick DPM


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Julie

location unknown
Thank-you so very much for responding so quickly and in such detail to my question!! I will give my surgeon a call today!! This website is terrific!!!! Thank-you again!

Renae

North Carolina
Many Thanks Dr Marc!
Thank you for your response. It sounds like a good plan to me. He did not cut the wart out first ...

KG

location unknown


Thanks again doc for having this website and we STILL need qualified Podiatrists in beautiful sunny Tampa Bay (Bradenton) Florida.

Bessie Mae

Florida
Dear Dr. Mitnick, Thank you so very much for taking your time to answer my question. You have greatly relieved my anxiety related to the continual tingly I feel in my feet. I will share your response with my podiatrist next week. God bless you for having this question and answer page on your website! Most gratefully,

Lynne T.

location unknown
Your webpage is excellent, I commend you on sharing your knowledge to the public.

Robert

New Jersey


Thank you. you were more detailed than what others have told me they finally called from the last xrays and my son is now in a cast for 2 weeks he did have a fracture that was not noticeable.

a mom

location unknown


I have read your website and I have to admit that I am amazed at all the information that is on here. I have learned more than the three years I have been going to several doctors that I have seen!!

Melody

Lenoir, NC


Thank you so much Doc for a quick and thorough response!

Rustam

Bellevue, WA


I cannot thank you enough for your response, opinion, and suggestions! I want you to know how much it means to me, and I'm sure everyone else who has ever asked you a question! I feel like you're a lifesaver and have empowered me to take a stronger role and stand up for myself and my feet!

Jodi

location unknown