Peroneal Tendonitis in Runners

Peroneal tendonitis is not exactly a very common running injury, but it is something I did not use to like seeing as the management always seemed to be difficult; but now I don’t mind as we have learnt more about it and it is really not that difficult to manage. There is also not much, if any, specific research, to guide the understanding of it, except what I have done (and unfortunately not published yet!).

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The two peroneal muscles on the outside of the leg have a number of functions. The tendonitis of them usually starts of as an ache just above and/or below the lateral malleolus that gets progressively worse with activity. There may be some swelling.

What Causes Peroneal Tendonitis?
As with any overuse injury the cause is the cumulative load in the tissue is beyond what the tissue can take. This means that there are either/or a combination of activity levels (intensity and/or duration) and/or biomechanical factors that increase the load in the tendons. One of those on their own may not be enough to predispose to the problem, but a combination of both may be enough. To determine the biomechanical factors that may be predisposing them, the thought process to inform the clinical decision making is to consider the function of the muscles that attach to the tendons, specifically in the terms of what joint moments they provide and if there is anything in the biomechanics and gait that is increasing those joint moments (and also importantly, what can be done to reduce those joint moments as part of the management). The peroneal muscles also provide other moments at more distal joints, but will stay away from that to keep it simpler to understand for now.

What biomechanical factors can increase the load in the peroneal tendons? As these tendons provide a plantarflexion moment at the ankle joint (they pass posteriorly to the ankle joint axis), midfoot or forefoot striking is going to increase the load more than heel striking would when running. They also provide an eversion moment at the subtalar joint axis (they pass laterally to the subtalar joint axis), so anything that increases the eversion moment is going to increase the activity of the peroneal muscles and hence the load going through the tendon(s).

The research we did on this was to use the device to measure the force to supinate the foot. I recruited 13 cases of obvious peroneal tendonitis, which took 2 years to find (which indicates just how uncommon this is). The force to supinate these people using our device was a mean of 91 Newtons; whereas the reference group was 138 Newtons. This means that the foot was really easy to supinate in those with peroneal tendonitis, which means that the peroneal muscles are going to be very active trying to counter that. Combine this increased muscle activity with a higher sports activity levels, then this is probably putting the tendon at risk for injury.

What does this mean for the management?
As with any overuse injury the approach is 3-fold:

1. Reduce the load in the damaged tissues: You do this in three ways: One is to reduce the level of activity (intensity and duration) to sensible levels until improved and then extremely slowly progressively increase back up to previous levels of activity. Two is to reduce the joint moments that the muscles provide via the tendons. From the above discussion, we need to reduce the plantarflexion and eversion moments at the rearfoot – you do that by heel striking, (if currently a midfoot or forefoot striker) to reduce the plantarflexion moment and add a lateral wedge under the heel or whole foot to reduce the eversion moment (which you also need to be heel striking for the wedge to work). Minimalism and midfoot or forefoot striking probably increase the risk for peroneal tendonitis (they decrease the risk for other injuries). As to if the heel striking and the lateral wedge are medium to long term interventions will depend on the magnitude of the force that is causing the high joint moments and if the tissues can be adapted to that load (see 2, below). Three is to possibly the use strapping to hold the foot in a more everted position as a very short term measure, but I remained unconvinced it is very effective.

2. Increase the ability of the tissues to take the load: Like with any tendinopthy this is the slow progressive adaption to increasing loads and eccentric muscle activity.  Often this is plantarflexion and eversion against resistance. The exact nature of the intervention will depend on the staging of the tendinopathy. This is more of a medium to long term intervention compared to (1) which is more of a short to medium term intervention.

3. Help the tissues heal: I won’t say much here, but this is the usual array of interventions of varying effectiveness that are more aimed at helping the damaged tissues heal rather than reduce the load and increase the ability of the tissues to take the load. This includes things like ICE, NSAID’s, massage, electrotherapeutic modalities etc. In more sever long standing cases, surgical debridement or repair of the damaged tissues may be needed.

What about the strengthening exercises you often see mentioned for this? I am not convinced as I do not see how increasing the strength of the peroneal muscles will help reduce the load or increase the ability of the tendon to take load. I can see how eccentric activity of the muscles will probably help the tendon adapt to the loads, but that is not really dependent on just how strong the muscles are. I actually think that the peroneal muscles in those with peroneal tendonitis are actually quite strong! Paradoxically, if you do inversion and eversion muscle strength testing in those with it, the eversion strength generally feels quite weak; ie the peroneals appear weaker, but are they? We previously showed that about of the third of the variability in the force to supinate the foot is explained by variations in the transverse plane orientation of the clinically palpated putative subtalar joint axis. This means when the force to supinate the foot is low (as it is in those with peroneal tendonitis), the subtalar joint axis is orientated more laterally. This means the peroneal tendons have a relatively short lever arm to the joint axis to evert the foot, so are they really weak or do they just appear weaker due to the short lever arm that they have? It could be that because of that short lever arm the muscle is very strong as it has to work so hard to overcome the short lever arm and the low force needed to supinate the foot (and hence the tendonitis).

I mentioned at the start that I used to not like seeing this condition as it never seemed to respond very well to treatment. In our unpublished study I mentioned above, we also looked at the Foot Posture Index (FPI-8) as a measure of foot alignment; the mean in those with peroneal tendonitis was 5.6; 0-4 is generally considered normal and anything above 4 is pronated (above 10 is pronated a lot); so on average those with peroneal tendonitis have a slightly pronated foot and we all know that overpronation was evil and had to be eliminated at all costs, so what did I use to do to treat it? … when in reality, I needed to be doing the opposite and pronate the foot more. This is a perfect example of thinking more about forces and joint moments and reducing the load in the damaged tissue versus thinking about foot posture and foot alignment and trying to move that to a hypothetical normal. Now I like seeing it, as thinking that way makes it easier to treat.

As always, I go where the evidence takes me until convinced otherwise.

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About Craig Payne

University lecturer, runner, cynic, researcher, skeptic, forum admin, woo basher, clinician, rabble-rouser, blogger, dad. Follow me on Twitter, Facebook and Google+

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48 Responses to Peroneal Tendonitis in Runners

  1. Drew May 2, 2013 at 4:32 am #

    If I understand you correctly you are suggesting a heel strike to lessen the chance of perioneal tendinitis. Sorry the opposite has been the truth in my case. I suffered from pt and when I changed to forefoot strike it went away. Correct form and no interference with foot biomechanics sorted my ITB and runners knee out as well. The less we interfere the better the body works. Basic law of nature we tend to forget and think we are cleverer than millions of years of evolution.
    Regards

  2. Craig May 7, 2013 at 4:37 pm #

    Sorry its taken so long to approve your comment. I had to think long and hard if to or not. It is the sort of anecdotal clichéd comment that really does not contribute much and litters the comments section of so many other blogs reducing the value of them. It never ceases to amaze me the strong clinical opinions held by those with no clinical experience. I still working on developing a comments policy, but at the same time do not want to be accused of censorship and discourage comments from those worth engaging with and those that add value to the topic.

    Anecdotes are not data. This is a research based blog.

    You say: “I suffered from pt and when I changed to forefoot strike it went away.” That is an anecdote. How do you know it had anything to do with transitioning to forefoot striking? How do you know that it did not come right for another reason? How do you know that it was not ready to come right anyway as part of the natural history? You don’t, that is why we rely on research and scientific evidence; and in the absence of that: theoretical coherence, biological plausibility and consistency with the available evidence. See: Why ineffective treatments sometimes work.

    You are suggesting that clinicians should be treating peroneal tendonitis by getting people to forefoot strike based on your anecdote and lack of clinical experience. What do you say to:
    * 4 of the last 5 cases I have treated of peroneal tendonitis were in forefoot strikers. I had to transition all 4 back to heel striking to fix them. Given the >90% of runners heel strike; surely alarms bells should be going off if 80% of the peroneal tendinitis I seen recently was in forefoot strikers!
    * My motivation for this article was my email dialogue with a minimalist running who had just had surgery for peroneal tendonitis as it got so bad.
    * I have had 11 emails from runners since writing to the above and almost all of them were forefoot strikers or minimalist runners (and if any if them read this; sorry, I not properly following up, but there is only so much I can do in a day!).

    You also say: “The less we interfere the better the body works. Basic law of nature we tend to forget and think we are cleverer than millions of years of evolution.” I could ask you what evidence you have to support that, but I won’t as I know you have none. It is just a cliché and rhetoric. I should run a competition to see how many logical and rational fallacies can be found in that comment. I count the ‘appeal to antiquity’ fallacy; the appeal to nature fallacy; and the wishful thinking fallacy. Can anyone spot any others?

    As always, I go where the evidence takes me and will not fall for the anecdotal fallacy trap nor the rhetoric and propaganda full of logical fallacies from those with no clinical experience who somehow hold strong clinical opinions and just tout a particular party line.

    • mendy December 8, 2013 at 10:46 pm #

      I have been dealing with peroneal issues for a while now. I have always heel striked. It is just what my body wants to do. However, I developed pt while being a heel striker. I have other biomechanical things going on as well so I don’t know if my heel striking is the cause. I have custom made orthotics with a slight wedge. Everyone BUT my podiatrist tells me to change my foot strike. My dr told me that for my foot, heel strike not a bad thing. Everytime I have tried to change to forefoot or midfoot strike Iget issues with other things that is worse than my peroneal problems. I just wish I could get it to go away for good. I am very frustrated. I have a pretty neutral gait but I do supinate a little.So i buy neutral shoes and for the most part they have been great. I can go a good while without having any problem then poof…it comes back. But never as bad as my first injury. Sometimes I wonder if all the recommendations from other runners or running magazines about proper strike is a good thing. Everyone is made different. I have wide foot with high rigid arch. I am going to run differently than someone with a flat overpronating foot. I will also need a different type of shoe. Running is not a one size fits all sport. A midfoot strike may be great for one person but detrimental to another. I also have limited mobility in my ankles and a low degree of dorsiflexion. My physical therapist actually told me that he did not want to get my ankle too loose and mobile because it could cause other problems. He said my foot is my foot and it was just made that way. Other than the peroneal tendon issues, I have no other common running issues. my right hip gets tight but no IT band problems and no knee problems so I consider myself lucky. And like I said before I heel strike. If i change, my knees and back and hips hurt. But someone else may hurt like that if they heel strike. I think people just need to learn about there biomechanics and get good professional advice and work with their body to decide what works for them. If someone is told to strike mid or forefoot and they develope probelms……they should reevaluate. same thing with heel strike. It it works for you great…if not change. So for me keeping a heel strike which is just natural for my wierd shaped foot, even if it causes my peroneal tendoniits (which i still don’t know for sure it does), is better than going to mid strike and have three problems–back , hips, knee. I’ll take one problem over three.

      • mendy December 8, 2013 at 10:59 pm #

        I would also like to add that my original peroneal tendon problem started from an injury to my ankle (not from running). I sprained it on stairs and like an idiot never took proper care because it did not hurt or swell so I thought ok.I twisted it three more times after (all not running) It has never been the same since so I can not really contribute my problems to my heel strike. I heel striked with absolutley NO problems before injury. So i feel my problem is not so much an overuse injury than residual problems from injury. A MRI showed a probable partial split tear in longus and I had tendonitis and synovitis in both tendons. I was but in boot for 7 weeks and it cleared up so dr did not do any kind of surgery. It just wants to pop up now and then. Please…if you twist an ankle….don’t keep running on it. I regret that so much now. It did not hurt but still needed to heal.

  3. James May 29, 2013 at 4:04 pm #

    Thanks for this article. Although I only have personal anecdote (ie n=1), I’ve only experienced peroneal tendonitis since trying to transition from heel striking to mid/forefoot striking with more minimalist shoes. I’ve had relatively mild cases bilaterally (and twice on the right) despite transitioning slowly, and using so-called transition shoes.

    In the acute setting the pain was only bad when landing on the forefoot. In fact, in each case I was able to go back to heel striking fairly quickly without aggravating the injury (despite still having some discomfort when landing on the forefoot).

    I’ve since given up on trying to make the transition, and after reading this I’m happy it’s the right decision.

  4. Craig Payne May 29, 2013 at 10:47 pm #

    Thanks for the comment. I have also had a few emails.

    To make it clear: The peroneal tendons pass behind the ankle joint axis, so when you forefoot strike, the peroneal muscles work harder. Forefoot striking increases the load in the peroneal tendons. If someone has peroneal tendinitis and transitions to forefoot striking and get better, then they got better for reasons other than transitioning to forefoot striking or minimalism.

    Also, just because you have peroneal tendonitis or a history of it does not mean that you should or should not transition to forefoot striking or minimalism for other reasons – its just means that it is going to be more difficult and need to be done more progressively over a longer period of time to allow the tissues to adapt (that is assuming that is what you want to do)

  5. Rachael June 2, 2013 at 12:51 am #

    I am currently suffering from peronoeal tendonitis. It started 6 months ago (!!), and I can relate it to a change in running shoes – from a light trainer (Asics Gel-DS Trainer) to a totally minimalist running shoe / racing flat (some flashy New Balance runner). I normally don’t change runners, but for some odd reason, my city didn’t get a good stock of Asics, and I ended up trying to find something to hold me over. This turned out to be a bad idea. So, add another n=1 to the minimalism being an issue.

    I am generally a relatively “flat footed runner” and compete in track and field, so am coached to run with a mid foot strike. I am seeking physio (muscular-skeletal specialist), icing, lasering and am very frustrated that I have this injury.

    Curious what the verdict is on throwing orthotics into the mix. I have orthotics that, quite frankly, I don’t like using. Too bulky and my feet feel way to heavy. However, if using them would sort out the tendonitis, I would do it. I played around a little with wearing them and I can’t tell if they help or not. Thoughts on orthotics?

    • Craig Payne June 2, 2013 at 1:57 am #

      Thanks for commenting. Re the orthotics, I really can’t see how foot orthotics really can help peroneal tendonitis. A lot may depend on what they were made for in the first place. I would not stop using them immediately (or another problem might start), but slowly start weaning yourself off them to see what happens.

  6. Grace June 4, 2013 at 8:44 pm #

    Hi there, hoping you can help me.

    I have been having foot pain underneath my foot on the lateral side around and just in front of the tuberosity of the 5th metartarsal. It came on in a run last Sunday, went away for a couple of days and returned on Friday and is sore to walk on so haven’t run since then. Feels kind of like a bruise in the fleshy pad bit of the foot, pain isn’t localized and doesn’t hurt to hop or push on the bone so don’t think its a stress fracture.
    Dr google suggests Peroneal tendinitis and I came upon your post. but my pain goes slightly higher up from where the tendon connects.
    I was a forefoot striker but have been working to change to a midfoot strike around 3 months ago to reduce strain on my ITB on the other leg which I have had problems with.
    I can reduce the pain by cutting out a portion of my insole where the pain is but wasn’t sure if this is a good idea…
    I run in the asics 1000 and saucony guide. I have a history of metatarsalalgia in the same foot,
    do these symptoms fit? and can I start running again?

    Thanks

    • Craig Payne June 4, 2013 at 9:35 pm #

      Its really hard to give any advice online without seeing the problem and knowing more. You obviously have a complex range of problems. Based on what you have said, I would not jump to the conclusion that it is peroneal tendonitis; it could be a condition known as ‘cuboid syndrome’.

    • 359Mile July 12, 2013 at 2:04 am #

      I would stay away from Saucony or Asics if you have a history with PERONEAL TENDON problems. Those brands make shoes way too soft for a runner looking for a firmer shoe. If you’re a heel striker a soft plush shoe like Saucony and Asics would work great, but not if you’re a midfoot striker. I would try Mizuno if i was you.

  7. Franco July 3, 2013 at 9:06 pm #

    Hello Craig
    Thanks for your article.
    I have had knee surgery some years ago. Then, as my knee started feeling sore after my runs I swapped to minimalism like many others. The forums were very convincing about it. So I went all the way and dumped my shoes. I settled gradually into barefoot running and upped my weekly distance up to 30 – 35km in about a year’s time. Although I enjoy(ed) many aspects of barefoot running, asphalt kept feeling to hard even after a year. I tried lifting up my toes before touching the ground, forcing the foot in a more suppinated position and so getting the most of the arch of my rather flat foot, to soften the impact. That was the first time I felt the pt. I continued thinking that my lack of arch was responsible for this pain. I tried to train it with the “pen and penny” exercise (see YouTube) but the pt symptoms multiplied immediately. I also tried with 1footed equilibrium exercises to strengthen my foot, with the pt worsening again. I went back to heel striking with heavy shoes and the pt kind of stayed stable, but my knee did not.
    Now I’m biking whilst thinking of a way to get back to running, which is really what I wanna do.
    Franco

    • Craig Payne July 3, 2013 at 9:52 pm #

      Thanks Franco; its a typical story that we hear so often. You can change the way you run to off-load one tissue (in your case the knee), but the cost of that is other tissues are loaded more, which may or may not result in an injury in that tissue (in your case, the peroneal tendons).

      All I can suggest you do, is keep up with the shoes and heel striking if the knee can tolerate it to get the peroneal tendons better; then incredibly slow transition again to forefoot striking (+/- barefoot) to help the knee – but you have to do it as such a slow transition to allow the peroneal tendons to progressively adapt to the loads.

      • HendrikMDik July 4, 2014 at 6:45 am #

        Ramping up my training too quickly last year, along with an overpronating forefoot strike gave me medial shin splints that didn’t seem to want to go away. I switched to a heel strike as well as deliberately everting my feet (in an attempt to have a more even foot movement). This seemed to have cured my shin splints, that I now feel only when I do more intense speed work or longer runs and I get tired (then my form slips and I have some medial pain afterwards).
        A couple of weeks ago I went for a run a few days after a particularly hard speed session, it was raining, i had a cold, and I was obviously distracted. I didn’t notice a loose shoelace until I’d done a few miles in a lose shoe. I noticed the onset of what I have since self-diagnosed as PT at the same time that I noticed the loose lace, I tied it, but noticed before getting home from the 10 mile that the shoe was still very loose when I got home. My gut feeling from the run, was that the pain was caused by the tendon trying to compensate for the additional roll of the unsupported foot (exacerbated by my efforts to evert the foot to avoid my historical medial shin splints).

        I notice when paying attention to the natural movement of each of my feet, that my left foot tracks in a fairly straight line, the medial shin splints are not present in that foot to as great a degree. My right foot moves a lot more and is tricky to get it to follow a nice balanced line.

        Reading through the article above, it seems that the logical approach to avoid repeat of medial splints and now the PT would be to maintain my heel strike, maybe to consider a different type of shoe, one that provides more lateral support to resist rolling, and to continue focussing on developing a linear movement to each of my feet?

        I know its hard to assess with limited information, but any suggestions that may help would be appreciated.

  8. Richard Bailey July 29, 2013 at 4:10 pm #

    An interesting and useful article. I only wish I understood the biomechanics a bit better. If I grasp what you are saying here, it may be beneficial to place the foot into a more pronated position (such as with the lateral wedge) in order to reduce pronatory (?) moment on the peroneal tendons? I am treating a runner who recently developed PT immediately after changing from a neutral trainer to a stability shoe. Has this new shoe type some how increased the pronatory load – therefore overloading the PT’s ?

    • Craig Payne July 29, 2013 at 7:07 pm #

      Theoretically if they went from a neutral shoe to a stability shoe, then this could increase the load in the peroneal tendons by increasing the supinatory moment.

  9. Franco August 2, 2013 at 11:38 am #

    Thanks for your article.
    I’m experiencing peroneal tendonitis since about 3 weeks. Mostly I’m a trail runner using transition shoes (Brooks – Puregrit) since 7-8 months with no problems (300-400 KM/month). I had trouble more recently using New Balance MT110 and above all with MT10 and I ended with the tendonitis (these shoes have less forefoot protection compared to puregrit).
    Well, after several tries I understood that the best solution was to use shoes with higher drop such as Cascadia 7 (8 mm) or Mizuno Enigma (12 mm, for running on the field). This allows me to run 10-14 KM per day with basically no pain. Using ice after the runs (echography shows that the tendons are still inflamed).
    Running with a 4 mm drop shoes (whatever model) allowed me to run 2-3 KMs and I ended with painful tendons.
    Still trying to run with midfoot strike.
    I found your article quite helpful to have a better comprehension of the problem.
    Hope my experience can be helpful.

    • Craig Payne August 2, 2013 at 9:18 pm #

      Thanks Franco; what you are describing is consistent with the point I keep making about reducing the load on the injured tissue! However, if you want to stick to the midfoot and lower drop shoes, it might be a long slow adaptive process for the tissues to adapt to the load once the injury subsides.

  10. sho August 7, 2013 at 3:32 pm #

    This seems to be what I currently am suffering with.

    Two months ago I started running again (after years of dabbling with it on and off). This time I switched from cushioning running shoes to my lightweight trail running shoes (MT101). I also decided to do all runs at a 180 cadence.

    The result is that I have run better than I have ever run in my life. I did not get planar fascia or any shin splints.

    But it look like I have a case of Peroneal Tendonitis. At this point it is just a little irritating. I had a vacation of two weeks with no running and it slowly got better.

    Is it OK just to cut back my running? I was doing four 5-8 mile runs a week. I am thinking of just doing two 5 miles until things get better and supplementing with biking.

    I hate the idea of stopping running when everything was seeming to go real well.

  11. Peter August 12, 2013 at 11:40 pm #

    Interesting information about peroneal tendonitis. I am a regular runner of about 10 years standing. This uncommon running related injury (?) surfaced for the first time about five weeks ago after a six week incubation period during which time I unwittingly performed for the first time forceful dorsiflexion (static heel drops) after regular running sessions, usually about six sessions per week.

    The purpose of holding the heel drop for 60 seconds per foot after running was to stretch the achilles. This worked very well and removed achilles soreness but too much enthusiasm regarding the duration and intensity of the static stretch has produced peroneal problems, confirmed by a physiotherapist and local doctor, and of course Google.

    Initially I stopped running completely for two weeks, an eternity for runner tragics, then significently reduced quantity and intensity. Of course I have discontinued the heel drops. After five weeks the tendonitis has not gone away. Symptoms on one leg have disappeared more or less completely. However the other leg still produces symptoms with a vengeance. Not surprising since the heel drops on this leg were performed about 30 seconds longer than the other. Even brisk walking triggers pain an hour or two after subsequent rest.

    I have noticed that more heel contact during the running that I have ventured to do does provide momentary relief from the sharp peroneal pains that can suddenly appear.

    • Craig Payne August 12, 2013 at 11:44 pm #

      Thanks. The peroneal tendons pass behind the ankle joint axis, so the heel raise drops would be using the peroneal tendons more. More heel contact providing the relief works for the same reason – you not engaging the peroneal tendons as much when you do that.

  12. Matt August 13, 2013 at 1:57 am #

    Is it possible for peroneal tendinitis to show up as pain underneath the foot – a bit behind the spot where the tendon attaches to the 5th metatarsal?

    The timing of the pain (after I’ve been running a few miles and peaking about an hour after I cool off) seems a better fit for tendinitis, but the location is more like lateral plantar fasciitis – definitely on the underside of my foot, in the fleshy area two inches forward from the heel. (Except that it’s on the outer edge only.)

    No diagrams of foot anatomy I have looked at depict any organ in that area; in fact it seems to be the only spot on a foot WITHOUT organs in diagrams. If I were standing barefoot and you tried to wedge a penny under my foot from the lateral side, found the softest spot, and was able to get the penny about 3/4 of the way in, that’s where it is.

    • Craig Payne August 13, 2013 at 2:00 am #

      The peroneus brevis tendon inserts into the base of the fifth metatarsal, so there can be an insertional enthesopathy there or a tendenopathy back a bit where you are describing.

      HOWEVER, there are some other things in that area that can cause symptoms (eg cuboid syndrome)

  13. Bob Budding August 15, 2013 at 2:36 pm #

    I first noticed pain on the outside of my foot forward of my ankle when I walked a great deal wearing Birkenstocks. I ended up dumping the Birkenstocks and went to a shoe that has less arch support. hings improved, but the problem still persists. I’m now wearing a Vivobearfoot shoe, which likely has helped because I now pronate even more. I finally saw a podiatrist today – he diagnosed peroneal tendonitis and sugested NSAIDS and a foot brace.

    This problem has been going on for a full year. Hopefully I can heal and move on.

  14. carol Wright August 15, 2013 at 3:06 pm #

    I have been diagnosed with peroneal tendonitis about two years ago. I have a lot of tightness in the fascia of my foot (arch area). I also have pain around the fourth toe where the toe pulls up. I wear orthotics but they have not helped. I have resorted to wearing an ankle brace to keep the pain from the tendonitis to a minimum.

    • Craig Payne August 15, 2013 at 7:12 pm #

      If the orthotics have “anti-pronation” design features, then they will be increasing the load in the peroneal tendon.

    • carol Wright January 29, 2014 at 6:52 pm #

      found out I not only have peroneal tendonitis but also a plantar plate tear in 4th metarsal. Maybe one is the result of the other? I have not run for almost a year. I had PRP/Fat Graph injections 2 weeks ago. Still have minor pain in foot but much better. Swimming and biking (recumbent) are my only forms of exercise.

  15. Becky Johnson August 22, 2013 at 10:55 pm #

    Thank you for doing this research. I began running last year and decided a minimal shoe with mid-foot strike was the way to o to prevent injury. I now have pt. I have been sidelined for 5 weeks now. It’s aggravating. I started easing back into running this week and already feel a return of the irritation. I am going to get new shoes and build up more slowly. I was considering going *more* minimalist, so I am happy to find this!

  16. Martha September 1, 2013 at 1:00 pm #

    This is very interesting article. 15 months ago, I developed symptoms of Achilles tendonitis. As that gradually decreased, I developed bilateral PF. During this time, I tried to resume running but constantly had a nagging ache in my lateral calf and distal fibula area. To your point, I always feel like my foot is trying to supinate, maybe to avoid that uncomfortable PF spot? Anyway, I have tried orthotics, which significantly help heel pain but lateral calf and peroneal sx persist. I saw a sports med dr who dx’d tear in my peroneal and gastroc. Had PRP 4 mos ago. Have been in PT since last October for all this. I have MRI’d just about everything. I periodically have worn cam walker or another brace which decreases sx but can’t seem to progress to being able to run again, especially since I have symptoms w normal walking . Fixing one thing leads to issues w others. I feel like I’m never going to be able to run again, so I should just accept a certain level of discomfort as my new normal.
    But I appreciate the education and keep hoping for relief!

  17. Steve C September 5, 2013 at 4:40 pm #

    Wonderful post, thank you! I was diagnosed with Peroneal Tendonitis just this morning. I am a forefoot/midfoot striker, but never had any issues…UNTIL…until I gave some minimalist shoes a try. Within 1 mile of commencing my run, I felt pain. 5 days later (yes, I ran each day, albeit in different shoes) I went to the Podiatrist. Peroneal tendonitis.
    Although sample sizes of 1 do not make for good statistics, I think my case supports what I read in your post. I generally ran in more racing style shoes (e.g. Mizuno Ronin’s) but shoes that were traditional in their drop and cushioning. The minimalist shoes were 3mm drop and very firm.
    Peroneal tendonitis is NOT fun. The word ‘ouch’ comes to mind. And, I have a marathon in 17 days.
    As mentioned, thank you for this post, and I will research this some more.

  18. Jez September 10, 2013 at 6:36 pm #

    Hi Craig,
    I have been having this issue for about 10 days now, I really don’t want to stop running (about 3 miles, 5 times a week). I just started running about 1 month ago.

    I purchased used nike shoes on ebay to save money…

    My question is this: I’ve read the information and comments but I am not a shoe guru or super familiar with most of this. Can you please spell it out for me… what should I do?
    New shoes? What kind?
    Decrease distance of running temporarily?

    Oh, I had knee pain that went away right before this started.
    And I have had pain in the ball of my foot right in line with my big toe in the past….i find myself trying to overcompensate for that because i don’t want to allow my foot to lean inward and forward for fear of re-injuring that part of my foot.

    Please help!!! I don’t want to stop my activities.

    Thank you for this article.

  19. Jez September 10, 2013 at 6:41 pm #

    I forgot to mention that this didn’t come on right after running, it came on after driving for 3 hours – its in my driving foot….

  20. Krista November 11, 2013 at 8:21 pm #

    I began suffering from peroneal tendonitis a year ago while training for my first half-marathon. At the time, I was running in New Balance Minimus Zeros. For about two years before the half-marathon training, I had been exercising 5-6 times/week in the Zeros or Five-Fingers (running up to 3 miles), so I felt comfortable working up to the half-marathon distance in the Zeros – until the tendonitis hit. At the time, I managed to complete the half but it was incredibly painful.

    After my race I purchased a pair of Saucony Virratas, neutral shoes with a 0-mm drop but much more cushioning than the Zeros. I returned to my pre-race training schedule of 5-6 workouts/week, only one of which was running and 3 miles or less.

    I now have another half-marathon goal ahead of me. I recently went out for a 5-mile run in the Virratas and that familiar peroneal tendon pain is starting back. I’m surprised, because I’ve been in these shoes for the better part of a year with no pain, plus I’ve laid off serious running for that same time period. It’s now that I’m ramping up the distance that the pain has returned.

    What suggestion do you have for my next running shoe purchase? Should I try for a shoe with a higher drop? Should I stick with a neutral shoe? I’ve been assessed to slightly overpronate, but I’m wondering if I should target a shoe that corrects supination instead?

    • Craig Payne November 12, 2013 at 1:34 am #

      Go for a shoe with a drop and get a lateral wedge in it; and SLOWLY increase the load in the tendon.

  21. Rich November 18, 2013 at 2:51 pm #

    Hi,

    I was in the process of training for my first marathon when I’ve managed to come down with this issue. Looking back, I feel like I had some pain in my feet (likely the onset of plantar fascitis) which caused me to adopt more of a mid-foot strike and hence now I have issues with my paroneal tendon.

    I’ve since taken off from running for about 4+ weeks now but still doing cross training (mostly elliptical and biking) and while my pain has certainly gotten better and is now mostly down to a low level soreness I feel from time to time it still doesn’t feel normal. I’ve been wearing an ankle brace about 3/4 of the time to alleviate the load on the tendon but I’m curious about time frames related to this injury and if I’m better of taking complete rest (e.g. avoiding the elliptical and bike) until I’m symptom free.

    Also, is it necessary or preferred for me to wait until I’m completely symptom free before resuming running again or can some light running possibly help recovery? I’m anxious to start running again but I rather suffer through a longer period of not running if that really helps my chances of avoiding a re-occurrence.

    Any insight would be appreciated

  22. Steve C April 19, 2014 at 9:19 pm #

    Craig – Ran across this article in a bit of desperation. Hoping you might have a thought. Here are the facts:
    * 44 Years old, normal height (6′) and weight (175).
    * I eat healthy food and in good health, although I did develop tendonosis in my shoulder about 2 months prior to the ankle tendonosis — I’m still recovering from the shoulder after two cortisone shots in the shoulder under the care of an orthopedic surgeon (but the shoulder is nothing right now, compared to the ankle).
    * Began running for the first time in 20 years in March 2013. (Was in generally good shape due to regular weight training and exercise bike.) Ran almost entirely at local Division I college track (i.e. good surface, no roads) and treadmill.
    * I had previously been told I had flat feet and slight/moderate pronation
    * I was wearing cross-training Nike shoes designed for moderate motion control
    * Was running about 10 miles per week. Had gotten a mile down to about 6.5-7.5 minutes depending on the day and was running sprints.
    * Felt great.
    * Developed pain in my right peroneal tendons in July 2013. (Writing this in April 2014.)
    * Switched shoes to Saucony guide 6 to try to help.
    * Kept getting worse. I kept running (I know I know).
    * Pain become constant even while walking in dress shoes, etc.
    * Saw orthopedic ankle surgeon December 2013.
    * MRI showed little if anything but the “slice” didn’t catch the painful part of the tendons well.
    * Doctor recommended boot (2 weeks) followed by ankle brace (2 weeks) followed by PT (modalities, massage, stretching) & custom made orthodics.
    * After 7 weeks, the boot had messed up my knee a little, and the ankle was actually worse.
    * Doctor (who is a renowned athletic ankle orthopod) told me to stop PT (it had actually made it worse), to continue to wear orthodics and to get an MRI — if MRI showed tendonosis, he would give me a cortisone injection.
    * Got MRI, MRI shows tendonosis (thickening of the both the long and short peroneal tendons too, not sure if that’s the same thing). Had a little trouble getting in to see the doctor right away, and the ankle improved a little, so I’ve waited a bit to make the appointment get the injection.
    * Current status is the ankle still hurts – I can only wear the athletic shoes with the orthodics for any length of time. I feel better (slightly) in the orthodics but only if I wear them with athletic shoes (if I try to use them in dress shoes, awful result).
    * The ankle has stopped getting better, no more progression.
    * I’m planning on making an appointment to get the cortisone shot.

    Here’s my question: What’s the right thing to do (besides the shot) with respect to buying shoes? Althletic shoes? Should they be motion control? Not? Stiff? Soft? What about dress shoes? Any brands?? Are the orthodics helpful? Harmful? How do I tell? Even the doctor/person who made the orthodics warned me that sometimes people who wear them find that they IRRITATE the peroneal tendon, not make it better. I recognize this is an art more than a science but I sort of wish there was more science involved here.

    Long story short – Persistent peroneal tendonosis that lights up MRI, would love to just be able to walk without pain (not to mention run!), and really have no idea what to do.

    Any advice greatly appreciated. Thanks!

  23. Lance September 4, 2014 at 11:33 pm #

    Dear Dr. Payne, I’ve been running cross country for two years and am joining for my third year as a senior. I was diagnosed with low arches after seeing my sports medicine doctor for my first case of shin splints on my first year of cross country as a sophmore. I continued to run the whole year even though I was wearing stability shoes of approximately 12mm drop and had severe shin splints. Somewhere around the spring season, when I was on the sprinting team, I was given very rigid orthotics(non-cork and leather) and wore them in combination with my stability shoes to counteract my shin splints. They didn’t seem to work either. On the summer from sophmore to junior year, I stopped wearing orthotics but still wore my stability shoes and changed my form to that of a minimalist runner, trying to land on my midfood each step. I then developed what I believe to be PT in september of my junior year and ran with it during the fall season and winter season. I took a running break all spring and resumed a light running schedule in my junior to senior summer. Fall cross country is right around the corner as I will be returning to school the next week and I still feel pain in my peroneals. I currently wear the doctor scholl’s 210 custom orthotics for low arches, as prescribed by the machine. Since reading your article in the past ten minutes, I would like to know if you think I should return to heel striking, and any additional advice would be largely welcome.

    • Craig Payne September 4, 2014 at 11:39 pm #

      Of course. The first step is to reduce the load in the tissue that is hurt: heel strike and lateral wedging; after the pain is reduced, you can go back to midfoot/forefoot and do away with the lateral wedges/orthotics, PROVIDING that there is an incredibly slow transition to allow the tendon to adapt to the increased loads that get applied to the tendon when forefoot/midfoot striking.

  24. Dan R September 11, 2014 at 6:13 am #

    I developed self-diagnosed PT after just one 6 mile run in 3mm drop minimalist shoes. I have never to my knowledge suffered any PT issues. I use to play competitive basketball and have a history of ankle and foot sprains, some pretty severe, but was always able to run pretty far without pain or discomfort in my feet. I was running in the 10 to 20 mile range (mostly trails) without discomfort until my experiment with a friend’s minimalist trail shoes. Yes, this is antecdotal, but it seems consistent with what I’m reading here. Its been 6 weeks and I still can’t run at my previous level without discomfort. I also have done a poor job of resting. Its good to see some similar stories here. I have been trying to transition to mid to forefoot striking…I’m naturally a heel striker but I keep hearing the switching can help reduce other running injuries over the long term. I’m wondering whether that is also merely anectdotal or if there is evidence to support the transition away from heel striking in long-distance trail runners specifically??

    • Craig Payne September 11, 2014 at 6:27 am #

      Dan – changing the way you run will help one set of injuries and increase the risk for another set – that is what teh evidence is saying. Changing to a forefoot strike increases the risk of peroneal tendonitis…. as you found out.

  25. Kevin A. Kirby, DPM September 11, 2014 at 5:01 pm #

    I did a free-screening clinic at the largest running shoe store in Sacramento last night. My first “patient” was a 30-something year-old female runner who was complaining of plantar forefoot pain and lateral ankle pain.

    What was my first question to her?

    Did you recently change footstrike pattern or running form?

    The runner said, “Yes, how did you know? Just before I started getting this forefoot pain and lateral ankle pain I was told by my running coach that since I was a heel-striker I was running wrong and now am a midfoot-forefoot striker. My forefoot and ankle pain began about 2-3 weeks before I changed my running form and now I can’t run at all!”

    I told her that was starting to develop swelling and inflammation plantar to the second and third metatarsophalangeal joints and already had a pretty bad peroneal tendinitis on both ankles as a result of her switching from the heel-striking pattern which she had always run with for years before she met up with this “expert on running form” that was now coaching her. I told her to go back to her own natural heel-striking running form, start icing and take at least a week away from running.

    With a smile, I also told her to tell her running coach to be sure that he knows that I appreciated all the runners he was injuring for me by telling them they were “running incorrectly” since it was helping to boost my sports podiatry practice greatly. We both laughed and she was grateful that her injuries have a logical explanation to them.

    When will these “self-proclaimed experts” on running form quit injuring innocent runners who are natural heel-striking runners? It only seems to be getting worse and the BS that these “coaches” are teaching runners is only hurting them, not helping them. When will this nonsense stop?!

  26. dingle September 11, 2014 at 6:39 pm #

    Quote “My forefoot and ankle pain began about 2-3 weeks before I changed my running form and now I can’t run at all”…… So she was using her ‘natural’ heel strike when she got injured
    Got to love some anecdotes that stroke your own ego and add a dash of confirmation bias.

    Yes when the BS stop?

    • Craig Payne September 11, 2014 at 7:03 pm #

      So they got an injury and the coach changed their running technique to one that increased the load on the tissue that had the injury. How dumb is that?

  27. dingle September 11, 2014 at 7:38 pm #

    And then someone suggested they rest for a bit then carry on doing what they did previously. And all this without any idea of how they are running or distance or etc etc . The experts mind was already mind was already made up upon first meeting. Same old stuff from the same of voices.

  28. Kevin A. Kirby, DPM September 12, 2014 at 3:59 am #

    I just hope that these “self-proclaimed experts” on running form who think that everyone running with a heel-strike pattern is running “incorrectly” and continue to preach how midfoot and forefoot strike running is more efficient, produces fewer injuries and is done by all the better runners (none of which are true) keep up the good work they are doing at supporting my sports podiatry practice by injuring so many runners. I still have a few more years to pay off my mortgage and I appreciate all their help with all the injuries they are creating in the runners they are preaching to! ;-)

  29. dingle September 12, 2014 at 1:18 pm #

    What a cynical attitude from a so called health care professional. I think that must be the first time I’ve come across someone glad people are injured for their own personal gain.

    Intrigued by your claim that all the better runners don’t FFS. Define ‘better’ and then provide some evidence.

  30. Kevin A. Kirby, DPM September 12, 2014 at 3:33 pm #

    It was a joke, Dingle. Relax…and loosen up your panties. Didn’t you see my winky face at the end of the posting.

    More seriously, as someone who cares deeply about my patients and their well-being, in addition to caring deeply about athletes in general and their injuries (since I was a competitive distance runner for over 30 years with a 2:28 marathon best), it upsets me greatly when I see runners becoming injured after listening to the suggestions of others that their heel-strike running pattern is abnormal, inefficient and causes injury. Craig Payne and I share the common goal of educating runners as to what the scientific research says about running biomechanics, running shoes and running injuries, and cutting through the propaganda that has been so commonly been spewed out by the barefoot/minimalist shoe/anti-rearfoot striking crowd, like yourself, that is much better at making up things that they believe is true, than interpreting scientific research.

    Now, how about it, Dingle, who ever you are. Let me guess, you are a barefoot/minimalist runner that fell in love with Chris McDougall after you read “Born to Run” and you now go on as many internet sites as you can to criticize anyone that is blaspheming your barefoot/minimalist shoe/anti-rearfoot striking religion.

    Dingle, who ever you are, you are so quick to criticize, but have you ever written anything here on Craig’s blog that is evidence based or that you have support for in the scientific literature? No.

    Do you have any evidence to offer that supports your views or any positive advice to ever offer? No.

    Dingle, your purpose here on Craig’s blog seems to be as a Troll…to come here every now and then, say a few meaningless things, and basically be a useless disturbance here on Craig’s excellent blog on running research.

    Why not surprise us on your next posting here on Craig’s blog and actually make a comment that is supported by scientific research which will hopefully allow you to come out from under the shadows of opinion and supposition and into the light of evidence based research evidence.

  31. dingle September 12, 2014 at 4:19 pm #

    Nope. Read born to run but as interesting as it was to read it didn’t make me want to ditch my shoes. I run in whatever I feel like, (oh quick I might miss the bus, better slip my orthotics into my dress shoes before I run for it). Im not adverse to a bit of heel striking despite you making the claim I am. As usual you jump to conclusions and fawn at the alter of Payne.

    Perhaps you could answer the question I asked before asking me a multitude of them. That’s if you don’t mind me being a nuisance on such an informative blog. You can even add an anecdote if you like.