Updated: Aug 22, 2022
"Why does this part above my ankle hurt? It's so hard to describe! It's almost into my foot, but not quite…
I've tried a couple rest days. I finally took an entire week off.
I'm really hoping I can run pain free today...but…I'm scared. What if it's still there? What if I have to take even more time off? I've been doing these exercises off the internet every day; why don't I feel any improvement?"
Is this your story, runner?
That sneaky dread in the pit of your stomach thinking, "it might not work; it could! But what if.."
I see you, runner.
I hear you.
And I've treated exactly this in the clinic.
So who's the culprit of the mysterious side ankle pain that may feel like shin splints but not quite?
What's causing your symptoms that seem to move around, traveling up maybe to your knee, then back down to the ankle, then into the foot?
You're not crazy.
It's just peroneal tendonitis. (I know, what a mouthful).
Meet Your Peroneals
These are the twins to blame: peroneus longus and peroneus brevis.
Are the pieces starting to fall into place?
In that first image, did you notice how the tendons of these long muscle actually plug into the bottom of your foot? (sneaky, right?)
And then in the second image showing "area of pain", do you sometimes get symptoms there? But then you also get symptoms up a little higher?
I've seen both, and it was the symptoms higher up near the knee that got me scratching my head (yup, even physical therapists get stumped sometimes haha).
But what makes peroneal tendonitis so tricky?
It sometimes happens at the same time as shin splints or medial tibial stress syndrome (MTSS), but typically MTSS pain is located on the inside of your ankle and on the front of the shin. (hence the confusion. Want to learn more about shin splints? Click HERE!)
Peroneal tendinopathy happens on the outside or lateral portion of your ankle, getting its name "outside shin splints".
And like MTSS, it's still an overuse injury and because it happens fairly often with long distance runners (YOU!), it can get misdiagnosed, or at least misunderstood.
How to Tell if YOU Have Peroneal Tendonitis?
Let's do a few quick tests and answer a couple questions, following the exact steps I would use in the clinic:
Point your toes downward and scoop your foot outward.
Does that cause your pain or symptoms?
If you push on the outer border of your foot and resist.
(don't let your foot move!) Does this cause your symptoms?
Do you notice that hills bother you more than flat running routes?
Do you notice symptoms with push off, meaning when you roll off your toes while running?
If you answered YES to any of these and/or experienced your symptoms, then it's a good chance your peroneals are asking for some love and attention.
Now that you've done your tests and you know what's going on, let's take a second.
How do you feel?
Relieved to have answers?
Validated to know you're not crazy?
Or maybe more confident now that you have solid, objective tests that you can use in the future?
Because there are answers and solutions to what you're feeling. And now, you're in control.
Spilling the Tea…
With that foundation laid, it's time we spill the tea.
We need to talk about the elephant in the room.
We need to address some exercises I've literally seen runners warming up with and I shake my head.
Let me be abundantly clear: there are no "bad" exercises unless it's physically harming or hurting you.
So if you like these, and they work for you, then keep using them! You're getting a sneak-peak into my personal treatment theory. You are completely allowed to love it and take it or leave it and set it on fire…
Peroneal Exercises I've Seen Runners Use and Don't Vibe With*:
Toe walks*/heels walks
(*I actually LOVE these! The toe walks more than the heels walks; so I'm keeping these.)
Inversion/Eversion Walking (walking on the outermost edges of your feet and the innermost edge)
Abduction/Adduction Foot Walking
Walking toed in (also called pigeon walking)
Walking toed out (also called duck walking)
(apologies, I couldn't find videos for these, but I've seen runners doing them…)
Obviously…the majority of these are not my favorites.
If you've been around here long enough, can you start to see why?
Most of these walks don't LOOK like running!
While they *may* strengthen specific muscle group used while running, the exercises themselves do not translate into the movement you need for the sport you know and love so much.
Do we run on the outside edges of our feet?
Or on the inner edges?
Do we runs like ducks or pigeons? (I sure hope not!)
Can you start to see how these walking exercises are the opposite of that beautiful, tall running form we're all chasing after?
But can you see how the tip toe walking *can* look like running, more specifically, sprinting? That's what I'm talking about when I say I want your exercises to look like running and how they need to meet your needs as a runner.
So what do you do then if you're struggling with peroneal issues?
Don't worry, running fit fam, I've got you covered.
Preventing Peroneal Tendonitis
Let's take a look again at these muscles and tendons in question.
These muscle sit between your foot and hip, correct?
And if you've been around here long enough AND taken my Strong Feet Workshop, then you know how important the glute + foot connection is, (yup, it's real.)
A Quick Review:
Research has shown that after a lateral ankle sprain, your gluteus medias (one of your three glute muscles) down-regulates, meaning, the activation of that particular muscles decreases.
Think of it like turning down the volume.
We want that glute muscle to be strong and activated and have the volume cranked all the way up to 10, but your body senses something isn't right, something isn't stable down the kinetic chain and that ankle isn't healed completely, so it responds in turn (not saying it's a good response, but that's what happens).
Over time, the ankle heals, but sometimes the body doesn't remember to turn the volume back up on the glute med so it continues to live in this down-regulated state.
Why do you care?
Because those peroneals may be between a rock and hard spot.
The peroneals directly plug into your foot and provide lateral stability for your ankle, in addition to assisting that push off during running.
Is it’s foundation strong? The forefoot.
Is it's teammate above strong and activated or is it continuing to "live" in a downregulated state? The glue medius.
Can you see how important full body movement and exercises that look like running are so important?
It's not just about strength work and making certain muscles big and strong; it's also about teaching your body how to use all the teammates together to accomplish the task: running.
How Do You Fix all this and Prevent Future Peroneal Issues from Popping Back Up?
Phase 1: Use the Stronger Feet Workshop
My workshop, Blueprint for Runners to Stronger Feet, is specifically designed for runners with peroneal issues by activating and strengthening your forefoot (that foundation) .
At the same, this progression of exercises recruit the glute muscles (the supporting teammate) through movement that looks and feels like running and reminds the glutes how to work in conjunction with your forefoot, leaving you in control, pain-free, confident, resilient, and a stronger runner.
Read more about it HERE!
Phase 2: Use These Exercises!
Circuit: 2 rounds; 3-4x a week
1 round = 2-3 laps per exercise
1 lap = 20 yards (10 yards down; 10 yards back)
*NOTE: if you're fatigued after 2 laps of one exercise, rest! And move on to the next exercise. Progress number of laps and length of laps (by 5-10yds as a time) as you get stronger.
Tip toe lateral band walking with resistance band around ankles
Added core activation: Both arms straight overhead, biceps to your ears
Tip toe lateral band walking with resistance band around arches
Added core activation: Both arms straight overhead, biceps to your ears
Tip toe walking with carries with high knee marching
2 different carries: try them both.
Notice which is easier? Which is harder? Is one side easier compared to the other? Get curious and get to know your body!
Farmers Carry vs. Overhead Carry (both arms up overhead again, holding a light weight in both hands.)
TRICK for overhead carry: actively try to push those weight overhead as if you're going to touch the ceiling. If you're doing this right, you will get tired and you will feel your core kick on!)
Phase 2 vs. Weird Walking Exercises
Already, can you see how the tip toe walking lends itself to looking like sprinting?
And that last walking version where you add in marching, can you see how that high knee resembles that powerful knee drive, requires single leg balance needed for running, and demands a strong, tall core we all want in good running form?
Again, these exercises progress to LOOK and FEEL like running, serving you as a runner.
Also, these still directly address and challenge your peroneals.
With that added resistance band, you're challenging the actions the peroneal muscles perform, requiring stability and strength out of those ankle stabilizing muscles. Again, in a functional movement and form that more resembles running rather extreme, non-functional, end ranges of motion which the funky walks place you in.
Not to mention, the added pressure and resistance from the band, can potentially help restore ankle proprioception (your ankle joint and tendons communicating it's place in space to your brain).
But that's an entirely different blog post for another day. Just know, it's ok to double dip and get additional benefits on top of the primary objective.
What NOT To Do with Peroneal Tendonitis
Let's wrap this up with a couple things to be careful of, running fit fam.
Note on Phase 2 Exercises: if they huuuurt and do NOT feel good, don't do them!
This is your body's way of saying "hey there, I'm not ready for this yet!". Respect the healing process your body is at and stick with the Stronger Feet exercises.
Be careful foam rolling!
Check out this image:
See that common peroneal nerve and how closely it runs to the fibula bone?
Your peroneals are in the EXACT same neighborhood.
Which means, if you foam roll UBER aggressively, you could potentially irritate that nerve which innervates already really cranky muscles.
Can you see how that's gonna be a bad day?
So if foam rolling helps you, you can keep doing it! Just with respect for the other anatomical structures surrounding it.
Don't over do it.
This is a classic case of "more is NOT always better".
If your sore spots feel more irritated instead of tired by strong, after these, then it's a definite sign some rest days are in your future.
You may need to work into these 1x a day or 1x every other day.
But if after 2 weeks there is NO improvement or you feel WORSE, please seek out the medical care you deserve.
It's not worth the frustration of trying to google-doctor yourself back together. Go see your friendly, neighborhood physical therapist. We'll be happy to help you get back out on the road!
That's a wrap, running fit fam!
I hope you leave feeling empowered, knowledgeable, confident, and resilient.
You now know:
How to test yourself for peroneal issues/tendonitis
Have exercises to fall back on to treat *minor* cases (like when things first start to pop up and you're considering those rest days like at the beginning)
And a couple things to be careful about.
Your light years ahead of where you started at the beginning of this blog post! So give yourself a high five and as always…
Dare to Train Differently,
Marie Whitt, PT, DPT //@dr.whitt.fit
P.S. Want to get started on making sure peroneal tendonitis never leaves you feeling confused, overwhelmed, discouraged and bewildered again? Skip the unplanned rest days and check out the Stronger Feet Workshop!
Chiu, L., Yaremko, A., & vonGaza, G. (2017). Addition of Glute-Ham-Gastroc Raise to a Resistance Training Program: Effect on Jump Propulsion and Landing. Journal Of Strength And Conditioning Research, 31(9), 2562-2571. doi: 10.1519/jsc.0000000000002065
Guide | Physical Therapy Guide to Peroneal Tendinopathy. (2022). Retrieved 15 July 2022, from https://www.choosept.com/guide/physical-therapy-guide-peroneal-tendinopathy\