Case Study Peroneal Tendon Injury Rehab
THE RUNNER
Leslie is an avid runner, Boston Marathon Qualifier and part of the MyStryde community. After developing a running injury to her foot a year ago, she tried to ignore it and keep pushing through, hoping it would go away. The pain started to get so bad that she was finding even every day things like getting out of bed, putting on shoes, and standing for work activities painful.
Her goal when she came to Run RX: return to distance running (30-40 miles/week) and marathon training
THE FINDINGS
Gait Analysis
Overall, Leslie’s running form looked great and did not seem to be a contributing factor to her pain. She had a moderate heel strike, moderate pelvic drop on both sides (indicating some hip weakness), but overall good mechanics at the ankle. If her outside of the foot pain was due to ankle mechanics, we may have seen some excessive ankle collapse, and excessive toe out or in, indicating increased pressure and pull on the outside of the ankle. This finding suggested her pain was likely due to a mismatch between the demands her body was putting on the ankle, and her actual ankle and foot strength. In other words, Leslie was likely pushing the ankle further than the muscle could handle.
Physical Therapy Exam of Foot
Leslie’s pain was at the outside of her foot and ankle and we found she had a hypertrophic peroneal tubercle— a fancy way of saying one of the bones on the side of the foot, was larger and pointier than usual. This tubercle serves as a fulcrum to facilitate ankle eversion (movement out to the side) and ankle stability. Due to overuse and weakness, the peroneal tendons were rubbing back and forth over the tubercle, causing shearing, increasing inflammation, and ultimately leading to thickening and tearing of those tendons from repetitive stress.
Imaging
Though Leslie did have improvement over her first 3 PT appointments, given the painful area was very close to a boney prominence, we referred her out to an Orthopedic Specialist to rule out a bone stress injury and gauge if the accessory bone was surgical. If the source of her pain was a stress fracture, we would want her to rest as soon as possible (especially as she was considering running the Boston Marathon in the Spring at the time). An ultrasound evaluation revealed substantial thickening and partial thickness tearing of peroneus longus and brevis tendinopathy.
The Prognosis
The Ortho doc agreed that Leslie’s pain seemed consistent with significant peroneal longus and brevis tendinopathy. His words were, it might be “A Bear” to heal, but likely with time and PT, she could avoid surgery and return to running.
REHAB FOR PERONEAL TENDON INJURY
Progressive Peroneal Tendon Loading - Research shows the best way to heal a thickened, angry peroneal tendon is to LOAD it! Everything was done barefoot for foot strength, and we relied heavily on the use of the MOBO board and Toe Pro. We started body weight only with MOBO ankle taps, MOBO single leg RDL’s. Over 10 weeks, we continued to progressively work on systematically loading the tendon, eventually progressing to weighted RDLs on the MOBO board (20lbs) and weighted inversion biased lunges (20lbs). Side note: Leslie is now performing her single leg RDL’s with 30lbs!
Manual Therapy - For the first 6 weeks, pre-exercise, we performed soft tissue massage to the peroneal tendons, muscle bellies and calf muscles. Mobilizations and manipulations were performed for pain relief, to increase blood flow and to address ankle stiffness.
Plyometrics - Once Leslie was painfree with daily activities, it was time to test out the tendons. We started with Box Jumps and progressed to more calf heavy Pogo Hops, from double to single leg as tolerated. After all, running is a series of single leg hops!
Lateral Hip Strength - side planks, leg lifts and single strength leg exercises galore. Leslie was generally very strong from her runners strength workouts but still needed a little extra dose of single leg or glute medius isolated strength work.
Calf & Foot Intrinsic Strength - everything done barefoot and isolation of foot intrinsics to help with offloading that peroneal tendon. Added calf strength focus.
Cross Training - Leslie continued with swimming throughout her rehab for her cardio fix!
THE RUNNING REHAB RESULTS
Peroneal tendinopathy is a common running injury and can be a lingering issue when not well managed. Leslie bought herself a MOBO board and got to work, and did it pay off! She got SO much stronger in her feet, ankles, calves and hips, by being diligent and consistent with her progressive loading program. Most importantly, over the course of 16 weeks she went from having pain with walking and putting on her shoes in the morning to running 32 minutes (8 min running, 1 min walking x4) . Now, 6 months later from starting PT, she is running 40+ miles/week, doing track workouts and progression runs, working in a cross train day, and 2-3 days of strengthening/rehab exercises. She is training for a few 10ks over the spring and summer, and has plans for a PR in the half marathon this fall! She’s aiming to train for a 2024 marathon.
RUNNING INJURY TAKEAWAYS
DON’T dig yourself into the injury hole — when you feel pain, address it! Go to PT and figure it out before it starts affecting your day to day life. Leslie wasn’t sure what the mystery pain was outside her foot before seeking our help or how to fix it.
Your rehab should look like strength training! Single leg deadlifts with 30lbs, Split Squats, Lunges and Single leg ankle strength keep Leslie strong and stave away injury. Running is a tough sport and getting strong is the best way to heal and prevent running injuries.
A positive attitude, dedication and resilience will get you to your goals— we are so proud of Leslie, her hard work and her dedication to PT. She was a joy to work with, and we can’t wait to hear about her successful races to come!
Q & A with Leslie
1.) How many miles/week are you currently running? What is the longest run you have completed since returning to run?
“I'm up to 40 miles this week! Oh my gosh, can you believe it?! I climbed (adding 10%) each week since mid November. I'm running every other day at an easy pace. I'm trying to keep my heart rate below 140bpm on those days. Otherwise, I've been able to incorporate a speed day on Wednesdays, a cross train day, 2x (or 3x) strength days, and a long run…This week will be my "longest long run" since the Boston Marathon in 2022. I'll be running 10 miles on Sunday. I just completed a 9 mile progression run last Sunday with no pain to speak of. It's been a very long time since I could confidently say that.“
2.) Favorite strengthening exercises?
“How could I not highlight the single leg RDLs you taught me! A staple for me now. I'm up to 30# on each leg! Of course, the MOBO board is my best non-human/animal friend. I also love glute bridges, back squats and Bulgarian split squats. Non-strength training things I've forced myself to do now: I've been diligent about stretching and warming up before runs and foam rolling after hard days. “
3.) Favorite thing about The Run Rx?
“My favorite thing about The Run Rx is the education you ladies provided me with. I had no idea where to start with strength training. I was completely demoralized and unmotivated with the tendonitis. It was the combination of physical therapy and strength training… that really went the distance for me. You put me on a path for success and now it's up to me to keep it going so I don't get injured again. Better than traditional therapy in so many ways. You taught me what exercises to do and how to do them properly. At the same time you healed my injury and made me stronger.”
Somerville, MA
