Ankle sprains are the most common athletic injuries. Improper treatment can lead to longer-than-necessary disability
and may contribute to degenerative arthritic changes in the ankle joint
over the years.
The peroneal brevis, peroneal longus, and peroneal tertius complete a group of muscles and tendons that are located on the lateral side (outside) of the ankle. Injuries to this area produce disabling pain with difficult, long recoveries. The brevis and the longus are more susceptible to injury because of the anatomical track that they course. Both muscles originate on the lateral side of the fibula, forming tendons proximal to the ankle. A common tendon sheath holds both of them as they make an almost ninety-degree turn into the foot. This common sheath is held in place by strong ligaments called retinaculum. Two of these exist as the tendons travel distally into the foot. Additionally, the peroneal groove in the calcaneus (heel bone) assists the tendons in making this sharp corner. The groove also offers mechanical advantage and strength to the muscle group.
The function of the peroneals
All three, the brevis, longus and tertius muscles, and their associated tendons, help balance the side-to-side stability of the ankle joint and help prevent ankle sprains. They assist with plantar flexion of the foot at the beginning of the toe-off phase of a gait. They also are the prime everters of the foot. Eversion is a complex motion that causes the foot to bend downward (plantar flexion), while moving the sole of the foot toward the lateral sides of the body. This is not a motion that occurs with every step. Think of it as a balance motion, stabilizing the ankle and preventing invertion, or over-twisting/rolling to the outside.
I consider ankle sprains to be the most common athletic injuries and inversion is the prime cause. Ankle sprains are not usually treated with an aggressive format and this can lead to longer-than-necessary disability and may contribute to degenerative arthritic changes in the ankle joint over the years.
Overuse injuries
Peroneal brevis tendonitis is a common athletic occurrence with runners who are training on trails that may not be groomed, or are running on cross-country grass courses. The peroneal muscle group fires at heel-raise, just before toe off. Think about this motion a moment and you will find that it does not require strong energy. As your body moves forward your heel almost automatically lifts from the ground. The peroneal brevis is, in fact, a fairly small muscle; the longus has a longer lever arm, but is also a slender muscle; and the tertious is really an ancillary muscle with very little strength.
An overuse injury can occur when the muscles must repeatedly fire to stabilize the ankle on uneven surfaces or, frankly, to stop an ankle sprain from occurring. The increased gravitational forces produced on the lower extremity by running exacerbate the problem and increase the incidence of injury. Trail running is a good idea, but like any other training routine it should be added to your schedule in small doses so that muscles and bones have time to adapt to the constant uneven surfaces underfoot. The idea that trail or cross-country running is easier on your body because of the soft, resilient surface is, in my mind, negated if the constant stress on the peroneals causes overuse injury.
Recent studies on recovery from, and prevention of, sprained ankle injuries focus on the peroneal muscle group. One study revealed that strengthening this muscle group can help prevent recurring ankle injury. The recommended exercise is easy and requires no special equipment except a set of stairs. As with any exercise, care must be taken not to overdo the routine. Wear your running shoes because they will provide stability and purchase so you don't slip. Place the forward portion/metatarsals (balls) of both feet on the edge of a stair. Stabilize your body by holding a railing or wall. Slowly drop your heels lower than your forefeet, then perform a slow rise. Rise as high as your ankle will allow. Repeat this motion for ten repetitions. Any pain on the lateral sides of your ankle should not be overlooked and the exercise should be stopped if there is pain. Add this to your workout three times per week. The peroneal muscles will become stronger and the corresponding tendons will become more elastic. Do not try this exercise without good supportive, stable footgear. Your running shoes are the best choice. The hallmark to peroneal injury is pain and it will be at its worst when climbing a set of stairs or at the toe-off phase of gait.
Treatment
Usually an overuse injury will respond to rest. Like any tendonitis, once the condition becomes chronic, treatment becomes more involved. A foot that hyperpronates requires increased stability. Conversely, the foot that remains in supination will require more cushioned control. Proper running shoes can be key to the prevention of painful peroneal tendonitis.
Conservative treatment should always be attempted before moving to more involved treatment regimens. A complex, long-standing injury may require the use of a cam walker/cast for several weeks. Non-steroidal anti-inflammatory drugs are very helpful. The use of non-steroidal injection therapy is gaining support among sports medicine doctors. When conservative treatments fail, an MRI should be ordered to rule on possible tendon tearing, rupture, or avulsion from the normal course and tracking. In complex conditions, surgery may then be the option for recovery.
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