Peroneal strain?

[Sports_Rx]

Hi guys, some advice please from any sporty physios!

• History:female patient recreational runner, presenting with R) lateral lower leg pain, 1/52 P=6/10. Age 42, forefoot runner, 49kg. No change in footwear.
• Pain comes on during running ~1.5 miles. Has increased distance from 12 miles p/w to 15 miles p/w. Mixed terrain.
• Felt niggle on last run but disappeared after 1 mile. Felt it next 24hrs and since. Rested from running for 1/52.
• Pain on toeing off during walking and worse going down steps (ecc mvt) - feels like lateral lower leg is 'giving way' and weak.
• Calf raise bilateral ROM ok, slight pain on R).
• R) leg calf raise ROM reduced & slight pain.
• Doing calf raise with knee bent reproduces her pain significantly and whole leg shakes (+ feeling of giving way). Cannot walk upstairs on tiptoes.
  
• Full ankle ROM DF, PF, Inv, Ev.
• Passive Inv is painful.
• Had R) lateral ankle sprain GII 2 years ago.
• Knee ok.
• Hip ok (ltd LR) but NS.
• Lx ok.
• SLR -ve, good hamstring & calf flexibility. Single leg balance good both legs.
• Normal reflexes.
• Palpation on mid-belly of peroneal gives pain & numb feeling from ankle to hip (L5 dermatome).
• Several trigger points along lateral and posterolateral lower leg.

Have treated trigger points and some myofascial release on lower leg. Advised her to rest from running but cross-train. She has foam roller but I advised not to use it yet as palpation was v. tender. Anything else I should have checked..? Treatment - the usual rest, heat & stretch for a muscle strain?

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[msk101]

hi sports_Rx,

have you cleared for stress fracture? is it painful on ultrasound or tuning fork tests (good tests to do without having to do a full bone uptake scan)?

have you taped for offloading the peroneals and seen if that made a difference to pain and function.

have you checked biomechanics in the runner's shoes (are they old/worn/collapsed laterally?). is she a lateral heel strike, pronator/supinator runner? - put onto a treadmill and watch running... if you have time, get her to run until the pain starts and see if her gait is fatiguing or changing. perhaps some advice on footwear or supports is needed if she is going to increase running significantly.

if all that is clear then it does sound like she has increased her distance in training too fast - overuse issues. 10% rule should apply for incremental training increases. so a rest, some cross training, stretch and strength would seem like the way to go.

good luck.

msk101

[Sports_Rx]

Hi, thanks for your response. Will test with US for stress # next treatment. Haven't tried taping - never taped peroneals before - is it like doing an ankle with 2 anchors, but higher up, and then diagonals with the foot dorsiflexed & everted? Her shoes are not worn out <100 miles.

I got her running on the treadmill and she's a forefoot striker, her feet land under centre of gravity so no overstriding issues. But her R) foot does look like it lands more supinated than the L) which would stress peroneal tendon. R) shoe has wear on outer edge too.

Forgot to mention, observing her feet in long-sitting R) foot rests more medially than the L) - suspect laxity due to previous sprain injury.

I've told her tendinopathies need rest from the aggravating activity or it'll take ages to heal but runners don't like to hear that do they? She has 10k race in 6 wks.

[Canuck Physio]

How are concentric/eccentric/isometric resistance of the evertors?

How are static/dynamic/ballistic stretches of the lower limb movements?

How is the angle of impact, landing of the forefoot, righting reaction after a drop off from a certain height (ie. jump type tests)
Additional Comment I forgot:

have you cleared for stress fracture? is it painful on ultrasound or tuning fork tests (good tests to do without having to do a full bone uptake scan)?

Interesting, could you please explain this particular diagnostic.

[Sports_Rx]

How are concentric/eccentric/isometric resistance of the evertors?

How are static/dynamic/ballistic stretches of the lower limb movements?

How is the angle of impact, landing of the forefoot, righting reaction after a drop off from a certain height (ie. jump type tests)
Additional Comment I forgot:


Interesting, could you please explain this particular diagnostic.

Hi Canuck, evertors are 5/5 on muscle testing R=L. Stretches of lower limb are all normal R=L except slight pain lower 1/3 lateral shank on inversion. On hopping her L) foot lands more on the lateral aspect of BoF, more supinated.

As for US as diagnostic for stress #, I've read something recently but can't find the journal ref where US was better in diagnosing stress # when revealed with MRI compared to tuning fork which had low specificity / sensitivity. Dose was 3 mhz, 100%, 2 W/cm2 for 30 sec. (taken from pt record where I've used this diagnostic before). Never used tuning fork so no idea about them

[thabiso]

Haven't tried taping - never taped peroneals before - is it like doing an ankle with 2 anchors, but higher up, and then diagonals with the foot dorsiflexed & everted? .

Sorry I cant seem to visualise this. Yes there should be dorsiflexion and eversion. Like shin splints taping?

[msk101]

HI There,

Apologies for delay in reply.
Re tuning fork: it's a rudimentary test for bony irregularities and stress fractures as opposed to peri-osteal inflammation. You basically whack the tuning fork on a bench (NOT the patient) to get it vibrating then put the single tip end of the fork onto a bony prominence or as close to the "sore" spot as you can along the bone concerned. The fork causes a vibration in the bone... if there is a stress fracture you will be peeling your patient off the ceiling (it hurts!), if it's just periosteal inflammation it will be a tad uncomfy but nothing much. if there's no problem it just feels a bit tickly. good for testing 2nd MTP stress fracture points, and medial tibia too and far simpler than going for a full bone scan when treatment-wise, there would be no difference. but can't be done on bones which aren't so superficial.

Ultrasound works on the same principle that it's vibration effect on the periosteal surface hurts if there is a bony fracture. still keep the US head moving tho... the aim is NOT to cause a periosteal burn!

Re peroneal taping: Basically the principles of all taping apply to offload the muscle group so i would be placing the peroneals in a slightly shortened position (evert the foot slightly + or minus dorsiflexion depending on whether you suspect peroneus tertius to be involved as well), then tape along the line of the muscle to support it. i would also probably do a few perpendicular tape lines across the muscle belly as a means of force distribution. It's hard unless the patient is quite big, to do a full offload square/triangle around the sore part of the muscle but worth a try. remember don't use rigid tape for a full circumferential limb tape tho.

I hope that makes sense.

msk101

[Sports_Rx]

I know of a physio who's used a mobile phone on vibrate too

[thabiso]

Cool! Now all I need is someone with a stress # to test it on...

[Sports_Rx]

Update: patient didn't hit the ceiling when I tested for stress # with ultrasound. Last treatment I did some more myofascial release and worked on the trigger points. TPs since gone.

She said it was getting better (no running), has done cycling and swimming to maintain CV. Can walk upstairs on her toes and now do single leg calf raise pain-free. Single leg hopping is still painful and still feels 'weak' compared to other leg.

This bit's interesting: she used a foam roller on the outer shank and experienced severe 'electric shock' pain in the peroneal area. Afterwards leg was sore again as though healing was put back.

Could this have irritated the peroneal nerve? She reports soreness when sitting with legs folded underneath her (compressing the tissues), and can only stand light pressure on massaging the area.

Any feedback / comments welcome

[Physio Dace]

Hi Sport-Rx,

Sounds like it may be an irritation of the common peroneal or its branches - superficial likely given the symptoms reported. Either that or a superior tib-fib joint issue or both.

You mentioned SLR was -ve and I'm assuming you added distal sensitizing components (DF/PF inv etc). Did you try adding hip adduction at the limit of hip flexion - I find this works quite well in picking up neural tension disorders in this area. You can also add accessory movements to the superior tib-fib and assess its affect on symptom response.

What were the accessory movement of the superior tib-fib joint like?

[Sports_Rx]

Hi Sport-Rx,

Sounds like it may be an irritation of the common peroneal or its branches - superficial likely given the symptoms reported. Either that or a superior tib-fib joint issue or both.

You mentioned SLR was -ve and I'm assuming you added distal sensitizing components (DF/PF inv etc). Did you try adding hip adduction at the limit of hip flexion - I find this works quite well in picking up neural tension disorders in this area. You can also add accessory movements to the superior tib-fib and assess its affect on symptom response.

What were the accessory movement of the superior tib-fib joint like?

Hi, thanks for your reply. Yes SLR with PF & Inv was more painful on the affected leg, pain in the area of her complaint. I checked sup tib fib - NS accessory mvt on posterior anterior pressure. Are there any other tests for this joint I should consider?

Also both fib heads are tender on palpation (peroneal nerve again).

Patient has improved, resting from running's helped obviously. There is very slight discomfort on repeated single leg hopping so I've advised no running yet.

[Physio Dace]

Hi,

Most people are tender of the fibula head. Have you trialled neural mobilisations as a Rx?

[Sports_Rx]

Hi,

Most people are tender of the fibula head. Have you trialled neural mobilisations as a Rx?

No I haven't... like a slump but sensitised for the peroneal nerve?

Thanks for your input, much appreciated.

[bob78h]

Hi Sports_Rx, I am experiencing many of the same symptoms you described in your patient. Could you tell me what the final diagnosis was and what worked in rehab and return to activity? Thanks.

[chris400]

Hi,

I had a similar problem just over 12 months ago. I am a forefoot runner and would experience the same symptoms. The most confusing was definatly the pain when compressing the peroneii, initally the pain would spread along the nerve, settle and when compression was released the pain would return. I tried neural mobs, stretching, strengthning of soleus/gastroc etc to no effect.

However I did find that basic core stability with glute med and max strengthening completely erradicated the symptoms... Not 100% sure why this happened but i did find initially my symptoms were agrovated running on uneven terrains. Possibly eccess tibial rotation put the peroneal tendon on a stretch compressing the nerve underneath?

Either way, i personally found strengthening myofasicial slings, particularily the longitudinal sling seemed to erradicate my problems... Your patient runs accross mixed terrains... maybe their hip control?

[bob78h]

Hi,

I had a similar problem just over 12 months ago. I am a forefoot runner and would experience the same symptoms. The most confusing was definatly the pain when compressing the peroneii, initally the pain would spread along the nerve, settle and when compression was released the pain would return. I tried neural mobs, stretching, strengthning of soleus/gastroc etc to no effect.

However I did find that basic core stability with glute med and max strengthening completely erradicated the symptoms... Not 100% sure why this happened but i did find initially my symptoms were agrovated running on uneven terrains. Possibly eccess tibial rotation put the peroneal tendon on a stretch compressing the nerve underneath?

Either way, i personally found strengthening myofasicial slings, particularily the longitudinal sling seemed to erradicate my problems... Your patient runs accross mixed terrains... maybe their hip control?

chris400, could you let me know the healing time and what exactly you did to speed healing? I'm also a forefoot runner, and I have the same symptom, pain when pressing on the peroneus initially, going away as pressure is kept and then returning when released. The pain is in the body of the peroneus longus muscle it seems, not in the tendon by the ankle as is most common. It seems to have been brought on by running too many hard workouts in the same direction around a small indoor track. Its been three weeks of deep tissue massage, foam rolling, icing, and minimal running but the pain won't go away.

[chris400]

I had the pain for around a month with no improvement before i started general core stabilising exercises which then improved around 2 weeks later. I was doing transabs activation with legextensions, bridging w alternate leg extensions on a swiss ball, side plank w feet on a foam roller etc.. Generally targetted TA, Glute max, glute med. I found once my core control improved the pain disappeared (literally in one session had disappeared). Alot of the exercises i was doing can be found here:

Core stability exercises

But at the same time I was recieving treatment and did communicate everything I was doing with the person treating me which I recommend you also do as every injury is unique, what worked for me may not work for you. Hope this helps.