Peroneus Brevis/longus tendinopathy?

[Quickstart]

Hi,
I am a third year Physiotherapy student from Australia and I was hoping to get a little bit of help with self-diagnosis. I suspect a Peroneal tendinopathy, but would appreciate some feedback as to whether the symptoms fit. I'll give you my history.

I am a 20year old athlete getting back into running after 2 years off (I have maintained some light-level running every 2 days or so for those 2 years), and have only started getting serious about it over the last 4 weeks. I had previously competed at National junior level in cross-country.

Before becomming injured, I was getting back to 30mins every day (steady pace) outdoors and on a mix of fine gravel/asphalt/dirt terrain. Four days ago I was in the middle of a run when I felt some discomfort on the lateral border of my right foot, it was not particularly painful, but was bothering me enough to get me to turn back home. It slowly got more painful as I was running, and by the time I got back home I was limping quite badly. I got home and put ice on it for 20mins but it didn't seem to improve it much, I was limping slightly for the rest of that day and the next. I have not tried running again as I can still feel its not quite right when walking.

Other information:
- I had corrective surgery on a hallux valgus deformation (and associated problems) of my R hallux Dec 2004.
- I have not changed equipment (same shoes from 6 months ago - they have limited wear)
- I have progressed my training slowly (no more than a 10% increase per week)
- I have had no recent acute ankle pathology

Findings:
- Palpable tenderness posterior to the styloid process of the 5th met on the R foot
- No other tender spots found.
- Discomfort (not pain) on active eversion around that same area.
- During gait, I find that it is more painful during midstance to push off.
- Aggs: Activity
- Eases: Stopping activity/time.

I'd appreciate if anyone could give me some feedback as to whether a peroneal pathology is likely, or if not, what it could be. If you need any more info, let me know.
Cheers

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[alophysio]

Hi.

Sounds like you are right - I was thinking peroneus brevis.

My question is - why did you have the hallax valgus op? What did the surgeon do? Did it change your arch?

Mind you, if you have been runnning ok since then 3 times a week or so, this would have come up sooner.

Otherwise, I was thinking of an eccentric-only programme to try get the structure of the tendon back to normal and progress from there.

Have no idea why it might have happened...???

[Quickstart]

The Hallux op was performed because my Abductor Hallucis tendon had begun to calcify, and had also avulsed a chip of bone from my 1st met head. It was interferring with my running so when I had the chance I had it corrected by a podiatric surgeon.

The deformity itself was relatively mild, but due to my years of running the problem degenerated faster than would normally be expected.

The surgeon did an osteotomy - corrected alignment of the first met, altered muscle imbalance and cleaned up the area. I have had the same procedure performed when I was 13 by the same surgeon on the contralateral foot, and have had no problems with it ever since, so I am not too concerned about the actual surgery. As far as I have been able to tell my arch has not been altered, but I am wondering whether the correction (either surgical or behavioural) is causing me to invert more on initial contact as I have had a little bit of trouble with ITBS on the same leg - it has been relatively mild but frustrating all the same. Any thoughts?

No I honestly have no idea, there are no other obvious factors (that I can think of) that may have triggered it.

Thanks for the suggestions.
Cheers

[alophysio]

Hi.

How's your SIJ and glut medius stability?
Is your medial gastrocs tight?

Which institution do you go to? If you go to Sydney, I may have to explain how the SIJ works! hahahaha

[Quickstart]

SIJ and Glut med are both fine, but my musc/ortho tutor found that my gastroc/soleus' on both legs are hypertonic. He did not say whether the med head was worse than the lat head, but I do not notice much of a difference on palpation/stretch.

Sadly I'm a bit further south than that. I go to La Trobe Uni's new set-up in Bendigo, VIC. Nothing quite like Victorian winters to make you dread the season.

[alophysio]

Hi.

Try a load-transfer test (out of interest).

ASLR (Active Straight-Leg Raise) Test
1. Lie Supine
2. Lift one leg and note it's heaviness, the ease of action and whether your pelvis rolls. If you want to be really tricky, try to feel the obliques and TrAbs as well.
3. Lift the other leg and note the same.
4. Does one leg feel different to the other? If not, then the test is negative. If so, continue...
5. Try to compress (or have someone else compress) the p.symph (then re-assess by lifting that leg noting the above), PSIS (re-assess), ASIS (re-assess) and G.Trochanters (re-assess).

If any of these make lifting the leg easier, you may have a load transfer problem including muscle inhibition. If any of the above make it harder, you may have hypertonic muscles compressing your SIJ.

Just out of interest of course...

BTW, how do you know that the SIJ is not dysfunctional?
ITBFS is often due to a hypertonic TFL and inhibited Glut med - has that been addressed in the past?

[neurospast]

To get the facts right: You, quickstart, have an injury of the peroneus Brevis/ Longus. You started to get problems during the build up after an hallus valgus Op. The Gastrocnemius/Soleus are hypertone [antagonists of the Peronei] and no further hypertone or hypotone muscles of the leg or lower back. Your running shoes are about 6 month old but not hard worn. and you are back to running 30 minutes a day.
The primary possible causes of injury:
-Overuse by too fast progression, the injury [operation of hallus valgus] needs to settle and adjust with time to the new situation. You have been a runner so you know how fast and how long you could run and that tends to make people to become over enthusiatic [at least I have that tendency].
-Gastrocnemius is hypertone, why?, Any back problems level L4/S1? Since peroneus tend to become weaker with immobilisation and the length of the Gastrocnemius shorter, it changes the balance between Peronei and Gastrocnemius and therefor easely overuse/abuse of peronei.
I think you should take it slower in your build up, have someone check up on your walking/ running to illiminate foot problems causing you problems. Get good advice on new running shoes because 6 months using a pair of shoes might cause you problems. If you have stuck to a certain brand of shoes you used before the op. that might cause the problem since the allignment within the foot has changed due to the op and therefor you need different shoes [or even inlays]
Start to strengthen the peronei, that will effect the rest tone of the Gastrocnemius [a stretch of Gastrocnemius will have a good effect aswell]. Why not use PNF paterns to do so [ you might even cause a nerve mobilization ala Butler].
Mobilizing of the bony structures within the foot might be beneficial [being in plaster doesn,t help proper movements within articulations]
And if nothing seems to help be shure your lower back/SI is playing up but this should become evident within the analysis of your walking /running as well. I assume that in Australia sport shops do have a hamster belt and they do make videos otherwise go to a sportcentre and do the hamster thing on one of their belts.
Cheers