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Peroneal tendinitis is an inflammatory process of the lateral region of the ankle. Although it is not as frequent, it is a cause of pain that must be treated.
The ankle is one of the joints that we use most frequently, since it allows walking. It is made up of various structures that provide great stability and movement. Ankle injuries are quite common and peroneal tendinitis is one of the conditions that trigger pain here.
A tendon is a band of tissue rich in collagen and elastic fibers that joins a muscle to a bone. This, in order to transmit the force of the contraction to trigger the movement. Tendinitis is the inflammation of a tendon. It can be acute, subacute or chronic.
Peroneal Anatomy
The peroneals are muscles located on the lateral aspect of the leg. Two exists:
- The peroneus longus, which starts from the most proximal portion of the fibula.
- The peroneus brevis, which does so from the middle third of the same bone, which is also called fibula.
Sometimes an accessory muscle known as peroneus quartus.
The peroneal muscles descend down the posterolateral aspect of the leg until they reach a bony prominence at the ankle: the lateral malleolus, which they encircle behind through the retromalleolar groove. Both peroneals share a synovial sheath that gives them the necessary lubrication to reduce the friction of movement.
After skirting the lateral malleolus, the peroneals separate, each acquiring an individual synovial sheath. The peroneus longus passes under the foot to insert on the base of the first metatarsal. While the peroneus brevis runs along the lateral border of the foot to insert into the fifth metatarsal.
Important anatomical variations in peroneal tendinitis
In addition to the presence of an accessory fibular, there are individual variations that are related to a greater predisposition to peroneal tendinitis. Among the various morphological alterations are the following:
- Changes in the shape and depth of the retromalleolar groove.
- Lower location of the peroneus brevis muscle.
- Hypertrophy of the fibular tubercle, which is a bony prominence of the calcaneus.
- Alterations in the alignment of the ankle, such as hindfoot varus or pes cavus.
- A prominent foot arch.
Conditions that are associated with an increased risk of tendinopathy
Although peroneal tendinitis is rare as an isolated entity, it is common for the inflammatory process to also affect the synovial sheath, constituting a tenosynovitis. There are risk factors that help trigger these problems:
- Rheumatoid arthritis.
- Psoriasis.
- hyperparathyroidism
- Diabetic neuropathy.
- Fracture of the calcaneus.
What are the causes of peroneal tendonitis?
The mechanism that usually causes tendon inflammation responds to the joint mechanics itself. Involvement of the peroneal tendons is caused by microtrauma that generates the repetitive movement, since constant friction is produced.
Likewise, posterior fibular tendinitis is more likely to occur after a period of physical inactivity. For this reason, this alteration affects more runners and dancers than the general population.
Even so, within the predisposing causes the following can be named:
- The use of inappropriate footwear.
- Overload due to inadequate or prolonged training.
- The absence of a pre-exercise warm-up.
- Pre-existing ankle injuries, including sprains, fractures, and joint instability chronicle.
Direct trauma to the ankle also leads to tendon injuries.
What are the symptoms present in peroneal tendinitis?
The symptoms depend on the degree of involvement and the time of evolution of the tendinopathy, which can be acute, subacute or chronic. It is considered that it is acute when signs are less than 2 weeks old having appeared.
It is subacute between 2 and 6 weeks. And it is established as chronic when it lasts more than 6 weeks.
Ankle pain
The most common symptom is pain., which is located predominantly posterior to the lateral malleolus. In acute injuries, it can even follow the course of the affected tendon. The characteristic of tendinitis pain is that it improves with rest and worsens with movement.
Other symptoms
In addition to the painful sensation, various alterations may appear:
- Swelling on the outside of the ankle.
- Heat to the touch in the area posterior to the lateral malleolus.
- Joint instability.
How is peroneal tendinitis diagnosed?
Being a rare entity, not usually the first diagnostic option thought of, being often underdiagnosed. It is also not uncommon to confuse peroneal tendonitis with an ankle sprain.
It is important to establish the time of evolution and the characteristics of the symptoms. In addition, it is necessary to know the level, type and frequency of physical activity, underlying conditions and pathologies, and also any history of trauma or surgery.
Physical exploration
After collecting all the information concerning the clinical picture, a thorough physical examination is vitally important. The examination allows alterations in the ankle and any condition that predisposes to injury to be identified.
Among the clinical findings are the following:
- Exacerbation of pain with movements.
- Painful palpation in the tendinous trajectories.
- Tendons that feel thickened and indurated
- Observation of some morphological alteration of the foot.
Complementary studies that help the diagnosis
Imaging tests are widely used. However, conventional radiography could be seen within normal limits as there is no bone involvement.
The study to better evaluate the alterations is computed tomography, but it does not have good resolution of the soft tissues. For this reason, MRI is of choice for tendons.
In the same way, an ultrasonography can be requested. Although it is a useful means, it has the caveat of depending on the skill of the operating sonographer.
What treatment options exist?
In general, conservative treatment is sufficient to improve pain, at the same time that it allows the regeneration of the tissue. However, in severe chronic tendinitis and in those that are refractory to the conservative approach, surgery becomes a viable option.
Conservative management of peroneal tendinitis
Conservative management includes the following:
- Pain treatment with nonsteroidal anti-inflammatory drugs (NSAIDs).
- Rest of the joint in the initial phase.
- cryotherapy applied to the ankle.
- Lower limb elevation.
- Immobilization using a plaster cast or boot.
- Rehabilitation with physical therapy.
Currently, steroid infiltration is controversial, because due to the inflammatory process, the puncture of the tendon can cause tearing of the fibers, complicating the picture.
Surgical approach to peroneal tendinitis
Although surgery is a useful therapeutic option, should be relegated to severe chronic cases and those patients who are refractory to conservative treatment or who present relapses. The surgical approach It should also include the correction of diagnosed anatomical abnormalities.
Prognosis of peroneal tendonitis
Generally, when correctly diagnosed and effective treatment established, tendon regeneration is good. Recovery is quicker in acute cases than in chronic ones, but equally a hasty approach should not be taken.
Rehabilitation is essential to complete the treatment, both conservative and surgical, since it allows the strengthening and toning of the peroneal muscles and their tendons. Physical therapy includes eccentric, proprioceptive, and stretching exercises.
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