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Chronic Peroneal Tendonitis following running injury in minimalist shoes

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Mark Russell, Jun 25, 2014.

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    Twenty four year old female with a chronic perineal tendonitis R/F following injury sustained during a period of reasonably active running with minimalist shoes. I saw her shortly after the original injury and an ultrasound scan revealed peroneal tendonitis, retrocalcaneal bursitis and mild to moderate plantar fasciitis but no tear or disruption to the lateral ankle ligaments. Initially immobilisation in an air cast boot then a short course of strapping with lateral shoe wedging and regular icing appeared to settle the acute lateral pain, however I saw her again last weekend when she was home from London and the problem persists. She still runs - mostly on treadmills at her gym in regular Nike trainers, but experiences moderate lateral ankle and lower leg pain and stiffness for a few days afterwards. She has provided an excellent history which I have simply copied below together with some photograph of her current trainers (Nike) and her original shoes at the time of injury. I will upload some video of her running later which shows a forefoot strike pattern. Unfortunately, she lives in London and only visits her parents infrequently so I was unable to follow her up as I would have liked. From her description of her injury, it sounds like a classic inversion/supination sprain with secondary tendonitis which should have settled after a few months. She is a compliant, fit and healthy young lass and with a good understanding of her foot mechanics. My question is whether her forefoot strike pattern may be contributing to the chronic peroneal tendonitis, which is proving quite debilitating. If so, what might be the best approach - gait retraining (if such a thing can be achieved) or orthotic management? If the latter, what limitations are there with the usual rear foot devices and how can I modify this for a forefoot striker? All foot & ankle RoM ok - unremarkable gait and feet and aside from the tight hamstring she mentions, no other issues. I am a little concerned she is developing similar symptoms in the other foot and ankle but there is no significant family history and it may well be a secondary compensatory issue - or is peroneal tendonitis more common in FFS and if so, why?

    Many thanks.


    Attached Files:

  2. Lorcan

    Lorcan Active Member

    Perhaps you should consider unloading the Peroneals with valgus posting, orthoses etc. Also I would ask for the assistance of a competent Physio to probably apply the Continuum Paradigm to the Tendonopathy and investigate the core/lumbar issues. This combined approach will likely yield results.

    Last edited by a moderator: Sep 22, 2016
  4. Craig Payne

    Craig Payne Moderator

  5. Yes I read it. While I understand why it may be an issue in some, I find it more difficult to reconcile a connection with someone who is a FFS whete surely the only difference may be in the thickness and composition of the sole. What was the percentage of heel strikers -v- FFS in your email correspondence for runners with PT?
  6. Mark:

    The peroneals are also ankle plantarflexors so they will likely be recruited more heavily, along with the gastrocnemius and soleus muscles, by the central nervous system in those runners who run in minimalist shoes, those runners who run barefoot or in those runners attempting to become, for some reason, more of a forefoot/midfoot striker and less of a rearfoot striker. From my clinical experience over half the peroneal tendinitis injuries in runners I see are forefoot/midfoot strikers or are running in minimalist shoes. In my patients, only 15% of the runners are FF/MF/minimalist shoe runners. In other words, I consider FF/MF striking and minimalist shoes to be a cause of peroneal tendinitis in many runners.

    An MRI scan would be appropriate for your patient along with valgus wedging on the affected side and soft 1/4" (6 mm) neoprene heel lifts bilaterally to see it this helps along with some physical therapy.

    Good case!:drinks
  7. efuller

    efuller MVP

    Kevin, on the peroneals being plantar flexors I have to disagree. The original Hicks paper and the paper Nigg was a co author on looking at tendon excursion have the peroneals as very very weak ankle plantar flexors. Also, I started to do a study on tendon excursion, and then the Nigg paper came out. When you move the ankle joint, there is very little excursion of the peroneal tendons.

    When I was teaching gait analysis back at CCPM, there was one student who had one of the most lateral axes that I had ever seen. He often would forefoot strike when walking. Sometimes he wouldn't and sometimes he would. So, it was a choice he subconsciously made. My explanation was that the point on his foot that was most lateral to the axis was his lateral forefoot and that is what hit the ground first when he forefoot struck. Forefoot striking was a behavioral adaptation to decrease the supination moment from the ground.

    So, if this woman is choosing to forefoot strike because she has a lateral axis, she might still get peroneal tendonitis because of the lateral axis and not because she is forefoot striking. Regardless, some of the same treatments that have been suggested should still help. Wide lateral flare on the shoe, valgus heel and forefoot wedge.

  8. I'm not sure I subscribe to the core stability fairy dust approach, Lorcan. Why do think it might yield results?
  9. Thanks guys - I would have thought that if there was a contributory effect either from the minimalist shoes or a lateral displacement of the STJ axis, there would have been some symptoms prior to the acute injury. I appreciate she may have been below the threshold for injury before her fall and somehow her pedal mechanics are preventing a full recovery, but I don't think that is the case. She is not symptomatic other that when she runs, so I suspect that it is her FFS pattern that is the problem here rather that any functional issue with the foot or ankle during normal walking. I guess an interesting question for me is what makes someone a FFS as opposed to a heel striker during running - and can they change? I assume from what you say there is greater loading on the peroneal tendons in runners who FFS?

    Many thanks

  10. The peroneus brevis and longus are weak plantarflexors of the ankle joint, they are not dorsiflexors of the ankle joint. As far as the central nervous system is considered, the peroneals will be recruited when extra plantarflexion power is necessary in some patients, especially those with normal to lateral subtalar joint axis position. It is for this reason, I believe, that we see peroneal tendinopathy/peroneal tendon muscle pain more commonly in runners with a midfoot/forefoot striking pattern or in runners wearing running shoes with a low heel height differential.
  11. Mark:

    I have been asking the same question now for the past 30 years. In the thousands of runners I have examined during that time, there does seem to be one thing that correlates to someone being naturally more of a forefoot striker rather than a rearfoot striker: natural forefoot strikers nearly always have a lack of ankle joint dorsiflexion with their knee flexed while being examined in a non-weightbearing position.

    My hypothesis is that in those runners that have a tighter soleus and/or bony ankle joint dorsiflexion restriction, they need to use significant anterior muscle group power to get 10 degrees of ankle joint dorsiflexion with the knee flexed (the knee is flexed at footstrike during running). Therefore, they will choose, by central nervous system control, to footstrike on their forefoot, rather than their rearfoot since it is more metabolically efficient to run as a forefoot striker when the runner has restricted ankle joint dorsiflexion when the knee is flexed.

    However, the gastrocnemius does not seem to be involved in causing a natural forefoot striker since there are many runners with "tight" gastrocnemius muscles that rearfoot strike. In my three decades of observation and examination of runners, the only runners who naturally choose to forefoot strike at recreational running speeds (5:00 minute mile pace or slower) have a lack of 10 degrees of ankle joint dorsiflexion with their knees flexed while being examined in a non-weightbearing position.

    Now, if I could just get someone to do the research study to see if my observations can be confirmed, I would be grateful, since I have been talking about these observations and hypothesis of mine for at least the past 5 years but no one seems to take me seriously or is paying any attention.:bang:
  12. efuller

    efuller MVP

    I still have a hard time with the CNS reruiting the peroneals for plantar flexion moment. Maybe if there was a ruptured Achilles tendon. The gastroc and soleus have one of the biggest cross sectional areas in the body and the tendon is about 4cm from the ankle axis. The peroneal tendons are less than 4mm from the ankle joint axis. The additional plantar flexion moment from the peroneals would be a very small percentage of the plantar flexion moment from tension in the Achilles tendon. At the same time that the peroneals would be creating that plantar flexion moment, they would be creating a large pronation moment, that may or may not be helpful in performing the required task. It is possible that they are recruited, but seems unlikely. The FHL tendon has a much bigger plantar flexion lever arm than the foot extrinsics other than than the Achilles.

    It would be hard to do a study on them, because you can often see tension in the medial and lateral ankle tendons around the time of heel contact. You would think that they would need to be pre loaded in case of unexpected surface variations that could lead to sprained ankles. It would make sense that the pre load could also happen in forefoot strikers.

  13. No doubt there will be a variance but clearly the peroneals are involved to a greater extent in this case as she is symptomatic after running - where she forefoot strikes. Cause or effect? Returning to Rx options, how effective would typical rear-foot lateral posted devices be in forefoot strikers? Given that she is only symptomatic after running, I doubt whether these devices would be needed in her everyday shoes, in fact, thinking about it, I don't really see any disadvantage with wearing her minimalist shoes if she doesn't heel strike. What's the difference between these and the Nikes in the sole composition at the forefoot?
  14. efuller

    efuller MVP

    If (taking the cause option as opposed to the effect option) she is choosing to forefoot strike because of the lateral instability a rearfoot valgus post (lateral heel skive) might enable her to rearfoot strike. As an experiment, you could add a valgus wedge to the bottom of a rearfoot post. (I have used the term post loosely as it can have two meanings. It could mean creating a valgus wedge effect in the heel cup or it could mean the crepe glued to the underside of the shell. The first sentence above is valgus wedge effect, and the second sentence is the piece of crepe. )

  15. colpod

    colpod Member

    Firstly a couple of obversations from the video and pictures, her right tib ant is firing in stance and the left one is not. Her left foot appears to pronate more than the right - heel and knee valgus. Difficult to see from the video but her knees appear to be flexed at toe off, heel lift is low for a forefoot style, she is overstriding (contact infront of hips and knee), dropping onto contact foot rather than drawing foot back underneath her, leaning forward at hips and sitting back at contact. Right also appears to show no heel contact whereas left foot does.

    So she would appear to be more lateral on her right foot with less pronation, blocked at ankle or 1st MTPJ as restricted into propulsion, therefore not using her hamstrings / gluts correctly and hence low heel lift and overuse of hip flexors to pull her foot throught swing phase and so overstriding.

    So I would say the lateral position of her COM during stance and poor posterior biomechanics is causing overuse of the peroneals.

    I personally would not use any rearfoot posting with this patient unless she is prepared to change to a rearfoot strike (but why should she?) Need to work on posture of upper body, dynamic core strength - related to running motion, arm swing, pelvis position - reduce sitting back just after contact, working on 'pushing' with hamstrings and gluts to ensure power is coming from behind her and not pulling herself forward with her hip flexors/quads.

    Right foot needs to pronate more not be held laterally but she has to improve posture, dynamic strength and may need a bit more under her feet in the short term with regards to Nike over Vivo. Have the confidence to let her foot go and load it through the stance phase, power onto 1st MTPJ into propulsion. Will likely need ankle, 1st ray and midtarsal mobs to allow this weight transfer lateral to medial.

    A different approach maybe but one I am using more and more.

  16. I've now made this statement at least three times on Podiatry Arena, and every time I have made this statement, no one has commented on it. Is it because no one else has looked at ankle joint dorsiflexion with the knee extended measurements comparing RF and FF strikers? Is it because everyone agrees with me? Is it because everyone disagrees with me? Or is it because no one else cares?

    I'll say it now a fourth time: natural forefoot strikers nearly always have a lack of ankle joint dorsiflexion with their knee flexed while being examined in a non-weightbearing position.

    Does everyone agree, disagree or simply aren't interested enough to comment??
  17. Hi Kevin

    You might find this reply I received over the weekend from my patient interesting.
    Why do you think that there is restriction of ankle d/f in these patients?

    Kind regards
  18. Congenital, acquired ankle joint dorsiflexion restriction? I don't know. But it is there and it seems consistent. Did you measure her ankle joint dorsiflexion with the knee flexed and extended when you examined her?

    That is the question, is anyone else looking at this, or has everyone else not doing these measurements on runners anymore?
  19. Kevin

    Nope I didn't and even if I did I would have probably missed its significance, to be honest. Can you offer a suggestion why this and the loading from forefoot striking might be contributing towards her tendonitis?

  20. Mark:

    As I said earlier, forefoot strikers will tend to use their peroneals more than in rearfoot strikers to decelerate ankle dorsiflexion since they are landing on their forefoot during running, not their rearfoot. In rearfoot strikers, at foot strike, the anterior muscle group needs to be active and create an internal ankle joint dorsiflexion moment to decelerate ankle joint plantarflexion. However, in forefoot strikers, the posterior calf muscles (including the gastroc-soleus, peroneus brevis and longus and deep posterior group) all probably contribute toward decelerating ankle joint dorsiflexion by exerting an internal ankle joint plantarflexion moment.

    In watching your runner's video, she looks like she is artificially placing her foot into a plantarflexed position at the ankle before footstrike since most runners running at this pace will rearfoot strike and even those that naturally tend to forefoot strike are not this plantarflexed at the ankle at footstrike. Ask her next time you see her if she has been coached by someone or read somewhere that "good running form" includes forefoot striking, not rearfoot striking. If she changed her running form to being a forefoot striker a few months before the injury, you have just found the etiology of her injury.

    By the way, a change to forefoot striking from rearfoot striking causing peroneal tendon injury is more common than you think in runners. In the last few years, I have seen almost one runner a month with peroneal tendinitis/tendinopathy with this exact same history. This is why I now include a history on footstrike pattern in all runners I see in my office.
  21. drsarbes

    drsarbes Well-Known Member

    Hi Mark:

    Unilateral, Hx of acute onset.

    Although the US was neg for tear, you know that linear tears are very difficult to see either on US or MRI.

    If she fails to respond to your various Biomechanical treatments I would not rule out a linear tear of one or both Peroneals.

    Good luck

  22. Thanks Kevin - that's a lot of help :drinks:drinks I'll let you know how we get on.

    Best wishes
  23. HUGHESA1

    HUGHESA1 Member

    Heres my 'pennorth, for what it's worth. In my 'umble opinion, her running gait is decelerative in every foot strike due to an inadequate knee lift, (video 2) thereby not allowing an adequate swing phase that will ensure that the foot clears the ground during swing and is moving rearwards at 1st contact which kinda fits in with the peroneals having to cope with a decelerative force at every foot strike. To achieve adequate ground clearance there is therefore an abductory swing, (video 1 on treadmill) the knees are internally rotated and the contact phase is all pronated. All her running is coming from below the knee (see video 2).
    Running is nothing more than controlled falling over, should be as sagitall as possible and if you dont get the front foot forward fast enough, together with the foot moving backwards at 1st hit then you will get deceleration at every footfall, and subsequent tissue stress and injury.
    It doesn't matter whether there is a fore, mid or rearfoot strike as long as there is minimal decelerataive force at 1st contact. See any elite runner to see what I mean (Mo Farrah in Quorn advert!)
  24. I'm reviewing this girl in a couple of weeks time and would welcome your comments. The consensus would suggest offloading the tendon with lateral wedging - however, as she is a forefoot striker, rearfoot posting on any device would, I assume, have limited benefit. However I am still not sure that simply fitting a forefoot varus insert to her running shoes will change the dynamics sufficiently to offload the tendon - if she continues to forefoot strike. Is their any merit in having her try to change her running style - gait retraining - if it works?

    Many thanks
  25. Try getting her into higher heel height differential running shoes and then add a rearfoot valgus heel lift to both shoes to see if it makes her more comfortable. Don't use a forefoot varus wedge..if anything put a small forefoot valgus wedge also into her shoes along with the rearfoot valgus wedge. Even though it may be difficult to impossible to run more with a heel strike in her normal running shoes, using a soft valgus-wedged heel lift inside her shoes with a higher heel running shoe should get her to heel-strike which should take a lot of eccentric tension loading force off the peroneal tendons.
  26. Thanks Kevin - sorry I meant a laterally posted forefoot wedge which is of course a valgus posting. Will give it a try when I see her. I've been giving some thought to the issue of forefoot -v- rearfoot striking. I'm not a runner but clearly there are differences between the various disciplines - sprint, distance, jogging - that are more suited to one or the other. It might be fun watching the 100m with a heel striker - something akin to Basil Fawlty on speed I'd imagine - but in distance and jogging, I guess it's down to personal choice. Or is it? Do you think each individual has a preferred running style which is perhaps a default setting in our locomotor function - and if that is the case, do you think it can be changed or influenced by consciously changing the running pattern over a period of time. When I was looking up gait function over the weekend, I came across this
    As I mentioned above, I don't run - but I have played some racquet sports to a reasonable standard over the years, predominately badminton, when're most of the court movement is on the forefoot - and it certainly feels more 'efficient' in terms of agility and energy use. However, it's a learning process - the majority of beginners are, what I would call, flat-footed. It takes some time to 'learn' to play on your 'toes' - but it can be done and after a while it feels the most 'natural' position to play in. With that in mind, can we 'learn' to walk or run differently - would there be any merit in having this girl, for example, consciously alter her running style to increase the load on the medial side of the forefoot - which is in essence what laterally posted devices will aim to do anyway? I'm not sure what the current views on gait reprogramming are, but I would be interested to hear any comments.

    Kind regards
  27. Very kind, Kevin. Clearly a subject close to heart.

    Best wishes

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