Understanding, Treating, and Preventing Peroneal Tenosynovitis

For many Australians, an active, outdoor lifestyle is a part of life. Whether it’s hitting the pavement for a morning run, trekking up a challenging bushwalking trail, or playing a fast-paced game of netball or footy, our ankles and feet bear the brunt of our adventures. So, when pain strikes the outside edge of your ankle, it can put a real cramp in your style, sidelining you from the activities you love.

One common, yet often misunderstood, culprit behind this lateral ankle discomfort is peroneal tenosynovitis. It’s a bit of a mouthful, but understanding this condition is the first crucial step toward getting back on your feet and back into the swing of things.

What Exactly is Peroneal Tenosynovitis?

To put it simply, peroneal tenosynovitis is the inflammation of the protective sheath (synovium) surrounding the two peroneal tendons (the peroneus longus and peroneus brevis) that run along the outside of your ankle and foot.

The term itself is a blend of medical words: 'peroneal' refers to the fibula bone (also called the perone) and the tendons associated with it; 'teno' relates to the tendon; and 'synovitis' indicates inflammation of the synovium.

These two vital tendons have a crucial job: they stabilise the ankle and foot, particularly when you push off the ground, and are essential for movements that turn the foot outwards (eversion). When the tendons become irritated—often through overuse or poor biomechanics—the sheath surrounding them swells, leading to pain and discomfort along the lateral side of the ankle. It’s a signal from your body that something isn't quite right.

Spotting the Symptoms: When to See a Professional

Recognising the signs of peroneal tenosynovitis early is key to a faster recovery. While the symptoms can sometimes be mistaken for an ankle sprain, there are distinct differences.

The most common signs include:

1. Pain on the outside of the ankle and heel: This is often the most noticeable symptom, typically worse with activity, especially running or walking on uneven ground.

2. Swelling: You might notice localised puffiness or a feeling of fullness along the course of the tendons behind the bony bump on the outside of your ankle (the lateral malleolus).

3. Tenderness to touch: Pressing firmly on the tendons behind the ankle bone usually elicits pain.

4. Aching and Stiffness: The pain may be dull and aching when resting, and the ankle can feel stiff, especially first thing in the morning.

5. Weakness or Instability: Some people report a feeling of ankle instability, or difficulty pushing off the forefoot.

   
   

If you are experiencing any of these symptoms persistently, it's time to book in with a trusted Australian healthcare professional, such as a podiatrist, physiotherapist, or sports doctor. Self-diagnosis and self-treatment can often prolong the issue, so getting an accurate diagnosis is paramount.

What's Causing the Dramas? Key Risk Factors

For a condition rooted in inflammation, it’s not surprising that overuse is the number one culprit. However, in the Australian context, a few specific factors often contribute to the development of peroneal tenosynovitis:

• Sudden Increase in Activity (Too Much, Too Soon): A common scenario for the weekend warrior or athlete ramping up their training load too quickly. Whether it’s marathon training or getting back into the gym after a break, a rapid increase in intensity, duration, or frequency can overload the tendons.

  
  

• Improper Footwear: Running shoes or boots that lack adequate lateral support or are simply worn out are a significant risk factor. The wrong shoe can force the ankle into an unfavourable position, placing excessive strain on the peroneal tendons.

  
  

• Biomechanical Issues (Foot Structure): Certain foot types are more prone to this condition. People with high arches (supinated feet) are often at increased risk because their foot structure naturally places more tension and strain on the peroneal tendons.

  
  

• Running on Uneven or Sloped Surfaces: Given our love for trails and rugged terrain, the constant small corrections required when running on uneven ground, especially with a lateral slope (camber), can repeatedly stress the tendons.

• Previous Ankle Sprain: A history of a lateral ankle sprain is a major risk factor. The sprain may damage the stabilising structures, forcing the peroneal tendons to work overtime, leading to chronic irritation.

  
  

The Aussie Approach to Treatment: Getting You Back in the Game

The great news is that peroneal tenosynovitis is overwhelmingly treated successfully without the need for surgery. The treatment philosophy revolves around reducing the immediate inflammation, addressing the underlying mechanical cause, and gradually rebuilding the tendon's strength and capacity.

Phase 1: Immediate Relief and Load Management

In the initial, acute phase, the focus is on calming the area down. This typically involves the RICE principle:

• Rest: Significantly reduce or cease activities that cause pain. In severe cases, a CAM walker (often called a 'moon boot') or ankle brace might be used to completely immobilise the joint and give the tendons a crucial break.

  
  

• Ice: Applying ice (wrapped in a chux cloth or towel) for 15-20 minutes a few times a day helps to reduce pain and swelling.

  
  

• Compression & Elevation: Using an elastic bandage or elevating the foot can also assist in managing swelling.

  
  

• Medication: Over-the-counter anti-inflammatory medications (like ibuprofen) may be recommended by your GP or pharmacist for short-term pain relief.

  
  

Phase 2: Correcting the Mechanics and Rehabilitation

This is where the expert management from a physiotherapist or podiatrist becomes essential. They will conduct a thorough assessment—including a gait analysis—to identify the root cause of the tendon overload.

• Custom Foot Orthotics: For many Australians with biomechanical imbalances, especially high-arched feet, custom-made orthotics are a cornerstone of treatment. They work by precisely supporting the foot's structure, controlling excessive motion, and redistributing pressure to take the harmful load off the peroneal tendons.

  
  

• Physiotherapy and Strengthening: A tailored rehabilitation program is non-negotiable for long-term recovery. This progresses from gentle range-of- motion exercises to specific, targeted strengthening. Eccentric exercises—where the muscle lengthens under load—are particularly effective for tendon healing. Your physio will guide you through exercises like single-leg balances, wobble board drills, and resistance band movements to rebuild ankle stability and power.

  
  

• Footwear Advice: Getting into the right shoe is paramount. A professional will recommend footwear that provides the right level of cushioning and, crucially, lateral support for your specific activity and foot type.

  
  

• Advanced Therapies: In some cases, supplementary treatments such as Shockwave Therapy (SWT) or Dry Needling may be used by your podiatrist or physio to stimulate healing in the tendon tissue and accelerate your recovery.

Phase 3: The Surgical Option

Surgery is rare and typically reserved for chronic cases that have failed to respond to months of comprehensive conservative treatment, or where there is a significant tear or rupture of the tendon. The procedure usually involves cleaning up the damaged tissue (debridement) or repairing a split tendon. Following surgery, a prolonged period of rehabilitation in a boot and with a physio is required to ensure a full return to function—a process that can often take six months or more.

Prevention is Better Than a Cure: Tips for a Healthy Ankle

Once you've recovered, the focus shifts to prevention. Nobody wants this condition to be a recurring problem.

1. Warm-Up and Cool-Down: Never skip your warm-up. A dynamic warm-up prepares the tendons for load, and a cool-down promotes muscle relaxation.

   
   

2. Gradual Progression: Follow the '10 Percent Rule'—never increase your training load (distance, intensity, or duration) by more than 10 per cent per week. Slow and steady wins the race.

3. Invest in Quality Footwear: Regularly assess the condition of your sports shoes. If the tread is gone, or the cushioning is compressed, it’s time for a new pair.

   
   

4. Incorporate Strength Training: Regularly perform calf raises, single-leg balancing, and targeted peroneal strengthening exercises to build resilience in the lower limb muscles.

5. Use Your Orthotics: If custom orthotics have been prescribed, use them religiously, particularly during high-impact activities. They are your ankle’s best defence against recurrence.

   
   

Peroneal tenosynovitis can be a frustrating and painful setback, but it is not a life sentence. With early diagnosis and a professional, multi-pronged treatment approach—often led by a trusted Australian podiatrist or physiotherapist—you can successfully manage the inflammation, correct the underlying biomechanical issues, and rebuild the strength required to get back to enjoying the active Australian lifestyle you deserve, pain-free.

Don't ignore that aching on the outside of your ankle. Seek professional help, commit to your rehab plan, and you'll be hitting those trails and pitches again in no time.