Peroneal tendon injuries fall into three categories: tendonitis, tears, and subluxation. They are more common in active, athletic patients and can be acute (sudden) or chronic (lingering) in nature.

Tendonitis is inflammation, acute tears are caused by an injury and tendonosis (chronic tears) are usually caused by overuse and repetitive stress or chronic tendonitis. Subluxation usually occurs in an acute injury, like an ankle sprain, where the tendons actually dislocate onto the outer ankle bone and snap back and forth with activity.

The symptoms of a peroneal tendon injury can include swelling, pain, warmth, weakness and instability of the foot and ankle. Subluxation can also include a snapping feeling and sporadic pain with activity.

 Treatment of peroneal tendon injuries is often delayed by misdiagnosis. If you are experiencing any of the symptoms of a peroneal injury, seek medical attention from a foot and ankle surgeon urgently. The longer the tendons go untreated, the more damage occurs. X-rays and physical examination usually lead to an MRI to solidify the diagnosis. My patient’s MRI showed a severe rupture of peroneus brevis with a bulbous scar tissue formation which you can see in the below picture. Peroneus longus was normal.

Treatment include rest, casting, functional orthotics, anti-inflammatory medication or injection therapy, physical therapy, bracing, and in some cases surgery. Obviously, my patient needed a repair. We excised the torn and hypertrophied part of the tendon, then repaired the rest and fixed her ligaments so she would stop being so unstable and finally lose her “cankle”. Here is the piece of abnormal tendon we excised. Wow! Big chunk!!

Your disability from a peroneal tendon injury can be significantly reduced by early intervention, so if you are experiencing any of these symptoms, call or contact the office and be evaluated. The sooner you have a proper diagnosis, the faster you will return to normal activity levels pain-free. If my patient had come in earlier to have her “ankle sprain” evaluated, conservative therapy might have healed her tendon injury!

I normally do not comment on football in my blog, but I have been asked this question so many times this week that it is comment worthy. For the record, even though I have allegiance to the New England Patriots and the Cowboys, I have always been a Brett Farve fan. He is the epitome of the endurance athlete as a football player, just like Cal Ripken was an example of the ever present endurance baseball player. (Yes, I love Cal too!) That aside, I think Brett is crazy to play tomorrow!

Why? First, he has two fractures in his foot and ankle. A stress fracture in his ankle and an avulsion fracture of his calcaneus (the heel bone). His ankle is already a disaster in which he has had at least 5 surgeries that we know of and has significant degenerative arthritis! Why make it worse? The season is a disaster and the Vikings are losing confidence in him. If he can’t move tomorrow, he is either going to get seriously hurt or get pulled by the coach. Why not sit voluntarily?

On the flip side, he probably needs an ankle replacement already. He could numb up his ankle, play, then risk crushing whatever cartilage was left. Stupid! And a bad example to younger football players. Face it: the season should be over and he should call it a career. (Which he should’ve done at the end of last season anyway!

Brett, don’t play. You risk hurting yourself more or at the very least looking more stupid that your antics have been in the last two years!

Spring is in the air in North Texas. The brief snows are gone and recreational sports are starting their schedules. The soccer, baseball and lacrosse leagues are having their first games; the high-school track team is gearing up for competition, and The Leukemia Society’s Team-in-Training groups are just starting to increase their mileage aiming for an early summer marathon finish. Spring is in the air, and our old friend the ankle sprain is starting to show up more frequently in the office. Basketball and volleyball seasons are always the main producer of this injury; but you would probably be surprised how many ankle sprains occur in outdoor sports like soccer, baseball, lacrosse and of course track and field. Ankle sprains have been reported to be approximately 20% of all sports injuries with more than 25,000 occurring every day in the United States.

Uneven, wet fields coupled with early season fatigue and competitive full-contact intensity equal injuries. The ankle is the joint that compensates for uneven surfaces. 85% of ankle injuries are sprains, which are caused by a failure to compensate for this uneven footing. Jumping, cutting, and pivoting put the ankle at risk. Many athletes put themselves at further risk by not rehabilitating these injuries properly, returning to sport too early, and giving themselves an inadequate adaptive ability to uneven surfaces or sudden twisting. The use of narrow cleats with minimal arch support or the use of running shoes for a court sport can also place an athlete at risk for ankle sprains.

Ankle sprains occur in runners mainly because they are chatting away as they are on a long run and are simply not paying attention. How many runners have you seen fall off the curb or in a pothole while running? Lots…Pay attention to where you are going and you can prevent this type of injury. If you know you are a klutz, run on an even surface, like a track, when you are tired or distracted.

If you have an ankle sprain, you should be evaluated by a sports medicine podiatric foot and ankle surgeon if you have localized pain, swelling and bruising, as well as inability to walk more than 5-7 steps comfortably. Many a foot fracture has been missed in the emergency room when x-rays were taken only of the ankle and not the foot. The fifth metatarsal is often broken with the same mechanism of injury of an ankle sprain, so the foot should be evaluated as well. If severe ligament injury is suspected, an MRI can evaluate the grade of injury. This is really what decides whether surgery is needed for full recovery.

Treatment for ankle sprains really depends on the degree of severity, which can only be determined by your doctor. Initial treatment always includes “R-I-C-E” therapy – Rest, Ice, Compression, and Elevation. Pain and edema is usually controlled with NSAID’s (non-steroidal anti-inflammatories) like ibuprofen. Bracing or casting coupled with non-weightbearing on crutches may be needed in more severe injuries to rest and stabilize the ankle while it heals. Return to pain-free range of motion (ROM) and stability is the goal. Surgery is only recommended in Grade 3 severe injuries in athletes or in those patients who have had multiple ankle sprains and suffer from chronic ankle instability. Long-term ankle instability can often be avoided with an aggressive physical therapy program. Bracing should only be used in the short-term during rehabilitation because long-term bracing actually causes atrophy and decreased ROM.

Physical therapy is needed for all ankle sprains. The goals of physical therapy should be to regain full ROM, strength and proprioception (where your brain thinks your ankle is in space). Regaining strength in the peroneal tendons as well as overall balance training are the keys to successful rehabilitation of an ankle sprain. A maintenance program of ankle strengthening, stretching, and proprioception exercises helps to decrease the risk of future ankle sprains, particularly in individuals with a history of multiple ankle sprains or of chronic instability.

Bottom line: if you happen to fall down and go “Boom”, have your ankle sprain evaluated by a podiatric foot and ankle surgeon. Delaying treatment and rehabilitation can lead to life-long instability.

For more information on ankle sprains, go to our home page and click on "All About Feet".

What’s the Deal with Runner’s Knee Pain?

I had an email last week from a relatively new runner asking who they should see for their knee pain. I asked if they twisted, fell, or jammed their knee or if it was just a wear and tear injury? They confided that as they increased their mileage and distance, their knee pain started to increase. New shoes helped, but didn’t fix their nagging pain. Sounds like a biomechanical problem to me! But it could still be a traumatic injury they can’t remember…especially if they were out dancing on tables on a Friday night ... Just kidding!

Seriously, mechanically induced knee pain is extremely common in runners. A good analogy is that if you need a tire realignment on your car, the struts can wear out. In fact, you may have no acute foot and ankle problems at all and they can still be the cause of your symptoms.
The best way to assess a runner’s knee problem is to start with a sports medicine orthopedist who can rule-out a primary knee problem, like a tear in the meniscus (cartilage), ligaments or tendons. If a primary knee problem is ruled-out, but you just keep having this nagging pain; or if your tendonitis keeps recurring in spite of being compliant with physical therapy and rest; it’s time to look elsewhere for the cause.
Your feet affect the function of all their contiguous structures or in English, everything they are connected to. Yes, your feet can even cause back and neck pain!

How? Your feet affect your postural control. Postural control is the ability to maintain the body’s center of mass over the supportive foot, a.k.a. being able to keep your balance. Often, balance or proprioception is lost in patients with chronic foot and ankle instability from an underlying congenital foot type. This leads to lack of postural control which leads to knee, hip and back pain a.k.a. postural symptoms. Many studies have concluded that a functional orthotic reduces postural sway and improves stability, therefore reduces further injury in patients with congenital or acquired foot and ankle instability.

Bottom line, if your knee pain is chronic and you have ruled out a primary knee problem, look to your support structures known as your feet.

…..Run Happy! And be sweet to your feet (and knees too!)