Good post and may help others searching.

Without actually seeing you ... everything seems to be in order. Your treatment plan(s) seem reasonable and typical. 8 weeks in a CAM boot is a pretty long time - doing therapy with this, of course, is good.
Doesn't really matter if tendonitis/tendinosis at this point (unlikely just simple tendonitis, but your MRI appears to indicate no tendon pathology, but tendonitis only). Of course, MRIs can be misread, longitudinal tearing missed between the "cuts", etc. Since you are not responding to what would be expected, likely some further advanced imaging is warranted to guide your treatment plan (ultrasound, another MRI, etc.). Certainly no indications for surgery at this point, but possibly a PRP injection could be beneficial in a case like yours.

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Sounds like your rehab is heading in the right direction. Make sure that you remain pain free as your progression in PT continues. A key component to the ASTM treatment is to gradually add functional activities (i.e.running, jumping, etc) this allows the body to lay tissue down based upon stresses placed upon it. This is the exact reason why it is important to keep with your rehabilitation plan, despite the fact that when you came out boot you were relatively symptom free.

It maybe a good idea to have some high quality motion analysis of your running form / pattern done, as you progress rehab to that point. If you are working with a sports PT, they should be able to help with this.

Thanks to both of you for the help. Things are progressing along SLOWLY but i have been able to return to some very light running and cycling. no additional MRI but if i stall i will go back and demand one.

I'll add to this my MRI results in detail which i recently received in case it means anything different to you guys. this was 5 months ago.

DATE OF EXAM: Dec 07, 2011 09:57:25 PM
HISTORY: Lateral ankle pain and clicking after triathlon
FINDINGS:
Bone mineralization is normal. Fusiform thickening of peroneal longus starting
retromalleolar and extending to peroneal tubercle. No tear or tenosynovitis.
Peroneal retinaculum is intact.

Flexor and extensor tendons are unremarkable. Medial and lateral ligaments are
intact. No joint effusion or loose body. Achilles tendon and plantar
aponeurosis are unremarkable.

IMPRESSION:
Focal peroneal longus tendinosis. No tear.

also wanted to leave some links here to help others that may be reading this with their own peroneal tendon or tendinosis/tendonitis issues in general as i have found some useful stuff over many hours of searching...

wikipedia article on tendinosis
http://en.wikipedia.org/wiki/Tendinosis
lots of discussion of treatment techniques being used. very good citations, a jumping off point for lots of other research.

tendinosis.org
another surprisingly good collection of info and linked articles discussing symptoms and treatment options

Podiatry Today discussion of PRP therapy
http://www.podiatrytoday.com/...nd-plantar-fasciosis
good discussion of what it is and what evidence there is to support it. there are lot of clinics offering PRP injections. they aren't yet covered by insurance but at least in my case there is a local clinic that will do them for $500. the procedure itself is apparently very straightforward and doesn't require specialized equipment from what I can tell.

Lengthy, detailed explanation of what tendinosis is, how it differs from tendonitis and treatment theories (from a peer-reviewed journal)
http://www.smarttjournal.com/content/2/1/30

Another general article on tendinosis from AFP. an easy, shorter but still very useful read.
http://web.archive.org/...afp/20050901/811.pdf

Damn, IMHO your management has been terrible on so many levels. There is no need for time in a boot. No need for any investigations. No need for Ultrasound. No need for PRP. No need for extensive analysis to see if you have itis or osis. No need for any icing. No need for detailed palpation as it is not a good indicator. No doubt it has been profitable for you health care providers, but they have made your condition worse.

If its been around for longer than a few weeks it's tendinosis. If you aggravate it a bit you get some inflammation and it's an itis (if you must). The reason it came on is a mis-match between the strength of the tendon and the demands you laced on it. That is all you need to know.

Increase the strength of the tendon in question and decrease the aggravating factors slowly increase the strength using the correct exercises and slowly increase the demands on it until they are equal, and then get on with it.

sfgate, very helpful post.

I too have been searching for info on this subject. Have been getting conflicting information and looking for others with similar situation. Here's my story. About 6 weeks ago I had sudden pain in lateral left foot when pushing off of foot, no visible swelling or bruising (no apparent injury and no memorable history of ankle sprains). Limped around for 2 days. Actually my daughter had an appt. with podiatrist the next day. I asked his advice and he did a quick look. Said I could have a tear and a bone spur which could be rubbing and causing pain.

Suggested MRI which showed the brevis is abnormally splayed and frayed with short segment, partial thickness tears, the longus is abnormally thickened with tendinosis and fraying within the cubital tunnel and a large os perineum is present. There is also increased fluid within the peroneal tendon sheaths.

Podiatrist said surgery. I saw an orthopedic surgeon at a foot and ankle clinic who suggested a CAM boot and PT for 6 weeks as a conservative approach as a first step. I am one month into it and have started walking in an air cast this week. Still have pain and some swelling. Even in the boot there were times i would walk just right and get a shooting pain. I just don't feel like it's getting any better. Do I need more time? Will this really heal on it's own? Will it just keep coming back? Very frustrated because it is the beginning of summer and don't want to be laid up.

Are you considering surgery or are you still following a more conservative approach?

RRoof any ideas?

It really depends on the severity of your "injury"

Generally, longitudinal tearing/tendinosis of the peroneals heal with immobilization (CAM boot, etc.) if the tear is less than about 2.5 cm (1 inch). Larger tears generally don't heal, fibrose in, and are a pain in athletes since they initially do better with rest/PT, then come back to haunt. I generally rec surgical repair of these. Of course, figuring out the initial cause and dealing with any biomechanical issues is always a good idea as well.

So, both of your recs for treatment are "correct" depending on your severity. Can't be of any more help than that. Best of luck!

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Based on my experience I would say wait it out a while. If you see no improvement after 2-3 months of the conservative approach, then maybe consider injections and/or surgery. It took me a LONG time to see any improvement at all. It was unnoticeable at first and is still unnoticeable week to week but month to month i know i am still improving slowly. and at this point, im beginning to feel i have turned a corner. been running on it low low mileage and very slow with no real problems so that is giving me hope that i will eventually return to 100%. at this point, i wont be considering anything more aggressive unless i see more than 1 month of no improvement. even then, i would likely just consider an injection, no surgery. Everything I read led me to believe that surgery is no guarantee. and that there is little or no additional damage caused by waiting it out as long as you are not running on it. I too had a sharp pain every 100 steps or so in the very beginning but it does sounds like your case is different from mine so use your own judgment, but my general reasoning went like this.


- try the least risky stuff first (ie immobilization/rehab, then injection, then surgery)
- keep up with all the icing/rehab/etc... along the way so that if there's no improvement after a few months, i know ive done all that i could
- be VERY patient (give everything a long chance to work before going to the more risky/aggressive option). i got comfortable with the idea that this could take anywhere from 6-18 months to be back to 100%.
- take everything the doctors say with a grain of salt. surgeons do surgery, they aren't all in the habit of telling their patients surgery isnt for them and they aren't the "problem solvers" of the medical world. in my experience the older, professionally successful surgeons are going to have a little more respect for the wait and see approach. also, remember that not all the patients in medical studies are eating well, sleeping well, keeping up with what theyve been told to do so have faith that if you're doing everything you can do, youre more likely to have a positive outcome then the studies may indicate. that helped me stay motivated and kept the spirits up at least. and if all else fails, everything has a placebo effect.
- do my own research


also keep in mind, time in a boot is not good for other reasons. i had some serious imbalances after 8 weeks in a boot that i am still working out (3 months later). just remember to take things very easy when coming out of the boot. and gradually transition out of it if possible.


good luck

Hate to sound like a broken record here on the forum, but if there is no tear in the PB or PL tendons, then KT tape and massage should help. I am able to perform self massage effectively, although a good massage therapist would be better. As a massage therapist I really try an pay attention to my own body to see what treatments work. I do not train in KT tape, I only use it as a way to let the tendon heal throughout the day by reducing pressure on the area. I find that ice doesn't help at all. Foam rolling the lower leg muscles 360 degrees, should also help. You should be able to take your thumbs and lotion and stretch the muscle belly leading behind the LM to relieve the tension that the muscle is putting on the attachment point. Do this and it should help.

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"That doesn't make any sense at all, you can be second, third, fourth... hell you can even be fifth." - Reese Bobby, Taladega nights

Thanks for the info and the quick reply. That's the thing...I didn't really have an "injury". Which makes me wonder if it is chronic. I don't know how long the tear is. Neither doc mentioned it. I do have high arches. I am also wondering about the os perineum, it seems as this is an uncommon problem. The OS said it looked "not happy" on the xray. Will this always be problem too? Will PT help? As a rule of thumb how long should I pursue conservative therapies??

These are generally from overuse, not acute (although occasionally go undiagnosed from a typical inversion ankle sprain). Peroneal tendon issues are more common in people with high arched feet with tight posterior muscle group (calf).

If you are going to go the conservative route, then go that route (again, don't know the severity of your tendon tear). That means some type off immobilization, activity modification (i.e. NO running), PT for muscle/imbalance issues that can/will arise, etc. for at least 3 months + Don't worry about the os peroneum since it is present in many people. They can be symptomatic with peroneal injuries, but aren't often an issue.

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____________________________________
Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Thanks sfgate.
I have read that tendons do take a LONG time to heal due to the lack of blood supply to that area. Also, I do have actual tears in the brevis tendon. I was really hopeful that I caught it early enough and it would heal on its own. Now not so sure (based on the fact that it actually hurts more after the boot and PT). I also feel a "cracking" every once in a while when I put weight on it.
I do agree with trying the less risky stuff first though...it can't hurt. The only loss is time =) Icing does not seem to help at all. Funny thing too...the podiatrist wanted to jump into surgery and the surgeon wanted to wait. He said I had a "moderately good" chance of healing on my own. HAHA - I take that as 50/50.
I hate the boot anyway. 1 month is long enough, but with PT and stretching/exercises I still have most of my ROM. I am pretty good with the at home therapy =) I just want to give myself every chance to heal on my own.
Again thanks for sharing your info and the quick reply. I appreciate it. It's nice to have that extra support from someone who went through it.

I just had a follow up with the ortho surgeon. Follow up was not what I expected! Basically my foot feels the same as it did 2 months ago. I have good days and bad days. But most days I have an achey feeling along the side of my foot when I walk. Even with the stirrup splint (Aircast).
I was thinking I just needed more time, therapy, etc.. But he threw me a total curveball...He said he could just "Clean up the tendons" or try orthotics, but my problem was more than that. I have cavovarus feet. I need to correct that problem to actually fix it.
Now I'm looking at an even more complex surgery??? A Dwyer Osteotomy. I was not expecting this. I'm even more confused now. I have to decide if my good days outnumber the bad and figure out if I should go ahead with this surgery. Already 2 months of inactivity have been driving me crazy.
Can you give me any advice from your experiences?
Thanks for any help/advice/reassurance.

That is getting pretty aggressive (cavus foot reconstruction, Dwyer osteotomy, etc.). Definitely get a 2nd opinion there! That isn't to say it might not be in your best interest, but I'd hesitate to recommend cavus foot reconstruction in any athletic individual. VERY long recovery and frought with complications.

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Yes I know, that was my first thought too. However, this Dr. came highly recommended by 1 doctor and 2 other people. I 'm just having a hard time wrapping my head around how we went from tendon repair to major foot surgery!?!?
And I thought tendons took a long time to heal, so why after only 2 months go to this? Is it typical to see some relief/change in pain after that short of a period of time?
He asked me if there was any improvement and I said no, not really. There were days that I had no pain, but after I walked around more, was on my feet longer the pain came back.
He told me the tendons are stretched and the only was to keep that from happening again is to fix the anatomical problem causing it. Side note: I also have a pins and needles feeling, like tingling down my leg and in my ankle. he said the sural nerve is stretched as well.
I'm not sure how to proceed with this...

Start by getting a 2nd opinion of course. Cavus foot reconstruction may very well be your best option, but if you have any doubts in your mind, I'd be sure to clear those up! That is for you and the surgeon(s) to discuss. I assume he understands your athletic needs/wants, etc. for after?

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____________________________________
Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Wanted to update this with my progress and a few more questions for the ST docs. Thanks to you guys (rroof, eg159, avagoyamug, crolson24) for the help thus far.

Basically, my peroneal tendon seems to have been getting gradually better. ill roll my ankle every once in a while (just optimistically doing trail running too early) and i have to take a week or two off but every time it seems to get better. just had another MRI that was completely normal according to the doc. that said, i have some concerns i wanted to run by you guys.

1st, ive been having a dull achey pain in the front of my ankle, slightly left of the midline. it generally aches whenever ive been walking on it. worse in sandals and a lot worse after and during a long run. it also prevent me from fully stretching my calf. especially when bending my knee to stretch the soleus. so much so that i can't fully stretch my calf any more. when i feel the left side vs. the right it also feels like there's more bony hard stuff in that area on the left side. this pain started during my 8 weeks in the boot and seems to have very gradually gotten worse over time. the boot was pretty tight so the top of it pushed down on that spot in my ankle. wondering if this is ankle impingement. because he can't cause pain during the physical exam by jerking my ankle up with his hands he doesnt think anythings wrong. thoughts?

2nd, the peroneal still hurts and is very sensitive to rolling my ankle a little. is it possible that the mri isn't showing the chronic degradation of the tendon(s) and i will be very susceptible to future injury? ie in cases like mine, what are the odds of returning to marathons and ironmans?

finally, id like to see a local doctor with experience seeing high-level athletes ideally. any thoughts? should i be looking for sports medecine, podiatrists, chiropractors? im a little lost. if this isnt a surgical problem i shouldn't see a surgeon but i dont know what the other options are.

thanks again for the help all

This mid 50's guy has a partial tear of the peronous brevius at the insertion of the 5th metatarsal. No longitude tear. Injury was from trauma (bump) in the second week of March 2012. Thought the pain would go away and continued running until April 10th. Pain got worse in that I could not sleep on my right side as the pressure on the right side of foot was unbearable. Finally saw the Podiatrist later in April. X-rays negative. Medication and injections over the next month did nothing. MRI the last week of May revealed the tear. Put into a walking boot/cam and told to use ice as needed, swimming is ok if pain free and expect a long recovery. It took nearly six weeks for a notable slight change. Additional x-rays were taken in July and were negative. I began home Ultrasound treatment and simple foot/ankle AROM. Told to keep wearing the boot for several more weeks (9 total). Now in a transition and again told not to RIUSH back into activity. Healing of six or more months would not be uncommon. Walking without the boot on slanting surfaces can induce the "abnormal" sensation otherwise there has been an improvement. I have no interest in developing a chronic foot condition and will gradually increase activity thru the rest of 2012.

sfgate and others - all of your comments from May '12 to Aug '12 were very helpful to me. I searched on Google: "Why is peroneal brevis tendonitis taking so long to heal?" and found your experiences. I have been wearing a boot, ultrasounds three times a week, occasional icing, a cortisone shot that did not help (expecting another one next week), and I am getting extremely frustrated. As a teacher on my feet all day going into my fifth week in the boot, I realize from your comments and other informative websites that I was making it worse with my walking and cycling through the pain (with Dr. Scholl shoe inserts I thought were helping) before seeing a podiatrist and I need to be more patient with the healing. It feels fine in the boot, but outside the boot it feels like there is no real change. I look forward to reading about your successful recoveries...

I have enjoyed this forum and have found it very informative. After about 8 months of constant pain and discomfort the podiatrist performed Plantar Fascia Release surgery February 14, 2014. After the surgery I had the normal weekly follow up appointments. The doctor had me walking on the foot 4 days after surgery. I was told that I should expect to be back to normal activity in about 6 weeks, which would take me to the end of March. During the six weeks I was experiencing pain in other areas of the foot not necessarily the heel. Most of the pain was along the outside of my foot (felt like a fractured bone) I also had burning sensation on the inside of the foot. The good news, the pressure in the heel area was gone. For over two months the doctor insisted that the pain was being caused by the way I was probably walking on the foot after surgery. I went to PT 10 times but it was aggravating the foot and seemed to be making it worse. On June 4th (almost 16 weeks after surgery) the doctor wanted to give me cortisone shot for the pain. It was also suggest that it could be CRPS. I objected to the shot and told him I wanted an x-ray and an MRI. The x-ray came back fine and the MRI was scheduled for June 6th.

Long story short the MRI shows a longitudinal split tear of peroneus brevis, beginning at its retromalleolar groove and extending distally 3 cm. After seeing the MRI results, the podiatrist gave me an ankle support sock along with a prescription for an ibuprofen cream and told me not to overdo it. He said let the pain be the judge. Go ahead and bike and swim but no running! Like I could even run if I wanted to, walking has been a challenge for the last 19 weeks.

After I left his office I put myself into an air boot and have been wearing it for the last two weeks. At this point can you give me any suggestions? Feeling very frustrated.

Ugh.

Lateral column pain is common after plantar fascia release (or acute rupture - same thing) and this is why most will have patients in a CAM boot as the plantar fascia "heals". This is even more likely if you have a high arched foot.

In my experience, peroneal tendon tears over about an inch (2.54cm) don't heal well even with immobilization (yes, NO therapy for acute tears) and need to be surgically repaired.

I would suggest getting a second opinion regarding your peroneal tendon tear since you can loose a lot of time "waiting" for this to heal (which is certainly wouldn't do in an ankle support sock and activity as tolerated). At least stay in the CAM/air boot.

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Thank you for your suggestions. I do have a very high arch in my foot so I guess this isn't a surprise. Unfortunately every time I asked the doctor if I should be on crutches or in an air boot he said no! Even after I told him it felt like I had a fracture and the foot was unstable he didn't think I needed to be off of it.

At this point I will look for a second opinion.

one word....accupuncture! Worked wonders for me.

I actually tried acupuncture for the plantar faciitis, before I had the surgery. I found it to be extremely painful and it did not provide relief. It might work for the split tear tendon I will look into it. Thank you!

rroof, since you mentioned PRP, what are your thoughts on stem cell vs. plasma injections for Achilles tendinopathy? I am wavering on a 2-injection process that will encompass 8 weeks (injection-boot-injection-boot).