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Another Peroneal tendon thread
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Hi Everyone,
I'm turning to ST for some help after exhausting all the limited resources Kaiser has to offer.

I've been experiencing pain in my Peroneus Brevis tendon since late 2020. It's right where the calcenus meets the cuboid. Initially I went to my PCP and got an X ray, they said the pain was caused by a non union fracture of the very top of the calcenus, i probably did this in 2017 when I was tryinga jump line on a gravel bike and fell, the lace of the shoe exerted a lot of pressure on the top lateral part of the foot. At the time, I was told it wasn't broken based on one x ray and the fact that it "would not be possible" to ride my bike to the ER with a broken foot (fwiw I broke my Pelvis in 2011 and walked home, where i passed out from the associated blood loss).

They told me the pain would continue, on and off, until I had the bone chip surgically removed. It took the better part of a year to get a kaiser podiatrist to actually show up for an appointment. When, eventually, I had surgery scheduled in my pre op I said I had no pain, and that i had a similar pain in my right foot. The surgeon suggested the pain might be tendon pain not bone related, and ordered an MRI. The MRI showed mild tenosynovitis in my peroneus brevis and posterior tibial tendon with no evidence of a tear. After getting the MRI I got a DMT shot in the foot, not in the tendon but near it, which helped a lot with the pain on a work trip that had me walking a lot. I then developed PTT pain.

After I got back I met with the surgeon, who looked at the MRI, and essentially told me to rest until the pain stopped. No physio or other meds. I've been avoiding anything that makes it worse for two months. Some days are better than others but as SOON as I get on the bike it kicks off, in less than 5 minutes. Some days I can walk a bit in boots with my custom orthotics, some days I can't. I have very high arches, and I've tried various custom orthotics, they don't do much on the bike. I wonder if the BOA, which is the commonality on the half dozen shoes I have tried, might be not helping? The only shoes which let me ride a bit longer are BONTs with the older ratchet strap.

Am I looking at surgery here, even if there is no evidence of a tear? Would PT help? I'm using custom orthotics for walking, and was using green specialized insoles for riding. Custom orthotics i had made to ride in make it worse, they post me medially too much I think. It's serious depressing having had this pain and had to bail on events for coming on two years, and I want to do whatever it takes to at least be able to ride a little again.
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Re: Another Peroneal tendon thread [aeroisnothing] [ In reply to ]
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Just to clarify, are you having the pain on the outside of your foot, or the inside? Or both? I ask because you mention pain where the calcaneous and cuboid meet but then mention “PTT pain”. PTT is the posterior tibialis tendon on the medial (inside) part of your foot so I wasn’t sure.

Also, orthotics have never worked for me. I’ve tried a ton of different ones…..made at doc office and ones purchased off the shelf. Like you, I felt like they made my pain worse.

I had tenosynovitis (peroneal tendon) of my right ankle that required surgery to clean up (and look for a possible tear…..no tear). After giving it time to heal, it felt tremendously better
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Re: Another Peroneal tendon thread [EyeRunMD] [ In reply to ]
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Thanks, how was the surgery? How long was the recovery?

I have had both, sadly, but the pain that has been going on for several years is the outside of the foot. The PTT pain came after the DMT shot in the outside. I had the MRI before this but it took 5 weeks to get it read and in the mean time the PTT pain came on. After some rest the PTT seems better but the peroneal is back.
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Re: Another Peroneal tendon thread [aeroisnothing] [ In reply to ]
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aeroisnothing wrote:
Thanks, how was the surgery? How long was the recovery?

I have had both, sadly, but the pain that has been going on for several years is the outside of the foot. The PTT pain came after the DMT shot in the outside. I had the MRI before this but it took 5 weeks to get it read and in the mean time the PTT pain came on. After some rest the PTT seems better but the peroneal is back.

I’ve had surgery on both of my ankles. The recovery for the right ankle was definitely easier, but there was no tear. A small bone spur was removed from the end of my lateral malleolus and the tenosynovitis was “cleaned up”. It took me 12 weeks before I could start running again, and it was a slow build up. Six months after surgery, I was doing 3-4 hour trail runs without any problems.

The surgery for the left ankle was more involved. I had a repair of a longitudinal tear of my brevis tendon (the MRI had shown a tear involving both tendons but my surgeon said the longus tendon looked great) and a Brostrom procedure done (repair ligament damage). I was not actually running when I did all this damage to my left ankle. I had been running, but I stopped to walk because I saw a momma bear and three cubs. I was paying way too much attention to the bears, and not where I was walking, so I stepped off a big dip and rolled my ankle really bad. Recovery for this surgery also took about 12 weeks before I could try running again. Problem is, I was too eager this time, and over did it. So, I ended up with a reactive peroneal tendinitis and had to really back off any running and focus on PT (lots of calf raises, single leg strengthening, building up glutes, etc…). My surgery was in October 2021, and it was May before I felt “normal” running again. I’m very glad I did both surgeries.
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Re: Another Peroneal tendon thread [EyeRunMD] [ In reply to ]
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EyeRunMD wrote:
aeroisnothing wrote:
Thanks, how was the surgery? How long was the recovery?

I have had both, sadly, but the pain that has been going on for several years is the outside of the foot. The PTT pain came after the DMT shot in the outside. I had the MRI before this but it took 5 weeks to get it read and in the mean time the PTT pain came on. After some rest the PTT seems better but the peroneal is back.


I’ve had surgery on both of my ankles. The recovery for the right ankle was definitely easier, but there was no tear. A small bone spur was removed from the end of my lateral malleolus and the tenosynovitis was “cleaned up”. It took me 12 weeks before I could start running again, and it was a slow build up. Six months after surgery, I was doing 3-4 hour trail runs without any problems.

The surgery for the left ankle was more involved. I had a repair of a longitudinal tear of my brevis tendon (the MRI had shown a tear involving both tendons but my surgeon said the longus tendon looked great) and a Brostrom procedure done (repair ligament damage). I was not actually running when I did all this damage to my left ankle. I had been running, but I stopped to walk because I saw a momma bear and three cubs. I was paying way too much attention to the bears, and not where I was walking, so I stepped off a big dip and rolled my ankle really bad. Recovery for this surgery also took about 12 weeks before I could try running again. Problem is, I was too eager this time, and over did it. So, I ended up with a reactive peroneal tendinitis and had to really back off any running and focus on PT (lots of calf raises, single leg strengthening, building up glutes, etc…). My surgery was in October 2021, and it was May before I felt “normal” running again. I’m very glad I did both surgeries.

it is really great to hear you are better, sorry you had to go through that. I know how shit that must have been. Did you spend a lot of time trying to do conservative methods before and they didn't work? I have thought about putting the boot on, but I think it would just rub my outside of my foot and that would bother it even more.

right now I am two months into doing not very much other than the rowing machine and paddling my kayak. I can sometimes hike in boots pain free, other days it's agony. It has been incredibly annoying to say the least, and I really struggle to deal with stress well when I am not getting out most days. So I think in that sense making progress would feel good even if it was surgery.

Is there a name for the procedure?
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Re: Another Peroneal tendon thread [aeroisnothing] [ In reply to ]
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Thanks. Yes it is stressful to be limited by these injuries and I'm sorry you are dealing with it.

Yes I did try conservative approaches first. Tried a boot for a few weeks, tried taping the ankle, used KT tape, applied Voltaren cream to the hurt areas, used NSAIDs, tried inserts and/or orthotics, etc.... I did everything except a steroid injection to the area. I was scared of a steroid injection near my tendon because there is the suspicion it can lead to rupture. Also, the surgeon told me I'd have to wait something like 12 more weeks before he would operate on me if I went that route.

To me, it sounds like you've not been able to get solid answers, about what all is going on or how to best go about treating it. If this is the case, I would definitely be seeking another opinion, preferably from an experienced surgical podiatrist or foot and ankle fellowship trained orthopedic surgeon.
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Re: Another Peroneal tendon thread [aeroisnothing] [ In reply to ]
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Tendinopathy pain (including the peroneals) takes an active approach, and it takes time. Orthotics, injections, meds, rest are all passive approaches. Tendon rehab is gradual progressive loading to facilitate healing and improve the tendon's ability to handle load. I wouldn't advise having a surgical "clean up" either..based on current evidence and clinical experience. Find a PT that knows triathletes and understands how to treat tendinopathy correctly. All research in this area points to an active, guided, progressed loading protocol to get the best outcome.

CB
Physical Therapist/Endurance Coach
http://www.cadencept.net
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Re: Another Peroneal tendon thread [aeroisnothing] [ In reply to ]
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the only way I can help is to recommend a doctor in Portland, ME if that's local-ish at all to you. Best of luck

maybe she's born with it, maybe it's chlorine
If you're injured and need some sympathy, PM me and I'm very happy to write back.
disclaimer: PhD not MD
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Re: Another Peroneal tendon thread [Dr. Tigerchik] [ In reply to ]
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Dr. Tigerchik wrote:
the only way I can help is to recommend a doctor in Portland, ME if that's local-ish at all to you. Best of luck

Sadly I am in San Diego. I am about to change insurance though, Kaiser has been atrocious (I have had doctors no show to appointments and not return emails requesting a PT referral for several weeks). So any doc suggestions here are welcome.
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Re: Another Peroneal tendon thread [PTinAZ] [ In reply to ]
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PTinAZ wrote:
Tendinopathy pain (including the peroneals) takes an active approach, and it takes time. Orthotics, injections, meds, rest are all passive approaches. Tendon rehab is gradual progressive loading to facilitate healing and improve the tendon's ability to handle load. I wouldn't advise having a surgical "clean up" either..based on current evidence and clinical experience. Find a PT that knows triathletes and understands how to treat tendinopathy correctly. All research in this area points to an active, guided, progressed loading protocol to get the best outcome.

This worked very well when I tore a quad tendon in a bike race. But I can't seem to find any way to do it with this tiny foot tendon. Is there anyone in San Diego you'd suggest?
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Re: Another Peroneal tendon thread [aeroisnothing] [ In reply to ]
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I don't particularly know of a PT in SD that specializes in endurance athletes. I'm guessing a local tri club or running store would have a good recommendation? They tend to know these things. :-)

It's not super complex rehab but it does take the right approach.

CB
Physical Therapist/Endurance Coach
http://www.cadencept.net
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Re: Another Peroneal tendon thread [aeroisnothing] [ In reply to ]
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aeroisnothing wrote:
PTinAZ wrote:
Tendinopathy pain (including the peroneals) takes an active approach, and it takes time. Orthotics, injections, meds, rest are all passive approaches. Tendon rehab is gradual progressive loading to facilitate healing and improve the tendon's ability to handle load. I wouldn't advise having a surgical "clean up" either..based on current evidence and clinical experience. Find a PT that knows triathletes and understands how to treat tendinopathy correctly. All research in this area points to an active, guided, progressed loading protocol to get the best outcome.


This worked very well when I tore a quad tendon in a bike race. But I can't seem to find any way to do it with this tiny foot tendon. Is there anyone in San Diego you'd suggest?

Agree with PTinAZ about rehabbing the tendinopathy first. Problem is finding a good PT for this. I've had some that I felt like made my condition worse, and others who definitely had a plan and knew how to adjust to my healing. Ask other runners, in your area, and you may be able to find a good PT who has experience working with runners.

As PTinAZ said, it takes an active approach. When I developed postop (reactive) tendinopathy, I did not stop running. I backed off the running, a lot, and increased my physical therapy. It took a while to heal up but I am glad I took the approach I did because I am back to running and I feel I have the strength and conditioning to back it up.
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Re: Another Peroneal tendon thread [EyeRunMD] [ In reply to ]
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Can you recall what exercises you did. My Pt has focused entirely on soleus and calf stuff, nothing in the foot itself really. I have had good weeks and bad weeks, but i am months down the line and it seems like a half decent training week will immediately result in a flare up. Some manipulation has helped, generally orthotics have not, and some seem to make it worse. I am considering PRP as I want to exhaust all my pre surgery options. It seems like every time it happens it is the same way, a slight pain in my peroneal tendon, then the next day a worse pain in the PTT.
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