I’ve been struggling with peroneal tendonitis in my left leg as well as a bad left ankle off and on for over a year now. Seems to come and go and is affected by cycling as much as running. I am in the process of deciding on new cycling shoes and was wondering if anyone has discovered a certain pair or brand they feel has helped with this problem. Anyone have any experience with peroneal tendonitis that can offer some help an/or insight? Thanks!
A Sidi vs. Specialized vs. Shimano is not going to make any difference in your peroneal tendonitis. Fixing the biomechanical issue that is causing your peroneal tendonitis will. Do you use LeWedges under your cleats? How was your tendonitis diagnosed?
No wedges, but I could certainly take a look at them if you think it will help.
I had an MRI done last December. It showed “mild” peroneal tendonitis. Took a couple off months off, did PT but it came back. No racing this year- lost year do to this problem. Any advice going forward so I don’t loose another year of racing? I am starting to think this is going to eb somethign I have to live with the rest of my life.
You certainly don’t “live” with peroneal tendonitis. The peroneals are being “overworked” for some reason. Most common cause is a hypermobile first ray, forefoot varus deformity, or possibly tarsal coalition (how old are you). Significant limb length deformities can also do this (rare) as can posterior ankle joint spurring irritating the tendons (should show on MRI, but not always). Have you had an ultrasound exam of the tendons? Gait analysis? Been to a good PT I hope. How old are your?
PM if you want, although dialogue on the main page often helps others as well.
I appreciate the help with this. I apologize in advance for the length. Hopefully this will make some sense.
Here is a little background info:
*37 years old now, 36 at time of injury, first notice of pain and problems.
*I had sprained my left ankle before in 1992. Playing basketball in running shoes of course. Probably never let it heal and ran every day. I was 22 or so at the time. I think the sprain was fairly bad. I remember being on crutches for at least a few days.
*Never had a gait analysis done. I have been told I am a neutral pronator with normal arches. Not sure if this is the same thing.
- No leg length difference that I know of.
Here is the time line of my injuries:
May 2006- While riding I notice a burning / pulling sensation on the side of my lower left calf. The area is on the side of my Achilles tendon, but definitely not the AT. This sensation kind of comes and goes for the next few months and is only noticeable during riding at this time. I am on a new bike with a new position and I start to think this may be the reason. The pain is far worse while riding hard or racing. This is a period of low biking and swimming volume and I was planning on focusing on running last year and take a year off from IM. The 5 previous years were spent racing IM and running marathons. 5 IM’s and 15 marathons. I am very durable during this time. Typical weeks were between 200-300 miles biking and 40-50 miles running. No injuries in these 5 years worth bragging about. At the time I first notice problems I am sitting at a good weight. 6’1" 180 pounds. For the spring this is good for me.
Around July while running I took a wrong step (actually, it was a perfectly normal step on level ground) and felt a sharp intense pain in my left outside ankle. The pain was on the outside of the ankle under and around the bottom and front of the ankle joint. Kind of from 6:00 to 12:00 looking down at it. I was done running at that point due to the pain and thought maybe it was a sprain. Of course I didn’t rest as I was ramping up for the Twin Cities Marathon. Continue to run and the ankle kind of heals (or at least stops hurting) although I can tell it’s not perfect. Peroneal pain (if that’s what it is) starts to get worse. Burning and pulling pain while running or biking at this point. Still not biking hardly at all. Maybe 100 miles per week. Not a constant pain at all, but sort of an off and on pain that happens for a few seconds several times during a run. Keep running, up to 60 miles a week with 20 mile long runs weekly. What can I say, I am a dumb ass.
TCM was in early October. Took the last three weeks off after the marathon, which went horrible FWIW. Started running again in November. Very easy miles. Maybe 30 miles per week. No biking. Go to Hawaii in late November and keep running. By December 1 the pain is to the point that I know I need to stop and rest for good. Now the peroneal tendon area and the ankle hurts and hurts badly all the time.
December 15 or so, finally go see a Sports Medicine doctor. X-ray and MRI done. X-ray was negative, but the MRI shows peroneal tendon inflamed. Doctor also mentions that it looks like my ankle had been repeatedly sprained over and over an never healed. Sent to PT for 6 weeks. No running for another 8 weeks (maybe 12 total). Do my exercise religiously and only swimming at this time. It does actually hurt to push off the wall when I swim, and kicking hurts as well. Mostly just my ankle hurts though at this time not the peroneal area. I try not kick or push off the wall in order to heal.
Things seem to be going well by February 1 and the PT says I am ready to start running. Initially it goes real well and I start off really slow and low volume. Nothing over three miles. In March I take a work trip to Stuttgart Germany and am forced to run in an area of the world that lacks any sort of level ground. On my way up a hill I feel the burning pain and pull, and then my ankle gets the sharp pain that tells me I am done running for a while again.
Get home in April and go see another Sports Medicine doctor- and orthopedic surgeon specializing in the ankle and lower leg. She agrees with the first doctor that it is my peroneal tendon and that there is no silver bullet for this problem. She also says I appear to have some scar tissue around my ankle that is probably causing the pain in my ankle. She says she can give me a shot in the ankle joint to help eliminate the scar tissue and that should eliminate the pain in my ankle. I have no idea what type of shot this was and I pass. Probably a bad idea in retrospect.
That’s about it. I biked a little this past summer but not much at all. Ran a little bit (up to 50 miles a week) all while dealing with the constant lower calf / ankle issue. Nothing I couldn’t train through, but definitely not something I want to keep living with. At this time I am only running (no biking) and can run an hour or so 3 or 4 times a week with out pain. My ankle does see to hurt in the morning for the first 1/2 hour of the day. Not sure what to make of this. I can run now, but if I start going over 30 miles a week, or more tha an hour at a time it all comes back.
That’s really about it. If you have any ideas or thoughts about what I should do next I would appreciate the help. Also, if you know a good doctor in the Minneapolis area please let me know and I will get to them ASAP :). A few questions:
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What type of shot was probably advised to me for my ankle? Is this something I should do?
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What activities make this ailment worse? Some times I think it is running (up hill especially) and sometimes I think it is biking. What can I do while letting this heal?
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What is the prognosis for this sort of injury? Is this something that can heal after this long of letting it go?
Thanks in advance for the help, and again I apologize for the lengthy reply.
T.J.
Do you know where I could buy the LeWedges?
I wouldnt really think of this as a shoe issue. This is a more mechanical related type of injury. You should look at orthotics or cleat position/angle.
I can see this being the case. I am confused as to how I can run and ride my ass off for many years, and then in a period of really low volume develop this injury. Does this make sense? Just seesm so odd to me…
Wow - that is some main page reply! I usually only get ones this long via PM.
First: was an repeat MRI when you saw the 2nd specialist? You seem to be describing a peroneal tendon tear that was either not seen on the initial MRI, partially healed (PT always helps calm things down), but then you reinjured.
OR (more likely) you have some sort of biomechanical issue that has yet to be addressed. Also, which peroneal tendon (brevis or longus) was inflamed (or both)? I’m still betting you have some forefoot varus, coupled with an unstable ankle from repeated sprains, run/bike like you/we do and BAM!
Another good, relatively cheap and painless exam would be an ultrasound by a good examiner (preferably the physician/specialist himself). I can really see subtle tendon pathology better on a good ultrasound exam that I spend 10 mins on than any MRI for a case like yours.
The injection was a corticosteroid like dexamethasone, celestone (betamethasone) or kenalog (triamcinolone). Commonly known as the “cortisone shot”. Sorry, I don’t know anyone that I would recommend in the Mnpls area.
Lastly, on some occasions, an actual “exploratory surgery” with tenosynovectomy is performed (like a diagnostic knee arthroscopy) to actually SEE what the issue is if all else has failed and/or has been ruled out. You would like be “down” less from this surgery than part of your down time anyway.
Good luck!
Thanks for the reply. Just a couple of more questions for you as I don’t have any of the specific information you wanted. MRI results and X-ray are at the doctors office…
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Should I be considering the shot in my ankle joint? Is there any reason not to do it?
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I assume I need to get back to the doctors office. What doctor should I be seeing? A general Sports Medicine doctor, or the orthopedic surgeon that specializes in ankles and lower leg? The orthopedic surgeon works out of a sports medicine clinic as well, FWIW.
Thanks for the help with this!
Definitely go see the specialist and not the “sports medicine” doctor (that can just be an internist who does a 6 month to 1 year fellow in “sports medicine”). Unfortunately at this point, you need all options open, including surgery.
Discuss the injection with him/her. The injection won’t be in the ankle joint anyway, but along the peroneal tendons/sheath. Yes, there are reasons to not get it. But with your history, not much of one. Problem is, you still don’t have a good diagnosis! If a tear is still present/missed, the steroid injection can delay healing (but delayed past what, 1 year!?) or could predispose to complete peroneal tendon rupture - which then takes you to surgery anyway. Best case scenario is your pain improves again, you go back to running, but might be back again.
Again, I’d strongly recommend a good biomechanical/gait analysis - literally watch you run/bike (although I doubt this will turn up much if you have run 5 IM and countless marathons and are 37). And also, better imaging such as a diagnostic ultrasound or repeat MRI since it has been 1 year. 2 neg MRIs, 2 years apart can probably rule out a tear.
Good luck!
Preface: This is coming from a doctor of PT, who has also competed in triathlons for 16 years (including many Ironman distance events, so you know I’ve had the injuries, too).
I’d also recommend seeing a good PT who specializes in running (and cycling, if you can find such). “Calming” the area down is not enough. Even if you don’t have a tear to the peroneal area, it would seem definitive that you do not have tendonitis - it does not last for nearly the duration you are describing. What you would have (presuming no significant tear) is tendinosis. Think of this as your tendon turning somewhat into swiss cheese. You need to rebuild the tendon. The best way to do this, per research, is to emphasize eccentric exercises (the “negative” portion of a lifting exercise). You’re looking at 12 weeks of consistent, religious work on such. If all goes well, this is weeks longer than it will take to start feeling better. Unfortunately, getting something healed and getting something just better are often significantly different durations.
Has your balance been assessed? I agree with “rroof” that you undoubtedly have instability of the ankle, and that you are recruiting the peroneals excessively due to this instabililty (all the more reason to concentrate on the eccentric portion of your PT exercises, incidentally, as this part can help retrain the neuromuscular control over the joint). Balance work can often help improve your stability. This is key to avoiding overuse / inappropriate use of the stabilizing musculature in and around the ankle.
Don’t rule out the peroneus tertius, either!
Hopefully you are not taking NSAID’s (ibuprofen, naprosyn, etc) as these have been shown to be detrimental to tendon healing.
To answer your initial question, it is very unlikely the shoe. If anything, it is the shoe/pedal interface. Having a shoe which has float (to allow subtle motion through the lower leg rather than resisting such and just having muscles try to move the foot) and yet not have any tilt in them (meaning that you can make your foot go left and right, but not tilt like your bike when you’re climbing out of the saddle) is paramount. So I would ask you back: what pedals are you using, and how old are they?
-chris
Thanks for the reply. Just a few short answers as I am sitting at work at the moment.
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Did PT for 12 weeks between December 2006 and February 2007. Did a lot of negative exercise stuff. Started with calf raises, but only using the down ward movement. Moved on to full calve raises, etc. Did the side to side strengthening with the bands, and some balance work. Stand on one leg with eyes closed, etc. My left ankle is definitely less stable than my right. For instance, I can’t balance at all with my eyes closes on my left ankle. Did balance exercises and this did get better. Haven’t done them in the last 6 months. Maybe I need to get back on my exercise again? If so, how long should I be doing them for?
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No NSAID’s during treatment. None at all.
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I ride Speedplay pedals that were about 6 years old. X-1’s. I replace my cleats often. I just bought new pedals this past summer. Started with Shimano platform pedals but didn’t like them. Back to Speedplay X-2’s.
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Just did a 1/2 hour massage session for my leg. It seems like it really helps. Tender / sore spots are on the ends of the tendon or muscle. Near the bottom and near the top. The middle is o.k… Does this make sense?
BAck to the doctor for sure. I actually found one that does IM and is a competitive marathoner. Hopefully I can get a good diagnosis from him and start figuring this stuff out.
Looks like this place ghas them for all types of pedals.
The problem with spraining your ankles is that you stretch the ligaments. There is no way (shy of surgery) to shorten them. I’m not advocating surgery, btw!
What you’re left with is a need to bolster your muscular control over the ankle to improve the stability that is lacking due to the ligamentous instability. You do this by improving the neuromuscular system (i.e., balance, eccentric control, etc). Unfortunately, this is use-it or lose-it. As an analogy, imagine you have not typed on a keyboard for 6 months - you’d be a little rusty at typing (more mistakes, not as fast typing, etc). Practice (type) and it comes back. Stop typing, and it gets worse again.
In the case of your ankle, how long you can be away from practicing? Don’t know. But if you find yourself getting better with your exercises (which it sounds like you were), and then you stop doing those things that got you better (stop “typing”), you will get worse.
So how long should you keep doing them? Until you decide you don’t need to run anymore. Seriously. It’s not good, it’s not bad; it just is. You have an unstable ankle, and you need to keep the neuromuscular system sharp so it “takes up the slack” and keeps things working well. Think of it like diabetes - if you have it, you ahve to watch what you eat and check your blood sugars. If you do, you’re probably going to be just fine. If you don’t it will probably catch up to you. You don’t have diabetes (well, who knows, maybe you do?), but you do have instability and you have to do those things to keep it under control when you’re going to be doing high-level activities. Sorry!
-c
Remember, the body changes over time. Adapting to the environment and biomechanical changes. The ortho mentioned scar tissue, the peroneal problems could be a result of the injury that caused the scar tissue. Peroneal tendonitis is an overuse injury, did you ease back into training after years off? If you took time off and went back to your origional training that you were using in the past; your body may have changed, your running form may be different, the same shoes that you used back then may not be the correct ones for you now. There can be all sorts of things that can contribute to developing this condition. Your ortho would be the one to ask, does she have a sports medicine background? I would look for someone with that type of background to better understand your injury. Good Luck!
I think what you are saying makes a lot of sense. Still, I am not sure if my ankle / peroneal tendon was getting better because of the rest, the PT, or both. So in short I have to keep doing an ankle PT plan all of the time? Like every night? To go through all of the exercises I did was like 30 minutes a night. Seems a bit extreme- no? Or am I looking at maybe every other night? This is the disconnect I have. I am willing to go through PT again, and massage, and stretching- what ever. I am just not sure what “it” is that i need to be doing. At this point I don’t think I have found a doctor that does either. I think rroof had it nailed when he said that I don’t have a good diagnosis yet. With out that it is hard for me to have a lot of faith in anything I do to rehab this. I need a plan, but I can’t seem to put something together that gives me a lot of confidence.
I never took years off, just 12 weeks in oder to rehab my ankle / peroneal tendons. I did ease back into it. Easy running. No big volume. I still have never gone over about 40 miles a week since getting back to it. The last doctor I saw is an ankle / lower leg specialist and works out of a sports medicine clinic. It ws about the best fit I could find. Tried all different types of shoes but nothing seems to have helped.
I am not sure what to think about concerning the scar tissue around my ankle. Isn’t there some way to get rid of that stuff? She did mention a shot that she could do, and I thought she said it would be into my ankle. She said it would eliminate the scar tissue. If this is a cortisone shot then I am kind of afraid as I have heard that it will eat away all tissue, nut just the scar tissue. Am I wrong here? Should I be considering this shot in order to eliminate scar tissue?
Sorry, I missed your length of time off in your post. Tendonitis is tricky, some people have a problem, get treatment and are fine, others it is really tough to get rid of. Tendonitis is an overuse injury, I would say cut your miles down to allow your tendons heal.
Scar tissue can definetly be a hindrance. Some people it is fine, but other run in to pain, loss of range of motion, changes in body mechanics to adjust to scar tissue. I am not familar with a shot that reduces scar tissue (not saying that it doesnt exist) I think she may be offering you a cortizone injection or something similar. That may take care of the pain, but not necessarliy the problem. Cortizone does have some drawbacks too. I would definetly talk to your doctor about these questions.
When I asked her about the negative affects of the shot she just mentioned infection. That kind of put a red flag up to me. What are the potential side affects / outcomes of a cotizone shot? I think rroof mentioned possible rupture, but that was for the peroneals. Since this is about the ankle I don’t think that would apply.