Good day dear gurus ,
For the past couple months I’ve had pain on the outside of the right ankle, mostly in the mornings and after in activity. After some really smart efforts, such as 12 mile mountain trail run (Floridian) it really flared up. I dialed my training down hoping it was going to solve itself, which it didn’t. Naturally the dialing down was not complete inactivity, but mainly dropping runs to lower intensity. Ice and ~200mg ibuprofen did not seem to do the trick, so 3 weeks ago I dropped running altogether and finally got some swims in, that i do desperately need. I find that bike does not seem to aggravate it too much as long as stay on the saddle. However the pain still resided and after self diagnosing it as an Peroneal tendon related issue, went through the super helpful posts here. the reason for a new post is simply that it appears that my issue is a bit milder and does not seem to require surgery and as such could be helpful for others. I met with my Dr, who agreed with the diagnose and mentioned that i may know more about it than he does (now that’s funny). I had x-ray done, since it seems that insurance companies require that before signing of an MRI. The x-ray showed pretty much nothing (transcript below). MRI was approved and I got that done last Friday. As far as i can tell it is not in the “put a boot on it” or “cut it open and sew it back together” shape. The dear Dr suggested RICE, which is funny since he is also an triathlete. We all know that RICE means something different to everybody and certainly to tri geeks.
Finally to the question: What next? Should I see a podiatrist or ortho? How would I find and specialist that is not going to give the standard “stay off activities for N weeks and we will see then” suggestion. Keep on swimming and biking? When should I introduce running?
Obviously I want the tendon area heal, but the season just around the corner, obviously wouldn’t want a complete non activity either.
MRI
INDICATION: Lateral right ankle pain. Attention peroneal tendon.
719.47
COMPARISON: X-rays of the right ankle dated 3/11/14.
TECHNIQUE: Multiplanar, multisequence imaging without contrast.
FINDINGS:
SOFT TISSUE : Mild soft tissue swelling and edema most pronounced
about the lateral aspect of the ankle and hindfoot. There is no
discrete soft tissue mass or abscess for an unenhanced exam.
LIGAMENTS: Anterior and posterior inferior tibiofibular ligaments
and the distal tibiofibular synchondrosis are intact. Anterior and
posterior talofibular as well as calcaneofibular ligaments are also
intact. The deltoid ligament complex and spring ligament are also
intact.
TENDONS: The Achilles tendon is intact. Flexor and extensor tendons
are also intact. Peroneus longus and peroneus brevis tendinopathy and
tenosynovitis.
BONES: Mild edema is seen in the plantar aspect of the calcaneus
posteriorly most compatible with stress response. No discrete
fracture.
ARTICULAR CARTILAGE : Relatively well-maintained.
JOINTS: Small tibiotalar and subtalar joint effusions are noted.
ADDITIONAL FINDINGS: Mild edema about the proximal plantar fascia.
IMPRESSION:
1. PERONEUS LONGUS AND PERONEUS BREVIS TENDINOPATHY AND TENOSYNOVITIS.
2. MILD ACUTE PLANTAR FASCIITIS AND MILD STRESS RESPONSE IN THE
PLANTAR ASPECT OF THE CALCANEUS.
3. SMALL TIBIOTALAR AND SUBTALAR JOINT EFFUSIONS.
X-Ray
ANKLE COMPLETE 3 OR MORE VIEWS ANKLE COMPLETE 3 OR MORE VIEWS
CLINICAL INDICATION: Right ankle pain
COMPARISON: None
FINDINGS:No evidence of acute fracture or dislocation. Medial and
lateral malleolus demonstrated evidence of prior trauma with calcific
densities. No other abnormal calcification or soft tissue masses.
Small inferior calcaneus spur seen.
IMPRESSION: NO ACUTE BONY ABNORMALITY.
Thank you so much in advance. As a disclaimer I am not seeking for a medical advice and understand I am not given one 
Go get Grastons and Acupuncture from someone reputable. I had it done for for this exact issue last year. 2 weeks later I ran a Half Marathon pain free. I could barely walk on the onset of pain. It only took a couple of sessions. My case was probably less severe than yours but it was incredibly painful none the less. Also I took Cissus to supplement my recovery (popular in the weight lifting crowd for its anti inflammatory properties and tendon repair ability (Not proven))
I’ve just successfully rehab’d something similar. I recommend in addition to the massage treatments suggested that you go see a physio (or similar) and find out what biomechanical wonkiness is the trigger.
For me I have a mild ‘duck foot’ out on my right side, probably brought about my my tendency to flop my right knee out when I lay on my back and drive. I did a bunch of strengthening of my hips including some to compensate for that external rotation. Back running etc but can tell when I am behind on my drills and massage.
Good luck!
I met with my Dr, who agreed with the diagnose and mentioned that i may know more about it than he does (now that’s funny).
If that is in jest … ok. If it is has any semblance of accuracy … find a new doctor.
Finally to the question: What next? Should I see a podiatrist or ortho? How would I find and specialist that is not going to give the standard “stay off activities for N weeks and we will see then” suggestion.
You should see an orthopedic surgeon who specializes in the foot.
Several years ago I had what turned out to be a small ‘vertical’ tear in the Peroneal Longus tendon. In a 6 month search, I went through 2 podiatrists and an orthopedic surgeon all of whom misdiagnosed it. Then I found an orthopedic surgeon who specialized in the feet and who had done thousands of surgeries. He accurately diagnosed it in 2 minutes. Since it is a tendon issue, the Xray is useless. He did have me do an MRI but he told me that 50% of the time a vertical tear will not show. Mine didn’t. He repaired it and 2 months later I was back to running without pain.
Darned, I sure hope I won’t need stabbing. How did he diagnose it, if it didn’t show on MRI? But in the big picture, surgery might be the fastest option. Problem I have is that I sure don’t want this to come back in middle of the summer.
Another thing I did not mention; during activity, I can barely feel any pain. Unfortunately that allows me to pushy bit too hard.
Have a friend in the needle stabbing business, so that’s a great idea to consider
Two years ago I accidently banged my right foot on the corner of the Comptrainer platform and immediately had acute pain. Pain somewhat relieved with NSAID and was able to run on it but pain flared up big time after running on it. Podiatrist examined and did the X-Ray, oral steroids and steroid injections routine without relief. After four weeks, he got the OK for a MRI which revealed partially torn Peroneal tendon at the insertion. Wore a boot for nine weeks and then another four weeks of gradual removal of the boot. Swam all I wanted. No biking for 13 weeks and another 5 weeks before a slow and gradual introduction of running. Tendons don’t heal quickly especially as one get older.
well, I have been saying that I need concentrate on swimming…
What got me through my peroneal tendonitis:
- a couple of sessions of dry needling by physio
- no running at all for what seemed like forever (probably 6 weeks)
Very lucky to have no issues now (knock on wood). Was so painful at one stage I battled to walk.
I never had an MRI or xray or anything like that.
How did he diagnose it, if it didn’t show on MRI?
The pain was behind my ankle. He put my foot in a position and then worked those tendons under the ball of my foot. Same tendons, just where he could access them. Literally played them like guitar strings. He knew which tendon went where and when I felt the pain he recognized the relationship. Like I said, he has done over 20,000 surgeries in his long career … so he has encountered this many times previously.