Running & Rehab: Peroneal Tendon Injuries

A true runner without a history of pain or injuries is one in a million. The constant pounding on the ground through all of the joints in the body is bound to put stress on some area of weakness and eventually cause discomfort. If you have searched for the most common running related injuries or pain, you have probably come across knee or IT band issues. The ankle and foot are almost, if not just as common as those two. It makes sense why—the feet take on the most pressure during running since they carry our entire body weight throughout the running cycle. Foot structure and deformities are one of the main reasons injuries to this body part occur. Unfortunately once you injure the foot or ankle once, you are prone to getting injured again, especially if you do not take care of the cause.

Besides foot structure, general ankle instability is a problem for runners, causing a large percentage of traumatic injuries such as sprains and tears, as well as overuse injuries and pain like plantar fasciitis and tendonitis. An overlooked and often misdiagnosed issue is peroneal tendon dysfunction. The two peroneal tendons run along the outer side of the lower leg, one connecting to the side of the foot and the other underneath the foot. These tendons are responsible for eversion of the foot, which is the movement of rotating the foot out to the side. It is quite common for peroneal tendon issues to be mistaken for ligament injuries (sprains). Understanding the causes and how to address instability is key to full recovery from and prevention of peroneal tendon dysfunction.

Types of Peroneal Injuries

Tendonitis

This diagnosis presents itself with inflammation in one or both tendons and is usually caused by activities that involve repetitive overuse of the peroneal tendons. Trauma, such as an ankle sprain, can also cause tendonitis since when rolling the ankle the tendons must powerfully try to control from rolling too far. Pain is normally felt behind or underneath the outer ankle bone during activity, and subsides with rest. Treatment involves using anti-inflammatory pain medication, rest, and activity modifications. If the tendonitis is severe, immobilization for four to six weeks in a walking boot may be necessary.

Dislocation

Also called ‘subluxation’, this injury consists of the tendons snapping out of place over the outer ankle bone. There is a sheath that holds the tendons in place at all times that may tear with traumatic events and cause this dislocation. Already present deformities such a shallow or nonexistent groove where the tendons lie or a loose sheath to begin with can also be the cause. After the initial trauma, it may be difficulty to diagnose this issue since there is subsequent inflammation throughout the entire joint. The snapping is felt during forceful dorsiflexion and inversion, or flexing the ankle joint upwards as if raising the toes while rotating the foot inwards. Runners will feel the snapping during the push-off phase of running since it is a forceful movement from heel strike or a neutral position to pointing the toes downward.

Treatment for initial encounter subluxations can and should be treated conservatively with rest, immobilization in a cast or boot, and anti-inflammatory medications. For injuries involving a tear of the sheath, chronic dislocations due to ankle deformities, or failed conservative treatment, surgery will be the only option to repair the cause. After surgical repair, physical therapy will be necessary to manage pain and inflammation and restore motion and strength. Individuals who experience chronic dislocations of the peroneal tendons should seek treatment as soon as possible as this consistent snapping can lead to tears.

Tendon Tears

This peroneal tendon diagnosis can be a result of an acute traumatic injury such as a severe ankle sprain. Chronic issues such as consistent dislocations or weakness and instability in the ankle joint can also cause tears by means of overuse leading to fraying and splitting of the tendon. Individuals with high arches are more prone to this type of overuse and should consider using arch support orthotics in their shoes especially for running and other high impact sports. Surgery is usually required to repair the torn tendon, followed by immobilization and physical therapy.

Ankle and Foot Strengthening

Since instability and weakness are a main cause of most foot and ankle issues in runners, it makes sense to incorporate direct strengthening exercises for these areas. A simple strategy is to perform a few before an easy run about three times per week. Resistance bands can be used to target the main movements of the ankle as shown below. Heel and toe raises will also strengthen the calves and dorsiflexors (muscles along the shins). The smaller muscles of the foot can be strengthened with toe curls using a towel on the floor and trying to pick it up with your toes for up to ten repetitions for two to three sets. More advanced exercises consist of using unstable surfaces such as a balance disc or foam mat to perform exercises.

Ankle pain and instability is often diagnosed as a sprain, especially if there was a trauma. It is important to keep in mind that sprains can also involve tendon injuries. If you are diagnosed with a lateral ankle sprain and have done all treatment correctly but continue to have pain, the next step should be to follow-up with your doctor to check for any peroneal tendon injuries. Most cases with minimal symptoms do well with conservative management. Unfortunately if there is a greater loss of function, especially for athletes who want to continue their demanding sport, surgery may be necessary. As mentioned above, the foot and ankle joints are very important for runners, therefore any instability or weakness should be taken care of to avoid injury. If not taken are of, foot problems tend to lead to issues in higher joints such as the knee, hip and back. It is useful to remember that healthy feet leads to healthy running!

Sources

Kinner Davda, Karan Malhotra, Paul O’Donnell, Dishan Singh, and Nicholas Cullen, Peroneal Tendon Disorders, Journal, Apr 28, 2020.

Mobility Exercises Every Runner Should Be Doing

If you are a runner, then you have probably been told about how important it is to warm up before heading out for your workout. Some of us get a few stretches in and go straight to the run and others are usually short on time so skip it all together. You have probably heard static stretching, such as a prolonged quad pull, is not a good idea before running. This usually elongates and relaxes your muscles, which is something you do not want when you are getting ready to run fast. Instead, we are told to incorporate dynamic stretching, which is actually a mobility exercise rather than a flexibility exercise.

Having good flexibility means you can passively move your joints and muscles through a wide range of motion—passively meaning ‘in a relaxed state’. Having good mobility, on the other hand, means you can actively move your muscles and joints through a normal range of motion, but with proper form and strength. Many runners incorporate stretching before or after runs to treat or prevent tightness in the muscles, which is common in the hamstrings, hip flexors, and calves for the most part. Although tightness can relieve, the actual joint can remain stiff, causing poor running mechanics, which affects stride length, push-off, and torso rotation. All of these outcomes will create inefficient running limiting you from reaching faster paces, as well as increasing the risk of injury.

Ankle Mobility

It is best to include a 10 to 15-minute mobility warm-up routine before every run. This will assure you are properly warm and ready to hit the road (or trails or track). A good plan is to begin with the lower, smaller joints and work your way up. The following ankle mobility drills will get you ready to push off the ground with your full range of motion and keep your calves from overworking.

Rocking

Forward and backward ankle rocking involves the dorsiflexors and plantarflexors of the ankle. While standing, lift the forefoot and toes as high as you can and rock forward to lift the heels. Continue rocking forward and backward for 15 reps or 30 seconds. Rocking with lateral movements will involve the invertors and evertors of the ankle/foot joint. Lift the inner part of the foot while weight bearing on the outer edge and rock the ankles to switch and weight bear on the inner foot.

Rolling

In a seated or lying position with feet unsupported, roll the ankles making circles in both directions—clockwise and counterclockwise. This is a great exercise to do before getting out of bed in the morning, especially if you have issues such as plantar fasciitis. Besides making circles, you can also try writing out the alphabet with your ankles and toes.

Knee Mobility

Circles

Stiffness in the knees is a common complaint from runners. Mobility exercises can help ease this stiffness and create more efficient running mechanics so that the knees do not bear too much pressure during the run. While standing bend your upper body forward and place your hands on your knees. Rock the knees in small circles in both directions for a maximum of 30 seconds.

Quad Pulls

Just like a regular static quad pull stretch in standing, you can incorporate a dynamic version for mobility. Grab your right foot with your right hand behind your back and hold for two to three seconds. Alternate legs until you reach 30 seconds.

Hip Mobility

Glute Pulls

The hips are probably the biggest problem area for runners when it comes to proper mobility. Hip Stiffness and lack of mobility is the cause of short strides, decreased upward knee drive after push-off, and limited torso rotation. Glute pulls, similar to the quad pulls for the knees, will help mobilize the back side of the hips. While standing, lift your knee to your chest and hug tightly for two to three seconds. Alternates sides for 30 seconds total.

Military March

Tightness in the hamstrings’ connections to the hip and knee joint can cause stiffness that limits stride length and upward knee drive as well. Kick up the right leg as high as you can and reach your left hand to the right foot. Switch kicks for 30 seconds.

The Rest of the Body

The legs aren’t the only parts that need to move while running. The arms and trunk need their proper mobility, as they help propel the body forward and stabilize the hips, respectively. Arm swings are easy to do during your walk towards your starting point. Standing upper trunk rotations for a few seconds mobilizes your hips and spine. Lastly, neck mobility can be incorporated for a few seconds as well such as with clockwise and counterclockwise circles. As mentioned, these warm-up exercises will take 10 to 15 minutes and can also be done at other times during the day. After just a few weeks of consistent mobility work, you will notice the improvements in not only your stiffness but also your running form!

Plantar Fasciitis: The Best Treatment Approach

Does foot pain have you limping every time you get out of bed? Do you find yourself constantly rolling your arch with a water bottle every day with zero relief? If you are dealing with plantar fasciitis, as I have for years, it can be an extremely frustrating condition. Unfortunately this particular foot condition can take a while to get under control, but if you are diligent about management techniques, you can limit the effects plantar fasciitis has on your training program and daily life. What has worked for me may not work for everyone, but there are several tried and true methods that are worth the investment in money and time.

Treat the Cause

To understand how to treat your plantar fasciitis, it is important to know the cause, since treating symptoms will only lead to temporary results. This condition can arise from many different problems, and many are issues that are easily corrected.

Improper shoes: Since foot form and landing style can vary from person to person, the style of shoes you wear for every day use and running will largely impact the wear and tear on your feet. Runners who consistently train in low drop shoes are constantly stretching out the Achilles tendon. This undue strain leads to heel pain since the Achilles attaches to the area where the plantar fascia attaches. Since runners also use the calf muscles with every push-off in the running cycle, the calves tend to get overused and tight. Wearing shoes with a higher heel drop decreases the stress to the Achilles, therefore less strain on the bottom of the foot. All of my running shoes have an 8mm or larger drop, and I always rotate between several different pairs at once to give the different muscles of the foot a break at times.

Muscle Tightness: As explained above, tight calves can lead to heel pain. The lack of flexibility causes tugging on the attachment point at the heel where the plantar fascia attaches. Those who suffer from pain right at the base of the heel versus the arch can have success at relieving their issue by simply adding in more flexibility exercises to their program. Stretching the calves in standing both with the knee straight and bent is necessary in order to stretch all of the muscles that attach to the Achilles tendon. Daily post-run foam rolling is also beneficial for breaking up adhesions in the muscles that are causing the lack of flexibility.

Weakness: There are 26 bones in the foot, which means that many muscle attachments and more. The foot is commonly ignored when strength training, but it is the most important body part for runners since the feet carry our entire body weight through miles and miles. The small intrinsic muscles that control toe strength, stability, and range of motion for the feet and lower legs are constantly contracting and if there is any weakness, you can guarantee that much of the pressure gets applied to the fascia at the insertion points of the balls of the feet and heel, as well as in the center at the arch. Exercises such as the well-known “calf raises” (which is better referred to as ‘heel raises’) strengthen the push-off muscles, but it is important for runners to be incorporating toe raises as well in order to strengthen the shin muscles. To work the tiny muscles of the toes, a great exercise can be done in the sitting position: Place a small towel on the floor under the foot and curl the toes as if trying to pick up the towel. Repeat this motion for 2-3 sets of 10 repetitions a few times per week and you’ve hit the toe flexor muscles and stabilizers of the foot. Stabilizing the foot also involves strength from the inverter and everter muscles, which are basically in charge of controlling lateral movements (think rolling your ankle).

Foot Type:Any foot deformity such as bunions, hammertoe, low arches, or flat feet can greatly impact the pressure through the plantar fascia. Particularly having low arches or flat feet is the most concerning as this causes the fascia to be on a stretch at all times. The best relief for this cause is to make sure to wear the proper running shoes, which help supinate the foot, or lift the inner part of the foot to mimic having an arch. There are many insoles created for this purpose. My favorites are by Profoot, which you can find here. Runners with flat feet should also incorporate more hip external rotation and abduction exercises to help keep the hip, knee, and ankle aligned. Good choices to add into your routine are clamshells, banded lateral leg lifts, and hip hiking off of a step.

Personal Relief Strategies

I have dealt with plantar fasciitis for at least 8 years. I used to try to ignore it as much as possible and I got used to always waking up with heel pain and stiffness and it relieving after a few steps. When it would get bad to the point that it would bother me several times a day I would just stretch my toes sometimes and ice my feet when I wasn’t too lazy. All I was doing was controlling the symptoms at the time. Over the years I have developed a routine of different treatment tactics that have gotten me to the point of being pain-free at least 95% of the time. Here’s what has worked for me:

• Using Normatec Compression boots for 45-60 minutes at least 4 times per week—this has helped with my lower leg circulation and relieves general tightness and soreness.

• Rolling my foot with a spike ball every night for a few minutes—breaks up tightness and adhesions in the fascia.

• Wearing insoles for both running and walking most days—Profoot Plantar Fasciitis have been the best! I also use the toe separators every night for just 5 minutes, which helps stretch all of those intrinsic muscles I was referring to.

• Rotating between 5 pairs of shoes for running—currently I use Nike Pegasus Turbo for long runs, Nike Zoom Fly for speed and track sessions, and Saucony Guide Iso 2, Nike Epic React, and Adidas Ultraboost 19 for easy runs.

• Leg strengthening: from the hips all the way down to those small toe muscles—I work them all twice per week!

This is a combination of strategies that has helped me personally, which all have treated different sources of my pain. These may not work for everyone, but I will emphasize that you MUST first figure out what is causing your plantar fasciitis in order to find the right treatment for you! Get advice from an orthopedic specialist or physical therapist to evaluate your issue. Not taking care of plantar fasciitis can lead to many problems from ankle injuries to hip and low back pain, which will only keep you from running you best.

Achilles Issues & How to Fix Them

Some muscles work harder than others during running. One of these star players is the calves. Well, they pretty much work during every movement we do. Crossing both the ankle joint and knee joint, the calf is involved with any activity that requires us to push off of our toes. Not only that but they are also highly active when trying to control our descent during downhill running or walking. Since they play key roles during every part of running, we should be taking very good care of them every day. Strengthening and stretching the calves on a regular basis is an important part of training.

Having limited strength and flexibility in the calves leads to numerous injuries and pain including shin splints, plantar fasciitis, tendonitis, knee issues, and even hip and back issues over time. One common injury experienced by runners and many other athletes is Achilles’ tendinitis. The Achilles tendon is a thick band that connects the calf muscles to the heel of the foot. It is a prominent tendon in most people. All of the forces generated during running, especially during the push-off phase, are transmitted to the Achilles’ tendon. Faster running usually transmits more forces leading to injuries in the area.

What is Achilles’ Tendinitis?

When there is increased strain to the Achilles’ tendon, inflammation, irritation, and degeneration occur. The overworking of the tendon creates tiny microtears that weaken over time and can eventually lead to larger tears and ruptures. The most notable symptoms of Achilles’ tendinitis is visible swelling in the tendon, tenderness, and pain when first getting in up in the morning and when trying to stand on toes. Once it is warmed up the pain will usually subside and runners are able to run through it. As the condition worsens, the pain will gradually reappear and eventually limit the volume and speed of running. Tendon tears and ruptures will either have a visible bump over the area and commonly a gap where the tendon is ruptured.

Biomechanics

Although high volume training, speed training, and lack of strength are all causes of Achilles’ tendon issues, many physiological and biomechanical factors can increase the strain on the tendon and risk developing these problems.

Foot Strike

You have probably heard about how terrible heel striking is for runners. Well, the truth is that the research is inconclusive and heel striking actually works for some people. The reason this type of foot strike is related to Achilles’ tendon pain is that it involves increased stretching of the tendon. So if you already have tight calves to begin with, then the constant pulling during heel striking can lead to overstretching. The opposite type of foot strike, forefoot striking, actually creates a worse strain on the Achilles’ tendon. With this motion, you are basically landing on the toes and pushing off for the next stride all without giving the calves a break.

Pronation

Foot form is different for everyone. Flat-footed people or those with pronated feet (foot is turned inward when standing) will have a more strained Achilles’ tendon, as well as impeded blood flow to the area. There is already an area with limited blood supply, termed the “watershed area”, where the majority of tendon ruptures occur. This area is located about 4cm above the end point of the tendon on the heel. Limiting blood flow further as in the case of pronation will increase the risk of damage and slow healing on the tendon. Using supinated running shoes or inserts to decrease the amount of pronation is a treatment strategy.

Treatment & Prevention

Runners should focus on incorporating calf strengthening a couple of times every week, especially during their training seasons. Heel raises in all planes—toes pointed straight, toes pointed inward, and toes pointed outward are the main exercise for the calves. Seated heel raises or while in a squat position will help strengthen the soleus muscle, which is a muscle found deep under the gastrocs, the main calf muscles, that also connects to the Achilles’ tendon. Eccentric heel raises are the best way to strengthen the calf muscles as this will prepare the tendon for activities in which it is required to control the descent from extreme positions. To perform eccentric heel raises follow these steps:

1. Stand on a step with both heels hanging off.

2.  Lift both heels together.

3. Once completely on toes, shift all weight to only one leg and slowly lower the heel to just below the edge of the step.

4. Repeat 10-20 times on one leg, then repeat the same with the other leg.

Essentially this exercise will create a type of damage in the tendon, which strips away the previously damaged fibers and encourages the development of new fibers as a form of healing.

Runners should also incorporate stretching after every run and activity that highly involves the Achilles’ tendon such as hiking and climbing stairs. Stretching with both the knee straight and bent is important in order to include both the gastric and soleus muscles. Foam rolling is also helpful to break up any adhesions and extreme tightness in the muscles. Although strength training is time-consuming during training season, it is very important in order to prevent injuries. Achilles’ tendon injuries can be frustrating as they are frequently overlooked since the initial stages involve pain-free running. Taking care of Achilles’ issues from the start will involve a short rehab time while waiting until the pain is unbearable and affecting your running can leave you out of the sport for several months.

Sources:

Răzvan Aniţaş And Dan Lucaciu, A Study Of The Achilles Tendon While Running, Journal, Sep 07, 2018