Quick Summary
Peroneal tendinopathy is a common cause of pain on the outside of your ankle, usually developing from overuse or after repeated ankle sprains. The two peroneal tendons that run behind your outer ankle bone become irritated and painful, often leaving the ankle feeling weak or unsteady. Our physiotherapists combine hands-on manual therapy, a progressive loading programme and balance retraining, and where suitable we offer radial shockwave therapy — typically 3–6 sessions.
What Is Peroneal Tendinopathy?
Peroneal tendinopathy describes pain and loss of function in the two peroneal tendons — peroneus longus and peroneus brevis. These tendons run down the outside of your lower leg, curve behind the bony bump on the outside of your ankle, and help turn your foot outwards and point it downwards.
They are key dynamic stabilisers of the ankle, working constantly to stop your ankle rolling inwards. Because of this role, they are placed under considerable strain during walking on uneven ground, running and changes of direction.
The term covers a spectrum of tendon problems: degenerative change within the tendon itself (tendinosis), irritation of the surrounding sheath (tenosynovitis), longitudinal split tears, and abnormal movement of the tendons within their groove. Current understanding follows the tendon continuum model, which describes overlapping stages from an early reactive response to overload, through disordered healing, to established degenerative change (Cook and Purdam, British Journal of Sports Medicine, 2009). Importantly, a tendon can move back along this continuum — which is why managing load sits at the heart of treatment.
Foot shape and previous injury both matter. A high-arched foot with a heel that sits turned inwards places the peroneal tendons under chronic strain, and research has found significantly higher rates of peroneal tendon problems in people with this alignment (Taniguchi et al., Foot and Ankle International, 2021). The condition is also closely linked with previous lateral ankle sprains and ongoing ankle instability, and it is frequently mistaken for a simple ankle sprain — which is why an accurate assessment matters.
Do You Experience These Symptoms?
✓ Pain and sometimes swelling around the outside of your ankle — above, behind or below the outer ankle bone
✓ Pain along the outer border or instep of your foot, sometimes reaching towards the base of your little toe
✓ Symptoms that worsen with walking, running, jumping or walking on uneven ground, and ease with rest
✓ A feeling of instability, or your ankle giving way, particularly on uneven surfaces
✓ Pain when rising onto the ball of your foot or turning your foot outwards against resistance
✓ Stiffness or pain after rest, especially with your first steps in the morning
✓ A clicking or snapping sensation behind your outer ankle bone
These symptoms can be treated.
The sooner you begin, the better your chances of a smoother recovery.
What Causes Peroneal Tendinopathy?
• Overuse and sudden increases in load
Peroneal tendinopathy is primarily an overuse injury, where repeated stress causes micro-damage to build up faster than the tendon can repair it.
A sudden rise in training volume, running distance or intensity is one of the most common triggers.
• Previous ankle sprains and ongoing instability
The peroneal tendons are commonly injured during lateral ankle sprains, and repeated rolling injuries place them under recurrent strain.
When the ankle feels unstable the tendons must work harder as stabilisers, driving ongoing overload and irritation.
• High-arched foot and inward-turned heel
A high arch with a heel that sits turned inwards shifts load onto the outer border of your foot and keeps the peroneal tendons under constant tension.
Research has demonstrated significantly higher rates of peroneal tendon problems in people with this foot alignment.
• Unsupportive footwear and uneven surfaces
Worn-out or unsupportive shoes, and repeatedly walking or running on uneven or sloped ground, increase the demand on your peroneal tendons.
Training technique and inadequate recovery between sessions can compound the problem.
• Contributing health and biomechanical factors
Carrying additional weight increases load through the tendons, and conditions such as diabetes and inflammatory arthritis have been linked with a higher risk of tendon problems.
Weakness or tightness through the foot, ankle, calf and hip can also alter your mechanics and overload the peroneals.
How We Treat Peroneal Tendinopathy at J&J Therapy
Hands-On Manual Therapy
Hands-on soft-tissue work and mobilisation of the ankle and subtalar joints to reduce pain and restore normal movement — alongside assessment of your calf, foot and hip mechanics to address what is overloading the tendons.
Shockwave Therapy*
Swiss Storz Medical MASTERPULS
to deliver targeted pressure waves to the peroneal tendons on the outside of your ankle, which research suggests may stimulate the healing response and help reduce tendon pain.
Non-invasive, evidence-based. Typically 3–6 sessions.
Targeted Exercise Programme
A progressive loading programme building from isometric work to heavy slow resistance and eccentric strengthening, combined with balance and proprioception retraining and a graded return to walking, running or sport.
When to Seek Urgent Medical Help
While most symptoms are not serious, urgent medical attention is required if you experience any of the following:
A sudden pop or snap followed by bruising and marked weakness turning your foot outwards
Inability to bear weight, or severe tenderness over the outer ankle bone or the base of your little toe
Increasing redness, warmth, swelling or fever suggesting infection
Spreading numbness, pins and needles, or difficulty lifting your foot
FAQs About Peroneal Tendinopathy
How long does peroneal tendinopathy take to recover?
Recovery varies from person to person. Many people improve within around three months of following professional advice, though for some it can take considerably longer, with occasional flare-ups along the way. Staying consistent with your loading programme is the single most important factor in your recovery.
Can I keep running or exercising?
Often yes, but with modification. A useful guide is that if an activity causes pain during it, immediately afterwards, or the following day, it needs scaling back. Low-impact options such as swimming or cycling can help you maintain fitness while the tendon settles, and we will guide a graded return to your usual activity.
Do I need a scan?
Not usually. Peroneal tendinopathy is generally diagnosed clinically through examination. Imaging such as ultrasound or MRI may be arranged if the diagnosis is unclear, if a tear or tendon instability is suspected, or if your symptoms are not improving as expected.
Can shockwave therapy help my peroneal tendinopathy?
Research into shockwave for peroneal tendinopathy specifically is still limited, but it is a recognised treatment option and evidence from similar lower-limb tendon problems suggests it may help reduce pain when combined with exercise. Our physiotherapists use the Swiss Storz Medical MASTERPULS radial shockwave device, usually over 3–6 sessions alongside your rehabilitation programme. It is non-invasive, and we will assess whether it is suitable for you.
Will I need surgery?
Rarely. Most people improve with conservative care. Surgery is generally considered only after a prolonged period of unsuccessful conservative treatment, or for specific structural problems such as an unstable tendon or a significant tear.
This page is for general information only and does not replace professional medical advice.
Reviewed by Lavya Arigalayan, MSc, HCPC Registered Physiotherapist.
Last reviewed: