Peroneal tendinopathy

What it is

Overload of the peroneal tendons, which run down the outside of the lower leg, hook behind the outer ankle bone and attach under the foot. Their job is to turn the foot outward and, more importantly here, to stop it rolling inward. In a tendinopathy the tendon has been asked for more than it can currently supply and has become irritated and sore rather than torn.

How volleyball causes it

These tendons are the ankle's brake against rolling over, and every step in sand asks them to work. They flare after a spell of beach or grass volleyball, after a lateral ankle sprain when the ankle is relying on them for stability it used to get from ligament, and in players who habitually land slightly on the outside of the foot. Uneven ground, an unraked court, or a partner's foot underfoot all add sudden demand.

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What it feels like

• Pain behind or just below the bony bump on the outside of the ankle.
• Worse with pushing off, cutting, or walking on soft or uneven ground.
• Tender to press along the tendon rather than over the bone itself.
• Sometimes a swelling or thickening you can feel along the tendon line.
• Often follows a period of increased beach play, or an old ankle sprain that never fully rehabilitated.

Stop and get it seen if

• A snapping or clicking sensation as the tendon moves over the bone, especially with a feeling of it slipping out of place.
• Sudden inability to turn the foot outward against resistance.
• Marked swelling, bruising, or an inability to bear weight.
• Pain over the bone itself rather than the tendon, which needs a fracture ruled out.
• Numbness or pins and needles into the foot.

What recovery usually looks like

Stages, not a schedule. Everyone moves through these at their own pace, and the ranges are wide because real recoveries are.

1. 1. Calm it down

   1 to 2 weeks

   Reduce the daily provocation while keeping the tendon loaded enough not to deteriorate.

   • Walking and stairs are comfortable.
   • Isometric holds turning the foot outward can be done without pain.
   • The aggravating volume, usually sand hours, has been cut rather than pushed through.
   • Pain settles within 24 hours of activity rather than lingering.

2. 2. Load the tendon

   4 to 8 weeks

   Build capacity in the peroneals and the whole ankle rather than resting and hoping.

   • Resisted eversion is getting stronger and is comfortable through range.
   • Single-leg balance is steady, including on an unstable or soft surface.
   • Calf raises are strong both straight and bent knee.
   • Hopping and lateral movement are tolerable.

3. 3. Back to the surface

   2 to 4 weeks

Ready to play again when

• Full pain-free range turning the foot in and out.
• Eversion strength comparable side to side.
• Able to hop and cut on the leg without pain.
• A full session on the aggravating surface without a next-day flare.
• No tenderness along the tendon.

Keeping it from coming back

This is ordinary training, so unlike the rest of this page it does tell you what to do.

• Train resisted eversion directly, turning the foot outward against a band for sets of fifteen to twenty. Almost nobody trains this direction, and it is the exact action these tendons exist for.
• Build single-leg balance on a soft surface, thirty to sixty seconds a side, eyes open then closed. Sand is an unstable surface and the ankle needs to be trained on one.
• Rehabilitate ankle sprains properly rather than to the point where they stop hurting. A ligament that never regained its stability leaves the peroneals doing its job every session.
• Build beach volume gradually when you move outdoors for a season, rather than going from indoor courts to five sand sessions a week in the first fortnight.
• Rake or walk the court before playing, and level obvious holes. Most sudden ankle loads outdoors come from a foot landing somewhere it did not expect.
• Strengthen the calf as a whole, both straight and bent knee, so the peroneals are not the only structure controlling the ankle when you are tired.