Picture this: you’re out for a jog, feeling great, when a sharp pain suddenly hits the outside of your ankle. You shake it off, but the discomfort sticks around, making everyday activities like walking or standing a challenge.

If this sounds familiar, you might be dealing with peroneal tendinopathy—a condition affecting the tendons on the outer side of your ankle that help stabilize your foot during movement.

Surprisingly, this common cause of chronic ankle pain is often overlooked or misdiagnosed¹.

But the good news? With the right care and strategies, you can recover fully and get back to doing what you love. Let’s dive into what causes this condition, how to spot it, and the best ways to treat it.

The Short Version

Peroneal tendinopathy is irritation of the peroneal tendons that run along the outer side of the ankle, and it is a common cause of outer-ankle pain, especially in runners and people who have had ankle sprains. It usually comes on gradually and tends to be worse with activity and on uneven ground. Most people improve with a graded plan of loading exercises, activity adjustment, and hands-on therapy rather than surgery, though it can be slow. A proper assessment helps confirm the diagnosis and rule out other causes of outer-ankle pain — such as a tendon that slips out of place, a ligament injury, or a fracture — that need different care.

If outer-ankle pain is affecting you, a proper assessment is the best place to start.

Make Your Booking

Chat on WhatsApp

What is Peroneal Tendinopathy?

Peroneal tendinopathy is a condition where the tendons on the outer side of your ankle—called the peroneal tendons—become irritated or damaged.

These tendons, the peroneus brevis and peroneus longus, are important for keeping your foot steady and preventing ankle injuries. They work hard during activities like walking, running, and balancing, which makes them prone to overuse or injury.

Who Does Peroneal Tendinopathy Affect Most?

This condition is most common in people who are very active. Runners, dancers, and athletes who do sports with quick changes in direction, like soccer or basketball, are at higher risk². For runners, things like poor technique or wearing the wrong shoes can make it worse.

People with naturally high arches or older adults are also more likely to develop this condition because their feet can put extra pressure on the tendons³.

How Common Is Peroneal Tendinopathy?

Peroneal tendinopathy is more common than many people realize. Studies show it’s a frequent cause of outer ankle pain and can be found in up to 40% of people who have long-lasting ankle problems⁴. The condition is often missed during diagnosis, especially if it isn’t looked for specifically¹.

Common Signs and Symptoms of Peroneal Tendinopathy

Pain on the Outer Side of Your Ankle: A dull ache or sharp pain that’s focused along the outside of your ankle, especially near the bony bump (lateral malleolus).
Swelling or Puffiness: You might see swelling around the outside of your ankle, particularly after physical activity.
Stiffness in the Morning: Your ankle may feel stiff or tight when you first get out of bed but loosen up after moving around.
Pain During Activity: The pain often gets worse during activities like walking, running, or balancing on one foot.
Tenderness to Touch: The area along the tendons may be sensitive if you press on it.
A Feeling of Instability: You might feel like your ankle is weak or could give out, especially on uneven surfaces.
Pain When Turning Your Foot Outward: Movements like turning your foot outward or pushing off your toes can make the pain worse.
Cracking or Popping Sensation: You might feel or hear a popping or snapping sound near your ankle when you move it.
Trouble Standing on Tiptoes: It may be difficult or painful to stand on your toes or push off your foot.
Pain After Resting: The pain can be worse after sitting or resting for a while, even if it felt fine during activity.

Why Does Peroneal Tendinopathy Happen?

Peroneal tendinopathy happens when the tendons on the outside of your ankle are put under too much stress or are used more than they can handle.

Over time, this can lead to tiny injuries in the tendons, causing pain and making it harder for them to work properly.

Let’s break this down into the key reasons why this happens:

Overuse of the Tendons

The most common reason for peroneal tendinopathy is overuse. Activities like running, jumping, or balancing on uneven surfaces put repeated stress on the peroneal tendons.

These tendons work hard to keep your ankle stable during movement, and when they don’t get enough rest, they can develop tiny tears. These small injuries don’t recover properly if you keep using the tendons, leading to inflammation and pain¹.

Poor Foot Mechanics

The shape and structure of your foot can also play a big role. If you have high arches (cavus feet), your peroneal tendons are stretched more tightly during movement. This increases their workload and can lead to injury. Flat feet, on the other hand, can make your ankle less stable, forcing the tendons to work harder to keep you balanced³.

Sudden Increase in Activity

Have you recently started a new workout or increased your training? Tendons take time to adapt to new stresses. A sudden jump in activity, like running longer distances or trying a new sport, can overload the tendons before they’ve had a chance to strengthen, leading to tendinopathy².

Weak or Tight Surrounding Muscles

If the muscles around your ankle and lower leg are weak, they can’t support your movements as well, which shifts more work to the peroneal tendons.

Tight calf muscles can also add strain by pulling on the tendons during movement. This combination of weakness and tightness can set the stage for injury⁴.

Poor Recovery After Injury

If you’ve had an ankle sprain or other ankle injury, your peroneal tendons may already be weak or damaged. Without proper rehabilitation, they might not recover completely, leaving them vulnerable to future injury. This is especially true if you return to activity too soon after an injury⁵.

The Body’s Response to Stress

When tendons are overworked or injured, they go through changes that can make the condition worse. Instead of being smooth and elastic, the tendon tissue becomes thickened and disorganized, making it weaker and more prone to further damage.

This is why the pain and stiffness don’t go away quickly—it takes time for the tendon to recover and for healthy tissue to replace the damaged areas⁶.

What Other Conditions Could It Be?

Ankle Sprain

An ankle sprain causes sudden pain after twisting the ankle, often with bruising and swelling. Peroneal tendinopathy develops gradually without a clear injury event⁵.

Peroneal Tendon Subluxation

This occurs when the tendons slide out of place, often after an injury, with a snapping sensation and instability. Tendinopathy causes constant pain rather than specific movement-related symptoms⁶.

Achilles Tendinopathy

Achilles tendinopathy causes pain near the back of the heel or calf, not the outer ankle, and is common in jumping or running sports. Peroneal tendinopathy pain is more localized to the outer side of the ankle⁷.

Lateral Ankle Ligament Injury

Ligament injuries often follow a twisting event and involve instability and bruising, unlike the gradual onset of peroneal tendinopathy⁸.

Stress Fracture of the Fibula

Stress fractures cause persistent pain that worsens with weight-bearing and doesn’t improve with rest, while peroneal tendinopathy pain may ease during activity but return afterward¹.

Types of Scans

Ultrasound

An ultrasound is often the first choice because it’s quick, painless, and shows how your tendons are moving in real-time. We’d look for signs of swelling, small tears, or fluid around the peroneal tendons. It can also show if the tendons are slipping out of place, which can happen with this condition⁹.

MRI (Magnetic Resonance Imaging)

An MRI provides a detailed picture of the tendons and surrounding tissues. It’s especially helpful for spotting more severe damage like large tears or degeneration in the peroneal tendon.

We’d also look for any changes in the tendon’s thickness or structure, which can confirm the diagnosis¹⁰.

X-Ray

While an X-ray doesn’t show the tendons, it’s still useful to rule out other causes of your pain, like a stress fracture or bone spur. If the bones around your ankle look normal, we can focus on diagnosing tendon-related problems⁶.

Is Surgery Needed?

Surgery for peroneal tendinopathy is typically considered only when other treatments haven’t worked. It’s an option for specific cases where the damage is severe or persistent. Here’s when surgery might be needed and what it involves:

Indications for Surgery

Large tendon tears that don’t recover on their own.
Severe degeneration where the tendon tissue is worn down and no longer functional.
Tendon instability, such as subluxation (tendons slipping out of place).
Chronic pain and dysfunction lasting for months despite therapy⁶.

Common Surgical Procedures

Tendon Repair: Repairing tears to restore function.
Debridement: Removing damaged tissue to support recovery.
Tendon Stabilization: Securing tendons that are slipping out of place⁵.

How Physiotherapy Helps After Surgery

After surgery, physiotherapy is critical for a full recovery. Here’s how it helps:

Restore Movement: Gentle exercises to regain range of motion in your ankle.
Strengthen Tendons: Targeted strengthening exercises to rebuild tendon and muscle function.
Improve Balance: Training to stabilize the ankle and lower the risk of future injuries¹².

When to Have Outer-Ankle Pain Assessed in Person

Most outer-ankle pain is mechanical and settles with the right care, but a few warning signs point to problems that need a prompt check. It is worth being assessed in person — or seeking urgent care — if you notice any of the following:

A snapping or popping sensation at the outer ankle, or a feeling that a tendon is flicking or slipping over the bone — this can suggest peroneal tendon subluxation or dislocation, which is managed differently from tendinopathy.
Severe pain or inability to put weight on the foot after a twisting injury or fall — this needs assessment to rule out a fracture or a complete tendon tear.
A hot, red, swollen ankle with fever or feeling generally unwell — possible infection, which needs prompt medical attention.
Numbness, pins and needles, or weakness spreading into the foot — this can point to nerve involvement rather than the tendons alone.
Pain that is steadily worsening, or not improving despite several weeks of sensible care.

These signs do not always mean something serious, but they are worth checking properly rather than guessing. When in doubt, get assessed in person.

Treatment Options For Peroneal Tendinopathy

If you’re dealing with peroneal tendinopathy, a physical therapist can offer a range of treatments that may help to help you recover.

These treatments focus on reducing pain, improving strength, and restoring movement so you can get back to your activities. Here’s what might be part of your therapy plan:

Exercise Therapy

Targeted exercises are the foundation of recovery for peroneal tendinopathy. Strengthening the peroneal muscles helps support your ankle and reduces stress on the tendons.

Strengthening exercises, such as resistance band exercises and balancing drills, build stability.

Myofascial Release

Myofascial release involves hands-on techniques to ease tension and improve blood flow in the tissues around the tendons. This can reduce stiffness and support the tendons during recovery. It’s especially useful if you have tightness in the calf or foot contributing to your pain¹².

Orthopedic Manual Therapy

Manual therapy involves gentle hands-on techniques to improve how your ankle moves. Mobilizations can free up stiff joints around your ankle, reducing stress on the tendons. Manipulations, if needed, can correct alignment and improve movement patterns¹².

Laser Therapy

Laser therapy uses light energy that may support recovery and help manage inflammation. It’s non-invasive and can be particularly helpful for relieving pain and speeding up peroneal tendinopathy recovery¹¹.

Dry Needling

Dry needling involves inserting very thin needles into trigger points or tight areas in the muscles around your ankle. This helps reduce muscle tension, improve blood flow, and relieve pain. It’s especially helpful if muscle tightness is making your symptoms worse.

Strapping and Taping

Strapping or taping can give your ankle extra support and offload the tendons while they recover. Techniques like kinesiology taping can help reduce pain during activity and improve stability.

Frequently Asked Questions

How long does peroneal tendinopathy take to settle?

It varies and can be slow. Many people improve over a few months with a graded loading programme, activity adjustment, and supportive footwear, though some take longer. A physiotherapist can help set a realistic timeline and adjust the plan as you progress.

Can I keep running or training with peroneal tendinopathy?

Often you can stay active, but it usually needs adjusting. Low-level pain that settles quickly afterwards is generally acceptable, while sharp or worsening outer-ankle pain is a sign to reduce load and get assessed. A graded plan tends to work better than pushing through or stopping completely.

What is the difference between peroneal tendinopathy and an ankle sprain?

An ankle sprain usually comes on suddenly after twisting the ankle, often with immediate bruising and swelling. Peroneal tendinopathy tends to build up gradually with overuse, causing pain along the outer ankle and behind the bone. They can occur together, which is one reason an assessment helps.

Do I need a scan to diagnose it?

Not always. The diagnosis is often made from your history and a physical assessment. Ultrasound or MRI can be useful to confirm the diagnosis or rule out other causes, but imaging findings are common even in people without symptoms, so scans are interpreted alongside your symptoms rather than on their own.

When should I see a physiotherapist about outer-ankle pain?

It is worth getting assessed if your outer-ankle pain is not improving, keeps returning, or is limiting your activities. Seek a prompt check for pain you cannot weight-bear on after an injury, or a snapping or slipping sensation at the outer ankle.

Conclusion

Peroneal tendinopathy doesn’t have to keep you from doing the things you love. With the right treatment plan—including targeted exercises, manual therapy, and options like taping —you can reduce pain, restore strength, and protect your tendons from future injuries. Recovery takes time and dedication, but each small improvement brings you closer to feeling like yourself again.

If you have questions or need help creating a personalized recovery plan, I’m here to guide you every step of the way. You don’t have to face this alone—together, we’ll get you back on track.

Ready to take the next step? Book a session at Daniel da Cruz Physiotherapy in Sandton.