Nagging Ankle Pain? Here’s How to Get Back to Sending

A loud audible “pop” is heard as you rock onto a high foot. Or, perhaps it was a recent knee bar or an aggressive sit start that did it. Almost immediately, you have diffuse pain along the outside of your ankle and into the foot. At first, it seems like maybe just a weird ankle sprain, but you can actually see and feel the tendons gliding across that knob on the outside of your ankle… and it doesn’t take a doctor to know that ain’t right! 

The peroneal muscles are important stabilizers of the ankle and foot.^1,2  They are responsible for pointing the foot downward (plantar flexion) and also outward (eversion). The tendons of peroneus longus and peroneus brevis wrap behind the knob on the outside of your ankle (lateral malleolus) and insert into the foot. The band of ligamentous tissue that keeps the peroneal tendons in place behind that knob is called the superior peroneal retinaculum (SPR). The SPR is essentially the finger pulley of the lower extremity.³ Lateral ankle sprains—and even certain climbing moves—can put extreme forces on the SPR, resulting in a tear and a “pulley” that no longer performs its proper function.³ If this has happened to you, read on for my recommendations on what to do for peroneal tendon subluxation.

Climbers, hikers, and trail runners—may be prone to another type of injury involving their peroneal tendons known as tendinopathy. Tendinopathy could either mean new inflammation of tendons (tendonitis) if this is the first time you are having this pain, or it could mean tissue degeneration from overuse injuries that never healed (tendinosis).¹ These types of tendon maladies are usually a result of both extrinsic factors (e.g. tight or worn out shoes, uneven terrain, training errors) and intrinsic factors (e.g. foot anatomy, age). Tendinopathy usually accompanies a change in the amount or intensity of loading for which the tissue was not prepared.^1,4,5 

A perfect example of improper tissue loading is the time I decided to go for a 20-mile through-hike with a multi-pitch alpine trad climb in the middle. This 21-hour car-to-car slog was a memorable trip without a doubt, but sadly, my feet were a tad under prepared. I wore a pair of well-traveled (read: worn out) runners, and I hadn’t trained much at all in the weeks leading up to the trip. Needless to say, an overuse injury was imminent. It was a week before I could walk normally and without pain.

A history of ankle instability, training errors, or poor footwear choices mixed with long approaches on uneven terrain can all lead to nagging pain on the outside of the ankle, even if you haven’t had a recent sprain.^1,6 Below, I have outlined some simple ways to diagnose a possible peroneal tendinopathy and how to rehabilitate this injury.

Signs and Symptoms^(1,2,5,7)

• What:
  • Pain, swelling, warmth, feeling of instability
• Where:
  • Outside of the ankle (just behind the malleolus/bony knob) perhaps extending down into the outside foot
• When:
  • Any movement which forcibly brings your foot toward your shin (e.g. landing from a jump/fall, rocking onto a high step, knee bar) 
  • Walking or jogging on uneven terrain
  • Rising onto the ball of your foot or remaining there for extended periods 
  • Foot jams

Assessment^(2,5,8)

The following videos will walk you through a brief assessment for diagnosing peroneal tendinopathy. Some key signs to look for are below.

• Pain and tenderness to touch along the peroneal tendons
• Pain and tenderness in the peroneal tendons with resisted movements and/or stretching

Peroneal Tendinopathy Assessment

Assessment Part 1

Assessment Part 2

Treatment Strategies: The Rock Rehab Pyramid

Below, I have outlined a progression of activities and exercises which may be helpful in treating peroneal tendinopathy. The framework for my ideas is based on The Rock Rehab Pyramid, a self-treatment approach for common climbing injuries designed by physical therapist Dr. Jared Vagy. For more information, please check out his book, Climb Injury-Free. Any advice presented here is not meant to replace the one-on-one guidance of a medical professional. Perform at your own risk.

Step 1: Unload + Activity Modification

Before resuming your regular training routine, you need to take some time to unload and let pain and inflammation subside. Depending on the extent of your injury, it could take days or possibly weeks for overloaded tissue to heal sufficiently to resume gradual mobility and strengthening work. While it’s never convenient to take time off or reduce the intensity of your training, keep in mind that tendinous injuries are infamous for lingering—it’s better to do things right the first time. Start by avoiding any activity or movement that provokes pain. Consider some of the following ideas to unload the tissue while pain and inflammation subside.

• Ease up on your climbing frequency and intensity or even take a few consecutive rest days if needed
• Wear an ankle brace for added support, particularly if you’ve recently sprained your ankle
• Avoid hard landings that force your ankle into a lot of dorsiflexion (consider down climbing or top roping for a while)
• Avoid stretching your ankle into any pain.

Step 2: Mobility

After the initial pain subsides, you may begin to work on your foot and ankle mobility as soon as tolerated. You will likely still have some pain with loading of the tendon, so it’s important to progress gradually and systematically. In the early stages of recovery, pain free range of motion and gentle stretching is key to promoting blood flow and healing, while also restoring any lost motion. 

• Active Range of Motion: Pretend your foot is a pen and spell out the letters of the alphabet multiple times a day. You might even gently massage along the peroneal tendons while you move the ankle if it helps. You may use lotion for increased glide. 
• Ankle Stretching: If your ankle is stiff compared to the other side, find a stair and something to hold onto, then perform each stretch as shown. (2×30 seconds twice per day)

Ankle Stretching

• Cross Friction Massage: Locate a tight/tender spot in the peroneal muscle belly or along the tendons and apply firm pressure as shown. Lotion is not recommended in order to maximize the friction against your fingers. It is common to feel an increase in tenderness at first. However, if this progressively worsens or does not go away after a few minutes, you should stop and try again at a later date. (5-10 minutes once per day)

Cross Friction Massage

• Dorsiflexion Self-Mobilization: Compare your injured ankle to your non-injured ankle by performing the knee-to-wall test as shown. 

Knee to Wall Test

• If there is a limitation in range of motion try the following exercise: using a step and a strap/heavy resistance band as shown, perform forward lunges while keeping the knee in line with the foot and pointed forward. (3×10 once per day)

Dorsiflexion Self Mobilization

Step 3: Strength

Now that the pain is well controlled and you have started to address mobility restrictions, begin to add in the following exercise progression to increase both the strength of the peroneal muscles and the load capacity of the tendons. Start with the first exercise and progress to the next exercise as you are able. In general, it is acceptable to perform these exercises despite mild pain (3/10). However, you want to avoid reactive pain that lasts longer than 24 hours. If your pain increases more than a slight amount or lasts longer than 24 hours post exercise, decrease the volume and intensity and progress even more gradually.

• Isometric Plantar Flexion and Eversion: Isometric holds (contracting muscle without moving the joint) have been shown to have an analgesic effect and can play an important role throughout the early rehab process of tendinopathies.^9,10 Perform as shown, using a wall (eversion) and some webbing (plantar flexion) for resistance. Start with 5×30-45 second holds at 50% max contraction and build up to 70%. Rest for 1-2 minutes between repetitions and perform once or twice per day.

Isometric Plantar Flexion

Isometric Eversion

• Resisted Eversion: Perform phase one as shown, then progress to phase two. (4×15 twice per day)

Resisted Eversion Phase 1

Resisted Eversion Phase 2

• Heavy-Slow Heel Raises: Heavy-slow resistance is strongly supported by research for treating tendinopathy.^10,11 Perform 4×15 slow heel raises every other day as shown, progressing from isometric holds to eccentric lowers, and eventually to single-leg heel raises and lowers. Gradually add weight (5-10lb per week) as tolerated while you decrease to 4×6 repetitions (near max effort) over several weeks.

Heavy Slow Heel Raise Series

• Balance and Proprioception: A basic series for improving the proprioception and stability of the ankle is demonstrated in this video. Starting with static balance/proprioception is always a good idea before progressing to dynamic drills and plyometrics.

Balance Proprioception Series

Step 4: Movement

Movement is both a restorative and a preventative medicine. To ensure a happy outcome, it is critical to modify habits and environmental factors that may have contributed to your injury in the first place.

• “Too much too soon” or the weekend warrior approach is often the culprit of tendinopathy. Gradually build into training programs and activities while maintaining a consistent routine. Proper warm-ups prior to activity are crucial. If you take several weeks off, take several weeks to rebuild toward your prior activity level.
• Consider updating your footwear if needed. 
  • Worn out running and approach shoes can put your foot in positions that stress the tendons and lead to injury. A shoe with good ankle support for uneven terrain is also a good idea.
  • Individuals with high arches are prone to peroneal tendon disorders and may benefit from a foot orthosis or a more flexible/cushioned shoe. 
  • Consider limiting time spent in aggressive downturned bouldering shoes if these increase symptoms. Climbing shoes that are downsized will likely increase compression of irritated tendons. Take your shoes off in between climbs and invest in a more comfortable multi-pitch shoe for longer climbs.
  • If you are doing lots of crack climbing, talk with your local gear shop about finding an appropriate shoe for this style of climbing.
• As you return to climbing, you might consider the following tips to reduce stress on the lateral ankle.
  • Avoid high-step foot jams which put more torque on the foot. Climb easier routes with foot holds outside the crack or work on your sport climbing game for a while. 
  • Steeper climbs may be less painful than slab routes with delicate footwork and lots of sustained plantar flexion.
  • It’s possible that inefficient climbing movement or a muscle imbalance could be setting you up for a future injury. Consider a climbing evaluation by a movement specialist to learn more.

When To See a Medical Practitioner

An injury involving the peroneal tendons may require seeing a medical professional to determine the best approach for you. Physical therapists are trained to diagnose and treat peroneal tendon dysfunction. They can help guide you through the rehab process step by step and ensure the best possible outcome. If conservative management were to fail, they can refer you to a specialist as needed. 

Peroneal tendon subluxation occurs when you can see and feel the tendons rolling over the lateral malleolus on the outside of your ankle. This is a more serious issue and it is recommended that you see an orthopedic surgeon as soon as possible. While conservative management of an acute peroneal tendon subluxation can be successful about 50% of the time,¹² recurrent subluxation is best managed with surgery.^13-15  Experts strongly recommended surgery for active individuals with peroneal subluxation.¹⁶ Various surgical techniques are used to prevent future subluxation of the tendons, including deepening the groove behind the fibula if necessary. A small percentage of individuals have a flat or convex shaped distal fibula, which may predispose them to peroneal subluxation.¹⁷

Don’t hesitate to reach out to me if you have any questions! My contact information is below.

Read More: 10 Science-Backed Exercises To Up Your Bouldering Game

About the Author

This article was written through a mentorship process in The Climbing SIG, a rock climbing special interest group for physical therapy students developed by Dr. Jared Vagy DPT –  The Climbing Doctor.

Todd Bushman

Todd is a doctor of physical therapy who works at Excel Physical Therapy in Bozeman, MT. He is a certified strength and conditioning specialist (CSCS) and a member of the American Physical Therapy Association. He has a passion for orthopedic manual therapy and working with climbers of all abilities. Todd is an avid climber who enjoys many styles of climbing and mountaineering. He and his wife are currently enjoying the adventure of introducing their one-year-old to mountains and crags wherever they go! To contact Todd with any questions or comments, you can email him at todd.climbingpt@gmail.com

About the Contributors

Jared Vagy

Dr. Jared Vagy “The Climbing Doctor,” is a Doctor of Physical Therapy and an experienced climber. He has devoted his career and studies to climbing-related injury prevention, orthopedics, and movement science. He authored the Amazon best-selling book Climb Injury-Free, and is a frequent contributor to Climbing Magazine. He is also a professor at the University of Southern California, an internationally recognized lecturer, and a board-certified orthopedic clinical specialist.

To learn more about Dr. Vagy you can visit theclimbingdoctor.com or visit him on Instagram @theclimbingdoctor

Jennifer Demyanek

Jennifer is a physical therapist, college professor, and rock climber in Las Vegas, Nevada. She is a graduate of the University of Maryland School of Medicine with a Doctorate degree in Physical Therapy. Jennifer is the owner of Onsight Movement, a private physical therapy practice located in Las Vegas, specializing in treating rock climbing injuries and improving climbing performance. She also currently serves as Adjunct Faculty at the College of Southern Nevada teaching Anatomy & Physiology.

Jennifer is an officer of the virtual Rock Climbing Special Interest Group as well as a member of the American Physical Therapy Association’s Orthopedic Section. She also holds a certification in Dry Needling from the American Academy of Manipulative Therapy. When not practicing physical therapy, Jennifer can be found outside rock climbing around the southwest or spending time with her husband, Dylan. You can contact Jennifer via email at jennifer@onsightmovement.com or by visiting www.onsightmovement.com.

Kevin Cowell

Kevin is a physical therapist, clinical instructor, and rock climber based out of Broomfield, CO. Kevin owns and operates The Climb Clinic (located at G1 Climbing + Fitness) where he specializes in rehab and strength training for climbers and mountain athletes. He found his passion for climbing in Colorado while attending Regis University for his Doctorate of Physical Therapy and has since become a Certified Strength & Conditioning Coach (CSCS), Board-Certified Orthopaedic Clinical Specialist (OCS), and a Fellow of the American Academy of Orthopaedic Manual Physical Therapy (FAAOMPT).

References

1. Ritter S, Moore M. The relationship between lateral ankle sprain and ankle tendinitis in ballet dancers. J Dance Med Sci. 2008;12(1):23-31. 
2. van Dijk PAD, Kerkhoffs GMMJ, Chiodo C, DiGiovanni CW. Chronic disorders of the peroneal tendons: current concepts review of the literature. J Am Acad Orthop Surg. 2019;27(16):590-598. 
3. Heid, Andreas & Popp, Dominik & Schöffl, Volker. Traumatic peroneal tendon dislocations in rock climbers “the climbers pulley lesion of the foot” – a case presentation. Medicina Sportiva. 2013;17(4):188-192.
4. Roster B, Michelier P, Giza E. Peroneal tendon disorders. Clin Sports Med. 2015;34(4):625-641. 
5. Simpson MR, Howard TM. Tendinopathies of the foot and ankle. Am Fam Physician. 2009;80(10):1107-14.
6. DiGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ: Associated injuries found in chronic lateral ankle instability. Foot Ankle Int. 2000;21:809-815  
7. Pedowitz D, Beck D. Presentation, diagnosis, and nonsurgical treatment options of the anterior tibial tendon, posterior tibial tendon, peroneals, and achilles. Foot Ankle Clin. 2017;22(4):677-687. 
8. Grivas TB, Koufopoulos GE, Vasiliadis E, Polyzois VD. The management of lower extremity soft tissue and tendon trauma. Clin Podiatr Med Surg. 2006;23(2):257-82, v. 
9. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277-1283. 
10. Kuczynski JJ. Tendinopathy clinical practice guideline. Columbus, OH: The Ohio State University; 2017:1-7. Available at: https://wexnermedical.osu.edu/-/media/files/wexner medical/patient-care/healthcare-services/sports-medicine/education/medical-professionals/other/tendinopathy.pdf. Accessed January 18, 2021.
11. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43(4):267-86.
12. McLennan JG. Treatment of acute and chronic luxations of the peroneal tendons. Am J Sports Med. 1980;8(6):432-436. 
13. Ferran NA, Oliva F, Maffulli N. Recurrent subluxation of the peroneal tendons. Sports Med. 2006;36(10):839-846.
14. Arrowsmith SR, Fleming LL, Allman FL. Traumatic dislocations of the peroneal tendons. Am J Sports Med. 1983;11:142-146. 
15. Brage ME, Hansen ST. Traumatic subluxation/dislocation of the peroneal tendons. Foot Ankle. 1992;13: 423-431 
16. Ogawa BK, Thordarson DB. Current concepts review: peroneal tendon subluxation and dislocation. Foot Ankle Int. 2007;28(9):1034-1040.
17. Edwards M: The relations of the peroneal tendons to the fibula, calcaneus,and cuboideum. Am J Anat. 1928;42:213-253