What are the four main causes of lateral ankle pain in runners? Well, that’s what we’re talking about today on the Doc On The Run Podcast.
If you’ve been running, training for a marathon or an ultra-marathon or something like that, and you start to get pain on the outside of your ankle, you do have a reason to be concerned and there are really four things that seem to cause pain on the outside of the ankle the most. We’re going to talk about those today.
What I’m talking about is the outside of your ankle, the lateral side of your ankle. This is your big toe here, your pinky toes over here. The lateral side is in the outside, on the side is on your little toe side, and the fibula bone is right here on the outside, and you have a couple of things that can go wrong. So, you have the bone itself and then behind the bone you have two tendons called the perineal tendons, the peroneus brevis tendon is up higher, comes down and attaches to this bump here, and then the peroneus longus is up above it.
The tendon’s longer which is why we call it the longus instead of the brevis and it comes down and goes down and attaches to the bottom of your foot here. Beyond that, we don’t have a lot of specific we need to talk about with the anatomy because there are really four things related to just those tendons and the bone itself that seem to cause the most amount of trouble in runners. And we’re going to talk about those today.
The first thing that happens is that you can get peroneal tendinitis, specifically peroneus brevis tendinitis, and the brevis tendon is the one that actually pulls your foot back onto your when you start to roll your ankle. So, if your ankle starts to flip over, the peroneus brevis being attached on the outside, swings your foot back under you. So, if you run a lot on really unstable surfaces, like you’re running on grass, or you’re running on trails that have a lot of either loosed dirt, dust or even if they’re wet and they’re slippery, or if you’re running on lots of leaves, then your foot is kind of working really hard and the peroneus brevis tendon as having to pull really intently and gets overused sometimes. It can develop tendinitis where you have inflammation within the tendon itself.
You can also get this in the peroneus longus. The peroneus longus is running right next to it, and it actually helps you hold your forefoot down against the ground. So, sometimes dependent upon your foot type, if you run on surfaces that are sloped, the peroneus longus tendon has to work too hard to try to keep your foot stable underneath you and that tendon becomes irritated, gets inflammation in it and we call it tendinitis when you have inflammation within the tendon itself.
There’s another condition that’s actually way more common and that’s where you get something called peroneal tenosynovitis. And all that means is that the tube that surrounds both of those two tendons where it curves around your ankle, goes down to your foot, the inside lining of that tube gets irritated and inflamed. It’s a tube, kind of like a garden hose. Like the garden hose, you turn on the water, it does not expand. On the inside of that tube is tissue that we call synovial tissue that actually makes the lubricating fluid called synovial fluid that actually lets the tendons glide back and forth inside that tube with very little friction. So, if you get inflammation of the sheath that goes around those tubes, then what happens, the tendon sheath is a tube but it’s basically within the tube is the two tendons and so the tendon sheath when it becomes inflamed, we call it tenosynovitis because the synovial tissue on the inside gets swollen and inflamed.
Well, unfortunately when it swells, it can only swell inward that decreases the internal diameter of the sheath itself and then the tendons being big cables of collagen, as they move back and forth that basically rub that inflamed tissue, and it really hurts a lot. There’s a big difference between these two because one of them actually doesn’t affect the tendons at all. It just sort of affects the wrapping of the tendons and if you do something to really aggressively decrease the inflammation, it might get under control really, really quickly and stop bothering you.
The fourth thing that it could be is a fibular injury. So, the fibula bone could get, you could get a fibula stress fracture or a stress reaction, which is basically like sort of a precursor to a fibula stress fracture. But sometimes it’s hard to tell the difference between these conditions initially because if you have a lot of pain and tenderness sometimes you have to just push around and figure out okay, test some things to figure out which one hurts the most. And most runners want to get an MRI to try to tell the difference but if you actually just got it after a long run on the weekend or something and you get an MRI the next day, you might have so much inflammation in the bone. The peroneus brevis tendon and the peroneus longus tendon and the tendon sheath around the peroneal tendons, that you can’t actually get an accurate diagnosis anyway.
Many times, it’s actually just really carefully and thoughtfully pushing around to figure out which thing hurts the most and then you do some things to try to get it to calm down and then the tenderness and the other thing should go away. And so, if you can use that as a way to tell the difference between the four conditions, you might be able to pinpoint the problem and then start figuring out how you can prevent it from happening again. Because if you get pain on the outside of the ankle, and you don’t figure out why you got it in the first place, getting rid of it is only going to be a temporary fix. It may come back and bug you again later and in my experience that happens right when you’re about to do your race. So, make sure that that doesn’t happen to you.
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