If I learned anything back in grad school it was that there is always a reason for injury, tendonitis being an injury in itself.  There is always an underlying cause to a dysfunction or in this case, peroneal tendonitis.  Tendons don't become faulty or pathological without reason, and it is the investigation and discovery as to WHY this happens that can be so tricky.

Recently I had a patient who came into the clinic with a diagnosis of peroneal tendonitis.  He did complain of pain along the lateral forefoot (5th met), where you would expect to have pain in this condition.  This particular patient also had an extremely high arch (pes cavus), hindfoot varus with moderate hammer toes.  His primary issue was pain in the peroneal tendons and so his podiatrist diagnosed him with peroneal tendonitis and gave him a brace. 

Initially my treatment was focused on subtalar and talocrural joint mobility with IASTM over the peroneus brevis insertion at the 5th met and toe extensor lengthening.  I did this for 2 visits and when the patient noted minimal change, it was time to look elsewhere.  The hip and knee appeared to be functioning normal and not a source of the problem.  I focused my attention to this patient's extremely high arches and noticed he actually had a lack of windlass mechanism.   The medial longitudinal arch felt like a bag of marbles, not like normal "cookie dough" tissue should feel.  I then used myofasical decompression over the medial arch, re-educated the peroneals on how to hold his foot in an everted position by way of isometrics and kinesiotape.  He's feeling a lot better at this point.

Question: why after 50+ years would this patient suddenly get pain in the peroneals?  There was no change in activity, shoe wear, or other obvious modification.  As a PT I always want to know WHY.  I'm still unsure but I do know that you have to look elsewhere other than the primary location of pain to try to get to some sort of logical hypothesis.  Here's mine: this patient has sharp pains in the morning when getting out of bed.  X-rays looked normal, per patient.  The location of pain is directly at the brevis insertion at the 5th met.  I think this is more than a tendonitis, I think it could be a stress fracture that was missed on XR.  

Here's the bottom line: regardless of this actually could be a stress fracture or stubborn peroneal tendonosis, consider the medial arch and 1st ray relationship.  When there is adequate or even subtle hypermobility in the 1st MTP joint, the medial arch may still not function properly.  Look a little laterally to the peroneal brevis tendon, and try to de-load this specific structure by means of taping into a slight midfoot pronation position and neuromuscular re-education to that musculotendinous region.

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