When a patient presents with peroneal tendonitis symptoms from the lateral fibula to the base of the first or fifth metatarsals, our treatment begins with identification of what phase of rehabilitation that they are in. Do they need to be immobilized completely? So the Immobilization Phase. Do they need some support, but definitely can not do their normal activity? Then the Re-Strengthening Phase. If they can do their activity (run, hike, ski, dance, etc), with some restrictions and some limitations, but keep the pain between 0-2, then they are in the Return to Activity Phase. This is extremely important to recognize as these phases help set the amount of protection needed to heal, the amount of anti-inflammatory measures needed, and the amount of movement allowed.
Of course, one of the modalities that should be in your toolbox to help these patients along the road to complete recovery is the right orthotic device. I am thinking about my orthotic choice the day the patient first comes into the office. I want to get the orthotics ordered as soon as possible, especially in my full immobilization cases as I want them to step from cast/walker to orthotic device without delay. As I mentioned briefly last week, and now want to reiterate, it is so important to identify your patient initially as primarily neutral, primarily pronated, or primarily supinated. This will create their baseline orthosis. Neutral will usually require your Gold Standard, or Go-To Orthosis. Pronators can start with the Pes Planus design.
I love to super analyze these for other inversion modalities like Medial Heel Skives (Kirby), or Inverted Cants or FF and RF Varus posting, but the pes planus design is a good starting point. In athletic shoes, I like 23 mm medial heel cups and 20 mm lateral heel cups. The supinators must have lateral column support. So, the lateral instability design is a good starting point. I like to remove the medial flange from this device and add a lateral frame fill (Denton). In athletic shoes, I use 23 mm lateral heel cups and 20 mm medial heel cups.
The presenting patient with your working diagnosis of peroneal tendonitis/injury is then categorized quickly in 4 ways (and we all get good at this):
- Type of orthosis needed (neutral, for pronation support, or for supination support)
- The amount of protection needed (this will change based on their phase) from permanent cast, CAM walker, ankle brace, and taping ranging also from neutral positioning, to more supinated or more pronated
- The amount of anti-inflammatory work needed, including PRP, shockwave, stem cells, etc
- The amount of activity allowed, here is where cross training rules when full activity is being restricted for months.
This is alot, but I like to manage it all. Yet, for some Podiatrists, they will work only on the immobilization part, and the rest goes to PTs, DCs, and CPeds to form a great TEAM approach. This is okay, but you should have some way of evaluating their work unless you are totally familiar with their approach.
