I was introduced to your practice and subsequently your blog(s) by a local (Austin) Neurologist whom you treated successfully. You receive our praise in absentia at our annual Fall Rocky Mountain hunting trips which involve hiking over rough terrain (as opposed to TX style hunting blinds). I use your advice remotely from Montana to treat various arthritic joints and keep my 62 year old decrepit body active. I have studied your therapy recommendations for tendonosis of of various tendons but have been unable to infer from those a treatment for my disabling peroneal tendonosis (it makes me want to scream while sidehilling or walking on rocks....bad for hunting). I know that it is a somewhat rare diagnosis but I would appreciate a blog dedicated to this diagnosis and its treatment.
P.S. I haven't tried downhill skiing yet...it will be interesting to see if the rigid boots stabilize the ankle enough to minimize the pain.
Thanks for your note Chuck and your question. Here are my thoughts on your situation.
- The more irritable the condition, the lower the load and the higher the volume you'll need. If your leg hurts quickly and takes a while to subside, days for example, you'll need low loads and high volume of reps to alter the tension capacity of the tendon. You have to sneak up on it and nudge it into a healthier state. The rep range is around 100 reps / set with low levels of fatigue and very mild discomfort. If you can hike for a hour or two and the symptoms subside within a few hours, then you can use a higher load and lower volume - around 30 reps per set with moderate fatigue and discomfort.
- Move your body over a stable, fixed foot. The peroneus longus muscle likes to restrain motion of the leg and provide stability to the arch of the foot rather than produce motion even though the classical definition of the muscle action is to produce eversion (moving the foot sideways) and plantarflexion (pointing the foot). This is because anatomists define muscle action as creating motion from the insertion of the muscle toward the origin. The peroneus longus inserts on the bottom the foot near the first metatarsal. So, if you flip the action around so the motion is from the origin to the insertion, the tibia moves back and down. When your foot is on the ground, the muscle is pulling back on the tibia to keep it from moving to quickly over your foot. This is, as you noted, the time when you're apt to feel the symptoms - when your foot is on the ground and you're decelerating your center of gravity as in walking down hill sideways or over uneven surfaces like rocks. Once your leg tolerates a stable surface, you can then advance to unstable surface training.
- Train to pain. You have to train hard enough that you produce some symptoms and this is where it's often tough to do alone. What's too much? What's not enough? Well, the intensity is too much when you compromise your motion and it's too little if you don't hurt at all. You want the symptoms to show up near the end of each set. And, ideally you want motions that produce the symptoms in real life. You use the very thing that bothers you to heal you but you control the load.
- Train the hip. Your hip external rotators counter the pull of gravity and the collapse of the leg toward the ground when doing things like walking, climbing and hiking . The stronger your hips are the more they will help the peroneal muscles do their job.
- Poke and Prod. Sometimes, I'll use a manual technique to induce an inflammatory reaction. The technique itself is probably less important than the intensity and duration of it. Tendonosis is a condition of tissue weakness. If you can create a mild inflammatory reaction (and this is what some of the drills do as well), you will jump start the production of collagen which is what the tissue needs. Rolfing, Deep Tissue Massage, certain forms of Myofascial Release, and Graston Technique all can create an inflammatory reaction (This is also the framework for Prolotherapy, an invasive technique used to promote soft tissue healing.) You'll need a professional to help you with this though.
As for snow skiing, the boots will help but your foot still works inside the boot as you carve in the snow to turn one way or the other. So depending on how irritable your tissues are, you may still hurt a fair amount.
Last thing specifically for you Chuck. If you have arthritic joints, such as a knee or hip, you'll want to recondition those joints so you get as much help as possible for your foot / ankle. Sometimes one area of the body ends up working too hard because the arthritic joints dial down the muscle power of the muscles around the effected joint (s). This is called arthrogenic inhibition. So, in the knee for example, you can lose some strength in the quadriceps, hamstrings, and even the gastrocnemius. The gasctrocnemius is a direct synergist for the peroneus longus meaning it helps it do its job.
Next time, I'll go over some drills for this condition.