The San Francisco Giants activated infielder Pablo Sandoval this past Monday after tendon pain in his foot had placed him on the disabled list for 15 days. Pablo is reported to have injured his peroneal tendons, a relatively common foot problem for athletes. Unfortunately for highly active individuals like Pablo, depending on exactly what structures are damaged around his tendons, surgery may eventually be necessary to achieve optimal function.
The two peroneal tendons that are injured are called the peroneus longus and peroneus brevis. These two tendons course directly adjacent to each other along the lateral side of the ankle and foot, where they are held in place by a fibrous band called the superior peroneal retinaculum. There are a variety of possible conditions that can develop with the peroneal tendons. Tendonitis may occur, in which the tendons become irritated and inflamed. This could be a portion of Pablo’s injury, as tendonitis is typically caused by repetitive activity, which is common during practice for high level athletes. Accessory bones and muscles can also develop and interfere with the normal function of the peroneal tendons. An extra bone called an “os peroneum” develops in about 20% of the population within the peroneus longus tendon. Like any other bone in the foot, the os peroneum can become fractured and cause pain. This accessory bone can also contribute to the development of tendonitis by irritating the tendon and disrupting its normal course. Having a supinated foot, which usually appears as a high arch, can also increase stress on the peroneal tendons. Supination causes the heel to be inverted, or “roll” inwards, increasing the work the two tendons must perform to maintain a relatively normal foot position during gait.
Conservative treatment is an excellent initial option, which is likely the treatment Pablo began with during his time on disability. Remaining off of the affected leg and taking non-steroidal anti-inflammatory medications can aid in reducing pain and inflammation around the tendons. Custom orthotics can be extremely helpful in controlling the abnormal foot structure and function that contributed to the development of tendonitis. Physical therapy to maintain proprioception is also a key portion of treatment, especially for athletes. After several months of these less invasive treatments, surgery may become necessary. Damaged tendons may need to be surgically repaired, the peroneal retinaculum may need to be tightened to better maintain the position of the tendons, or a painful accessory bone may need to be removed. Additional diagnostics studies such as an MRI or ultrasound are obtained as needed to aid your podiatrist in developing an appropriate surgical plan.
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