Peroneal Tendonitis from Walking and Hiking

by "Hooked on Hiking"
(Hawaii)

For the past 10 years I have walked / hiked 500 to 725 miles per year. I am 64 years of age. 5'5". 120 lbs. In good condition, generally. Excellent health.


On 12/30/10 I finished an 8 mile walk on pavement and felt fine. In the evening I started to have discomfort / pain in my left foot, in the area of the 5th metatarsal. At first I thought I had a stress fracture. Internet told me it wouldn’t show up on an x-ray for some weeks until the healing commenced. So I waited.

1/25/11 saw a foot specialist. X-ray indicated no fracture. Symptoms indicated and diagnosed as peroneal tendonitis. Rx = physical therapy for 4 to 6 weeks. Followed this Rx 1 x week with an experienced physical therapist. Lasered the area. Stretching and strengthening exercises. Massage.

Exercise during this period included elliptical trainer, stretching and strengthening. Icing once or twice a day. I am very diligent about this. I’ll get up at 4:30 a.m. to exercise and ice before going to the office.

It is now 2 months since the discomfort began. I don’t feel I’ve made the progress I’d hoped for.

I saw the doctor again today because in 36 days I am due to do 3 days of rock scrambling in NV. He confirmed the diagnosis. Most of the discomfort is in the area of the peroneal tendon, however getting some at the front of the heel and in the arch as well.

He does not think it is a tear. He suggested Aleve for 5 to 7 days to bring the inflammation down. Continue the exercises I learned in PT, but not necessary to go for more PT. I asked him if the discomfort continues, and since I’ve already paid for my 3 days of scrambling and all expenses to get there plus hotel… would I be doing any permanent damage if I did my canyon adventure.

He said I may irritate it, but didn’t expect any permanent damage.

I am continuing the icing, will step up the massage and will work on strengthening exercises unrelated to tendon movement to keep muscle strength and tone.

Would be interested in any additional suggestions.

Many thanks,
“Hooked on Hiking”



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Joshua Answers:

Hi HOH.

First off, rock on for being so active!


So guess what happens with each and every step you take? Stretching and strengthening. If you walk so much, your muscles aren't in need of strengthening. Stretching maybe, but it's physiologically impossible to stretch muscle, so really you're lengthening connective tissue.

Microfracture? Maybe, though unlikely unless you switched shooes or had them too tight or are short on Vitamin D and Magnesium and thus developing weak bones. (And just because you're outside a lot doesn't mean you're getting vitamin D, depending.)

The doctor really thought (hoped) that 7 days of Aleve would fix you? Crazy.

Would you be doing permanent damage if you go rock scrambling? Unlikely. Might you irritate it so much it will become disabling pain? Possibly.

If you don't have any actual damage at the moment, then it's unlikely you're going to get damaged. If you just have an irritated ecology right now, which is what really happens in most cases of Tendonitis.

Remember, There Are Two Types Of Tendonitis. One with damage, on without.


Now I have some questions.

1. How exactly are you icing? And where?

2. How exactly are you massaging, and where?

3. Did you do anything new, as far as shoes, jumping, running, etc?

4. Happen to know your Vitamin D level. (Here's where you say 'I live in Hawai'i and I'm out in the sun all the time so my Vit D level -must- be fine.' and I respond with 'Do you wear sunscreen, do you wear long sleeves and hats? Do you shower with soap after your walks, which washes away the oily layer on your skin where pre-production of vit D takes place?'

5. What's your daily food intake look like? Meat eater, vegetarian, etc?



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Joshua Tucker, B.A., C.M.T.
The Tendonitis Expert
www.TendonitisExpert.com
















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Mar 03, 2011
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Answers to your questions
by: Hooked on Hiking

Aloha Joshua and thank you for your communique.

A couple more details...
~ As a small business owner, I sit for hours on end at the computer, doing paperwork and meeting with clients in my office. Although I do walk a lot, during the regular work day I sit a lot.
~ The doctor did not suggest the Aleve would cure the problem, but might provide some relief during the healing process while I do the icing, exercise, etc.
~ Some of my sleep time I?m kind of in a ball with my legs pulled up? very comfortable. I do stretch them out during the night and can tell I?ve gotten a bit stiff (not 20 anymore!).
~ I have low (but not no) arches. Used arch supports until recently when the left one seemed to put pressure on the arch.
~ Doing in place exercise routine from the PT?ist plus using elliptical trainer, for low impact cardio and strengthening.

Answers to your questions:
1. How do I ice and where? Bag of ice with one thickness of thin towel. Icing the arch, to the outside where the tendon attaches, up under and around the ankle and half way up toward the knee on the outside (following the path of the tendon). It is stationary icing, no movement of the bag except to adjust the location.

2. How and where massaging? All the areas I mentioned that I?m icing. Light to medium movements on the tendon. Have not done cross friction or pressure and release, but think I should start. PT?ist also massaged the calf muscle and worked on foot, ankle, knee and hip strength and flexibility. He said the flexibility was good and the ankle/foot strength was quite good.

3. Anything new, shoes, activities? No new activities. I don?t run or jump. Knees wouldn?t appreciate the high impact. Have had patellar tendonitis of the right knee and when rock scrambling I wear a strap on that knee. Shoes: I have Merril hiking shoes for scrambling. High Tech for local activities (not as cushioned). Going to use the Merrils here for all now. A couple of weeks prior to the pain beginning, I did one (only one) walk with aqua shoes (no cushioning) because a part of the hike was muddy. Won?t do that again. I need cushioning.

4. Vitamin D level? Don?t know. Yes, I wear sunscreen or long sleeves as the sun here is piercing and dangerous to the skin. Lots of skin cancer in the islands. Yes, I shower with soap following the hikes. H-m-m-m. My daily multiple vitamin has about 133 mg Vitamin D-3.

5. Food intake? Diet healthy (i.e. little fast food if any). Homemade yogurt and home baked whole wheat bread, for example. Not a vegetarian, but don?t eat a great deal of meat. After exercising I make a protein shake with soy protein (25g), 6 oz. homemade plain low fat yogurt, 1½ to 2 frozen bananas, 4 oz OJ, and cinnamon. Not as much protein as I should? Good amounts of fruit. An egg 1 x week. Some tuna, salmon, sardines, peanuts. Could do more.

Does this answer your questions completely enough?

Hooked on Hiking

Mar 07, 2011
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Response to HOH
by: The Tendonitis Expert

Joshua Comments:

Hi HOH.

1, 2. Drop the ice bag. Get a frozen bottle of water. Ice massage. All the lower leg including up that structure you described.

Gets the cold in deeper, and opens up too tight tissue.


3. I don't know that you need cushioning, but you do need to SLOWLY break your feet into going (essentially) barefoot again. That's fine to keep whatever shoes you use, focus on opening up the lower leg.


4. Get your Vitamin D level checked. You're deficient.

I'll table the conversation on whether the sun is bad for you or not for another time. I totally disagree, but won't get into at the moment. The important part is to get youf Vit D# level up between 50-80.

First things first. Get tested. Either at the doctors or a home test kit for $65 at http://www.zrtlab.com/vitamindcouncil

If for no other reason than this: Vitamin D Disease Incidence Prevention Chart

Plenty more reasons.


5. I would adjust your nutrition intake like this:
Overall, more fat, more protein.
Homemade yogurt is great for the probiotics.
Just from what you've said, I'd say you aren't getting enough protein in general, and not enough good fats for healthy body operation.
Fat is super important (good fat is, anyway, from wild fish, cultured organic raw butter, pastured animal fat.
From a tendonitis perspective, if you're long walks and hiking and scrambling etc, your body needs protein. Over the long term, if you're short on protein intake then your structures get weaker and weaker. Not obviously noticeable, but you'll notice how 'natural' your foot pain seems.

It's possible it hasn't healed because you don't have enough of the necessary building blocks. Or it's possible that you still have pain because the structures in your lower leg are TOO TIGHT and have been for too long and it's just constant irritating tension.

There's other options, of course, but let's start with the basics of more nutrition and opening up the structures (muscle and connective tissue) of the lower leg. As well as getting the pain enhancing chemical of inflammation out.

Mar 10, 2011
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Peroneal Tendonitis from Walking and Hiking
by: Hooked on Hiking

Aloha Joshua,

Mahalo for your wise counsel. I had prepared a response days ago and when ready to send, my internet modem died! Since replaced it... and will try again.

Would you provide your suggestions on how to do ice massage with the frozen bottle of water please? How much pressure should be used?

Joshua Comments: Start light, and work in to tolerance. You want to work down through the layers. HOW you do it isn't as important as that you DO do it. You'll feel what is good. Don't hurt yourself, obviously, but get in there and get it. Imagine all your muscle is shrinkwrapped in connective tissue. Get in there and A. Stretch it manually and B. Tenderize it like a steak :)


Working on Vitamin D and nutrition suggestions of more good fats and protein.

In addition to nutrition and ice massage, do you have recommendations related to exercise to keep up muscle tone without further irritating the tendon? As mentioned, I have 3 days of rock scrambling in the first week of April and am doing whatever I can to stay in shape.

Joshua Comments: Exercise as usual, but Ice Dip, Ice Massage, regular massage. Little bits, as many times as possible throughout the day. This reduces new irritation, and makes it healthier.


Current routine:
25 minutes on elliptical trainer
Stretches (45 minutes) involving Achilles, toes, foot, ankle, hip and standing reaching stretches.
Step ups with knee raise (35 each leg with 2 x 6 lb weights)
Squats (20)
Toe ups (calf / foot) 20 times rolling up unto toes of both feet simultaneously then 20 on each foot separately
Toe crunches on a towel on the floor pulling a 3 lb weight

Would be interested in your thoughts regarding the sun. I enjoy it; however it?s intense here and can cause some dandy sunburns (without sun screen) and skin cancer.

Joshua Comments: In Short:
Vitamin D preproduction happens in the oily layer of the skin.

Turns out, that Vit D on the skin is what protects us from bad skin cancer. When we shower every day (wit soap, too) we strip that oily layer from our skin.

Then we're out in the sun with less protection. Add to that we wear lots of clothes and sunscreen. Then we get in the sun and get burnt. That's not great.

Regardless, it's worth it to get a Vitamin D level test, and then get your level up between 50-80. Adequate levels of Vit D3 reduce the incidence of breast cancer by 85%, and all cancer by 33%. Cheap, easy, and life saving.



I really appreciate your suggestions and am working diligently on improving before my adventure in the canyons.

Joshua Comments: Go after your lower legs with a frozen water bottle! Go go go, then ask more questions when you've been doing it a bit.



Mahalo,
Linda

Mar 21, 2011
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Peroneal Tendonitis from Walking and Hiking
by: Hooked on Hiking

Aloha Joshua,

Am following your instructions regarding vitamins, nutrition and ice massage. Minor improvement, but very slow.

Did an easy 2 miles yesterday to test out my tolerance for it as my hiking trip is in early April. Sore last night. Somewhat better today.

Additional question:
~ I am also experiencing discomfort under and in front of my heel, on the inside of my heel (right side of my left heel) and in my arch for the past few weeks. Can this also be related to the peroneal tendonitis? Seems to be including other areas. Doesn?t seem logical to be in these spots also.

Mahalo again!
Hooked on Hiking


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Joshua Comments:

Keep at it HOH!

Yes, it can be related. It's all related. It all works together.

How's ice massaging and self massaging going?

Describe what and how you're doing it.




Mar 25, 2011
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Peroneal Tendonitis from Walking and Hiking
by: Hooked on Hiking

Greetings Joshua,

Ice massaging: I?m using a small frozen plastic bottle of water like I would use my hands and fingers, working it into all the areas that hurt (which seem to be many!) by rolling it up and down. I use the bottom ?edge? of the bottle and the round part below the cap to get into the tendon areas. I use the whole width of the bottle up and down the calf muscle. I am doing it for about 15 minutes.

Following that I put my feet on a vibrator that sits on the floor for about 10 minutes to get the blood flowing into my feet, ankles and legs.

Then I manually massage the bottom and top of the entire foot, along the peroneal tendon (foot to knee), the muscle in front of my leg toward the shin bone and the calf muscle for at least 15 minutes.

After that (yes, I?m still awake) I wrap a heating pad around it for about 15 minutes.

Then I put the ice bottle back in the freezer and go to sleep!

I am making some headway? albeit slowly.

Also doing daily stretching exercises.

Am I on track with what I should be doing?

The problem began 12/30 so I'm just about at the 3 month mark now.

The countdown is 13 days until my 3 day hiking adventure. Pray for me! And I welcome any additional advice and appreciate your encouragement.

Mahalo,
Hooked on Hiking


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Great.

1. Start massaging deeper. Push it to tolerance level. Don't hurt yourself, but it's time really get in there. Start -forcing- things to soften up.

2. Personally I'd finish on cold instead of hot. Try it for a week to do the hotpad, then one more quick ice water bottle massage for one more circulatory response. Your body will push new blood back in, using heat or no.



Apr 29, 2011
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Peroneal Tendonitis from Walking and Hiking
by: Hooked on Hiking

Aloha Joshua,

Just wanted to provide an update since our last communiqué. I did go on the 3 day hiking adventure. Because the tendonitis is not yet gone, I adjusted the plan from rock scrambling to moderate hiking. I took Aleve 2 x day beginning about 3 days before the treks. The 1st day of hiking was just 2 ½ miles to test it out. Did OK, but was careful to avoid twisting my ankle. 2nd day = 5 ½ miles over moderate terrain. Again, OK. Last day 6 ½ mile trail, up and down, but no scrambling. I survived and had a great time!

Once I discontinued the Aleve, I could feel some soreness, but not too bad. Since my return, I haven?t been out hiking as I picked up some kind of bug during my travels and am not up to par. Also had cataract surgery 10 days ago and the other eye due 10 days from now. So, my foot is getting a bit of a rest.

Will continue rehabbing as you have recommended and trust that soon it will be totally back to normal, or perhaps even better!

Thanks for your valuable advice,
Hooked on Hiking in Hawaii


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Joshua Comments:

Great!

Keep me updated.



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