musculoskeletal? injury.? Peroneal? dislocation?
sing? the? case? study? in? Box 1
(Page??),? this? article? highlights?
the? importance? of? recognition?
and? appropriate? referral? of? a?
peroneal? tendon? tears? and/or? tendinitis? and?
damage? to? the? retinaculum? (Thomas? et? al,?
Anatomy and function
Peroneus? Longus? (PL)? and? Peroneus? Brevis?
This article is centred around the similarities and highlights some differences
between a sports injury compared to any other injury profile. The authors use
a musculoskeletal assessment, diagnosis and management of an injury based
on a particular case study. The intention is to highlight how problems maybe
masqueraded in the history and perception of the injured athlete and how this
perception may have complicated the injury and the rehabilitation process. This
issue generates a renewed awareness for all primary care nurses and health
practitioners who may be involved in treatment pathways for associated injuries
related to sports medicine problems.
The article gives an insight into peroneal dislocation/subluxation, but primarily
focuses on peroneal tendinitis/tendonosis. The management of the injury briefly
touches on the associated benefits (and risks) of barefoot running and its role in the
prevention of sporting injuries.
This article illustrates how the frustration of a chronic injury can lead to the
athlete making ill-informed decisions and highlights the need for a thorough
assessment and an evidence-based management plan that is negotiated with the
Key words: Sports injury n Recognition and Referral n Cellulitis, peroneal tendonosis n
Peroneal dislocation n Rehabilitation
Accepted for publication: June 2012
PL? arises? from? the? head? and? lateral? tibial?
Prevalence and epidemiology
sprains? are? the? single? most? common? sports?
injury,? accounting? for? 19–23%? of? all? sports?
(A&E)? departments? per? year.? It? has? been?
ankle? injuries? account? for? 3–5%? of? overall?
attendances? at?A&E? departments? in? Britain?
(Boyce? et? al,? 2005).?The? NHS? (2010)? state?
on? the? NHS? are? putting? a? strain? on? the?
Running? is? one? of? the? most? common?
A mistaken case of
Michael Concannon and Annabel Davidson
The Olympics are here!!
year? period.?The? most? affected? locations? of?
Sports injuries prevention
prevention? has? been? developed? by? Finch?
(2006).?The?TRIPP? framework? (summarised?
knowledge,? understanding? and? evaluation? of?
Assessment of injury
The? Medicine? of? Exercise? is? a? term? which?
(Brukner? and? Khan? 2006).?The? nurse? who?
the? lateral? ankle? problem? in? context? of? his?
establishing? some? of? the? influencing? factors,?
A systematic assessment
are? resolvable,? the? MDT? involved? in? Peters?
case? went? through? a? systematic? assessment?
This? is? arguably? the? most? important? part?
of? information? gathering? as? it? presents? the?
patient? with? the? opportunity? to? share? their?
lived? experience? of? the? problem? they? are?
and? started? to? open? up? the? possibility? of? a?
which? a? management? plan? was? initiated,? or?
at? least? a? referral? pathway? being? directed?
appropriately? (Cohen? et? al,? 2008).? It? also?
Peter? informs? the? podiatrist? that? he? had?
Table 1. Common locations
for running injuries
Patella femoral pain syndrome
Source: Braunstein et al, 2010
Picture 1 – showing the tendon pathway around the lateral/fibular malleolus (AQ1: Mention in text?)
Picture 2 – showing the muscular and tendon pathway around the lateral/fibular malleolus (AQ2: Mention in text?)
then? charted? the? description? of? symptoms?
onto? a? diagram? of? the? lower? limb? in? order?
to? take? base? line? data? of? exactly? where? the?
Red? and? yellow? flags? are? usually? indicated?
psychosocial? concerns? (yellow? flags).?This? is?
require? immediate? or? otherwise? appropriate?
with? the? previous? assessments? to? suggest?
that? this? is? a? local? infection? that? requires?
appropriate? pharmaceutical? and? wound? care?
management.? With? respect? to? yellow? flags?
Past medical, drug and social history
previous? episodes? of? the? complaint.? It? also?
may? assist? to? associate? this? complaint? with?
Pain (site, quality, intensity, and type)
Pain? differs? with? each? individual? because? it?
is? a? subjective? and? complex? phenomenon?
(Ryder,? 2011).? Peter? describes? two? different?
and? the? other,? generally? throbbing,? but? all?
particular? point.? It? may? also? be? useful? to?
use? pain? scales? to? indicate? any? progress? or?
The? chosen? method? of? pain? assessment?
Picture 3 – showing in flesh how to assess if the peronei are still located around the lateral/fibular malleolus (AQ3:
Mention in text?)
walking? or? running.? He? is? finding? the? pain?
more? consistent? than? previously? suggesting?
understanding of the
address mechanism of
testing of the
Understanding of the
Assessment of the
rolling out factors of
interventions in their
actual safe application
Formal evaluation of the effectiveness of injury prevention measures
Figure 1. TRIPP framework for sports injuries prevention (modified from Finch, 2006)
■ How? this? affects? them? emotionally? (the?
by? Melzack? from? the? original? McGill? Pain?
This? is? down? to? its? reliability? and? validity,?
which? has? been? extensively? documented? in?
line? with? its? application? for? both? acute? and?
acute? problem? and? a? numerical? rating? scale?
■ How? severe? the? pain? is? (the? evaluative?
■ How? disabling? the? pain? is? (the? functional?
Box 1. Case Study
Peter is a 24-year-old man who has recently
suffered with problems to his lateral ankle of his
right leg. He has recently increased his activity
levels and has noticed a swelling on the lateral
side of his foot and now ankle. It seems to be
getting worse and he pointed out redness in
the area. He had spoken with his coach at the
running club who had seen this kind of thing
before and suggested it may be a peroneal
He attended an appointment with his GP
who found there to be an infection of the local
tissues (cellulitis) that seemed to emanate
from a small break down of the skin around
the posteriolateral and plantar region of Peter’s
right foot. The GP prescribed a course of
antibiotics (Flucloxacillin 250mgs x4 per day for
5 days) and referred Peter to the practice nurse
for wound care management and requested
that he rested until the infection subsided and
the ankle was assessed properly.
The practice nurse established that Peter
had a history of lateral ankle problems. He had
undertaken some physiotherapy in the past
and was also told that he had a rather high
arched foot and there was some suggestion
that his footwear was not helping. He was
diagnosed as having peroneal tendonitis. The
practice nurse questioned Peter about his
activities and it became evident that Peter had
taken to barefoot running in the hope to avoid
the ‘sports injuries’ that he had suffered with.
This was an issue that had been getting to
him as a consequence of the frustrating time
lost to the injury that he feels has never been
resolved. The practice nurse dealt with the
local tissue infection using current concepts in
wound management and referred Peter to the
musculoskeletal (MSK) service with a suspected
peroneal dislocation. The nurse reminded Peter
to bring in his running shoes (that he was using
before changing to barefoot running).
Peter attended an appointment through
the MSK service. The podiatrist carried out a
functional assessment that highlighted that
Peter had a supinated foot type and dynamic
lateral ankle instability. His running shoes/
trainers had a remarkable undermined shoe
counter, which was a concern in particular on
the lateral aspect owing to further collapse
caused by the higher pressures and natural
wear on this side. The podiatrist discussed
Peter’s decision to change to barefoot running.
Peter informed him that he had become
‘despondent’ with the recurring problems
around the ankle and after doing some research
from running magazines and online, he felt it
was a good idea. Running barefoot seemed
to improve the injury in the early stages of
the change away from his running shoes. It
was during one running session recently that
he thinks he may have hurt his foot since it
was sore to even walk on and soon started
to go red and swollen. Peter was concerned
that his previous injury had returned or as his
coach suggested that he may have a tendon
dislocation. By the Friday of that week the
swelling was getting worse which forced him to
make the GP appointment.
and type of
A 24 hr
History of the
Figure 2. Systematic assessment profile
they? may? spontaneously? re? direct? themselves?
A? motorfunction? test? was? conducted? using?
a? resisted? (isometric)? test? that? highlighted? a?
eversion,? along? with? the? focal? tenderness?
and? swelling? in? the? retromalleolar? region,?
its? capacity? (Ranawat? and? Positano,? 1999;?
for? his? foot? type.? He? had? been? assessed? in?
and? subsequently? purchased? them? from? the?
design)? around? the? heel.? For? Peter,? the? fact?
This? developed? the? tendency? to? roll? over?
Training and environmental errors
method? of? ‘injury? prevention’? and? decided?
to? give? it? a? go.? Originally? he? found? that?
this? helped,? this? could? be? explained? as? a?
was? being? exerted? by? the? training? shoes,?
extenuated? the? supinatory? forces? that? were?
part? of? the? management? will? be? to? address?
Ultrasound? (US)? has? been? established? as?
an? excellent? diagnostic? tool? for? foot? and?
examination? proves? an? advantage? of? US? in?
evaluating? ankle? and? foot? pathology,? where?
Table 2. Intrinsic and extrinsic risk factors
Intrinsic risk factors
Femoral neck anteversion
Body size/body composition
Leg length discrepancy
Extrinsic risk factors
Equipment including footwear
Environment (playing surface and the resultant ground reaction force effects)
Rear foot Varus
Source: adapted from Dirix et al, 1991; O’Connor et al, 1997
Table 3. A comparision of three choices
of pain scale measurement tools
Verbal Rating Scale
Less sensitive to small
No pain mile pain
moderate pain severe
anchored at one end
with no pain and at the
other with worse pain
Usually 1-10 anchored
at one end with no
pain and at the other
with worse pain
Easy to use
Visual Analogue Scale
Sensitive to small
changes in intensity
Not easy to use with
people or small
Numerical Rating Scale
More sensitive than
Less sensitive than VAS
and requires translation
of linear perception of
pain to a number
Modified from Searle and Bennett (2008)
Table 4. Differential diagnoses for lateral ankle pain
Muscle Peroneal overuse
Extensor digitorum brevis
Abductor digiti minimi brevis
Tendon Peroneal tendonitis
Ligament / soft tissue Anterior talo fibular ligament
Posterior talo fibular ligament
Calcaneo fibular ligament
Superior and Inferior peroneal retinaculum
Inferior extensor retinaculum
Posterior ankle impingement
Avulsion fracture of peroneus Brevis/styloid process
Stress fracture, stress reaction, periostitis
Nerve Sural nerve compression
stressing? of? the? joint? may? be? particularly?
(Khoury? et? al,? 2007).? When? referring? for?
further? investigations? it? is? essential? to? take?
into? account? the? Ottawa? ankle? rules? for?
subjective? and? objective? assessment? above.?
It? will? inevitably? lead? the? practitioner? to?
a? preferred? diagnosis? and? this? in? turn? will?
Cellulitis? is? an? infection? of? the? dermis? and?
is? the? cause,? which? appeared? to? be? clear? in?
the? practice? nurse? managed? the? problem?
until? resolution.? On? this? occasion? it? was?
and peroneal pathology
Since? this? was? not? an? acute? problem? and?
was? further? complicated? by? the? local? tissue?
infection,? PRICE? therapy? was? not? elected?
(Protection,? Rest,? Ice,? Compression,? and?
Elevation).? For? Peter,? it? was? considered?
Khan? (2006)? may? be? owing? to? the? overuse?
Table 5. A summary of classic Western massage techniques
Effleurage Smooth continuous gliding
movement over the skin
Enhances venous return
n Beginning of the
n During a break
n End of the session
Petrissage Kneading of the soft tissue
between the hands
Mobilises deep muscle tissue
Assists venous return
Increases local circulation
Friction Kneading of the soft tissue
between the hands
applied through the
Striking of the tissues with
the hand at a fast rate
n To reduce muscle
Break up adhesions from
previous muscle injuries
n On finishing a
section of the body
n Before and during
Stimulates the tissue
muscle? fibres.? It? is? thought? that? this? leads?
to? adhesions? between? muscle? fibres? and? the?
formation? of? cross-linkages? in? the? fascia.?To?
The? next? part? of? the? rehabilitation?
programme? was? to? improve? mobility? and?
flexibility? while? starting? to? restore? balanced?
muscle? strength.? A? functional? assessment?
sprains? are? thought? to? be? associated? with?
one? or? more? of? these? factors? may? help?
and? reduce? the? rate? of? recurrent? sprains?
exercises.? In? order? to? improve? balance? and?
developed? to? using? a? wobble? board.? Sports?
massage? was? also? used,? which,? according? to?
benefits? to? assist? the? muscle-strengthening?
process? by? increased? blood? flow,? reduced?
muscle? tension? and? neurological? excitability,?
Barefoot running and
its role in injury prevention
Evidence? by? Stacoff? et? al? (2000)? supports?
the? notion? that? running? barefoot? could?
significantly? lead? to? fewer? running? injuries,?
Peter? believed? that? running? barefoot? helped?
to? resolve? his? previous? injury? of? peroneal?
tendinitis.?This? required? in-depth? discussion?
to? increase? Peter’s? awareness? of? the? issues?
Braunstein? (2010),? Jungers? (2010)? and?
centre? of? mass? relative? to? the? force? of? the?
Ground? reaction? force? can? be? explained?
of? the? body? resting? or? hitting? the? ground?
and? which? relates? to? Newton’s? 3rd? law? of?
Key? advice? for? Peter? was? to? purchase? new?
running? shoes? that? are? more? flexible? in?
the? midsole? and? do? not? purport? to? have?
Maximum vertical GRF
Figure 3. The vertical GRF of rearfoot strikers compared to forefoot strikers
Maximum vertical GRF
Vertical GRF of a rearfoot
striker when running
Notice the double humped curve
showing the vertical ground reaction
force. This first hump is the impact
peak which occurs when the heel
strikes, it relates to how hard a person
is hitting the ground. It is reduced by
heel cushioning yet still significantly
noticeable to view in comparison to the
adjacent forefoot striker.
Vertical GRF of a forefoot
striker when running
Notice how when the foot lands on
the forefoot, in this case barefoot,
the impact peaks are far smaller,
almost non-existent in comparison
to the rearfoot-striker data.
Rearfoot striker Forefoot striker
Figure 4. The undermining trainers affecting the lateral ankle
British?Journal?of?Nursing,?2012,?Vol?21,?No?14? Download full-text
to? demonstrate? the? effects? of? the? ground?
Reporting? of? sports? injuries? are? widely?
recognised? to? be? a? complicated? area? of?
musculoskeletal? care.? There? is? a? need? for?
based? problem? from? the? mechanisms,?
intrinsically? and? extrinsically? that? will?
Conflict of interest: none
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n Reporting of sports injuries are widely recognised to be a complicated area of
n Objectivity is needed to separate the injury as a pathology and the various mechanisms that
n Successful management will be determined by thorough assessment, recognition and
appropriate referral pathways
n Footwear advice and barefoot running must be considered in line with foot mechanics in
order to reduce risk
n Frustration of a chronic injury can lead to athletes making ill-informed decisions
n Evidence-based management plans also need skilful negotiation with the athlete