From the Guidelines
For an 83-year-old woman with a peroneus brevis tear and tendinosis of both the Achilles and posterior tibialis tendons, I strongly recommend a conservative treatment approach initially, prioritizing rest, ice, compression, and elevation, along with gentle physical therapy and proper footwear, as the most effective way to manage symptoms and improve quality of life. The patient should start with the RICE protocol, applying ice for 15-20 minutes several times daily, using compression with an elastic bandage or ankle brace, and elevating the affected foot when sitting or lying down 1. Over-the-counter NSAIDs like ibuprofen (400-600mg three times daily with food) or naproxen (220-440mg twice daily with food) can be used for pain and inflammation, unless contraindicated by other medical conditions or medications 1.
Key Components of Conservative Treatment
- Gentle stretching and progressive strengthening exercises through physical therapy
- Balance training to prevent falls and further injury
- Use of a CAM walker boot or ankle brace for 4-6 weeks to immobilize and protect the tendons while healing
- Proper footwear with good arch support and cushioning, and consideration of custom orthotics to redistribute pressure and support the arch 1
Considerations for Advanced Treatment
If conservative treatment fails after 2-3 months, consideration can be given to referral for corticosteroid injections, which may provide acute-phase pain relief, although they do not alter long-term outcomes 1. However, surgery is generally avoided in elderly patients due to increased risks and longer recovery times, and should only be considered in carefully selected patients who have failed extensive conservative therapy 1. The focus should remain on managing symptoms, improving function, and enhancing quality of life, rather than solely on repairing the tear or tendinosis.
From the Research
Peroneus Brevis Tear
- A peroneus brevis tear can be treated surgically with use of an autologous peroneus brevis tendon graft, as seen in a study where sixteen patients underwent peroneus brevis tendon graft reconstruction for a chronic Achilles tendon tear 2.
- The long-term results of treatment of chronic tears of the Achilles tendon by means of autologous peroneus brevis tendon grafting are encouraging, with patients retaining good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference 2.
- Surgical treatment of peroneal tendon tears, including peroneus brevis tears, can involve various techniques such as debridement and repair, excision of the damaged segment and tenodesis to the peroneus longus, and stabilization of the etiologic subluxation 3, 4.
Achilles Tendonosis
- Chronic tears of the Achilles tendon can result in substantial loss of function, and treatment options include surgical reconstruction using an autologous peroneus brevis tendon graft 2.
- Achilles tendonosis can be a complication of peroneus brevis tendon transfer, as seen in a study where one patient developed a tendinopathy of the reconstructed tendon 2.
Posterior Tibialis Tendonosis
- There is no direct evidence in the provided studies regarding posterior tibialis tendonosis in an 83-year-old woman with a peroneus brevis tear and Achilles tendonosis.
- However, peroneal tendon pathology, including tendinosis, is often found in patients complaining of lateral ankle pain and instability, and treatment begins with nonoperative care, but when surgery is required, reported results and return to sport are in general very good 5.
Treatment and Management
- Treatment of peroneal tendon tears, including peroneus brevis tears, can involve nonoperative care, but when surgery is required, various techniques can be used, including debridement and repair, excision of the damaged segment and tenodesis to the peroneus longus, and stabilization of the etiologic subluxation 3, 4, 6.
- The average postoperative AOFAS score was 85 in a study of patients who underwent surgical reconstruction for peroneus brevis tendon tears, and return to maximum function is prolonged, but good-to-excellent results were found in the majority of patients 4.