What are the treatment recommendations for a patient with common peroneal tendinopathy, nondisplaced fracture of the distal fibula, osseous contusions, soft tissue swelling, synovitis, and small ankle joint effusion diagnosed on MRI (Magnetic Resonance Imaging) of the ankle?

From the Guidelines

Treatment for a patient with common peroneal tendinopathy, nondisplaced distal fibula fracture, osseous contusions, soft tissue swelling, synovitis, and small ankle joint effusion should prioritize relative rest and reduced activity to prevent further damage and promote healing and pain relief, as recommended by the American Family Physician study 1. The initial management should include a period of immobilization with a walking boot or cast for 4-6 weeks to allow the fracture to heal properly, with weight-bearing status limited initially and progression to partial weight-bearing as tolerated after 1-2 weeks, guided by pain levels. Pain management should include NSAIDs such as ibuprofen (400-600mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks to address both pain and inflammation, as they are recommended for short-term pain relief 1. Additionally, cryotherapy provides acute relief of tendinopathy pain and its use is widely accepted, with repeated applications of melting ice water through a wet towel for 10-minute periods being most effective 1. After the immobilization period, physical therapy should be initiated, focusing on range of motion exercises, peroneal strengthening, proprioception training, and gradual return to normal activities over 4-8 weeks, with eccentric strengthening being an effective treatment of tendinopathy and may reverse degenerative changes 1. Some key considerations for treatment include:

• Immobilization for 4-6 weeks to allow fracture healing
• Pain management with NSAIDs for 1-2 weeks
• Cryotherapy for acute pain relief
• Physical therapy for range of motion, strengthening, and proprioception training
• Gradual return to normal activities over 4-8 weeks Regular follow-up imaging at 6-8 weeks is recommended to confirm proper healing before advancing rehabilitation. It's also important to note that locally injected corticosteroids may be more effective than oral NSAIDs in acute-phase pain relief but do not alter long-term outcomes, and surgery is an effective option in carefully selected patients who have failed three to six months of conservative therapy 1.

From the Research

Treatment Recommendations

The treatment recommendations for a patient with common peroneal tendinopathy, nondisplaced fracture of the distal fibula, osseous contusions, soft tissue swelling, synovitis, and small ankle joint effusion diagnosed on MRI of the ankle are as follows:

• Non-operative management may be considered for the nondisplaced fracture of the distal fibula, including the use of a splint or cast, allowing for early weightbearing when the ankle is stable 2.
• The presence of joint effusion in the tibiotalar joint is associated with an increased risk for severe structural injury, including syndesmotic ligament rupture and talar osteochondral lesions 3.
• The treatment of common peroneal tendinopathy may involve rest, ice, compression, and elevation (RICE), as well as physical therapy and pain management.
• The treatment of osseous contusions and soft tissue swelling may involve rest, ice, compression, and elevation (RICE), as well as pain management.
• The treatment of synovitis and small ankle joint effusion may involve anti-inflammatory medication, physical therapy, and pain management.

Considerations

When considering treatment options, the following factors should be taken into account:

• The mechanism of injury and associated injuries 2.
• The patient's comorbidities and preoperative mobility 2.
• The presence and amount of joint effusion in the tibiotalar and talocalcaneal joints 3.
• The severity of the structural injury, including ligamentous and osteochondral involvement 3.

Imaging

MRI is a useful diagnostic tool in the assessment of traumatic lesions of the foot and ankle, including subtle fractures, tendon and ligament injuries, and complications of trauma such as ischemic necrosis and bone and soft-tissue infections 4. A routine protocol for MRI of the ankle should include a state-of-the-art protocol, problem-solving tools based on specific clinical indications, and principles for the implementation of ultrashort echo time MRI of the ankle 5. Reporting ankle MRI involves the assessment of multiple joints, tendons, and ligaments in several planes and numerous sequences, and should include commentary on specific features and suggested terminology and phrases 6.