What is the treatment algorithm for a mild peroneus longus interstitial tear?

Treatment Algorithm for Mild Peroneus Longus Interstitial Tear

The optimal treatment for a mild peroneus longus interstitial tear involves functional support, early exercise therapy, and NSAIDs, with a progressive return to activity based on symptom resolution.

Initial Management (0-2 weeks)

Pain and Inflammation Control

• NSAIDs: Administer to reduce pain and swelling 1
  • Use maximum tolerated and approved dosage
  • Continue for 2-4 weeks based on symptom response

Functional Support

• Ankle brace: Preferred over immobilization 1
  • Use functional brace that allows controlled movement while providing lateral stability
  • Continue for 2-4 weeks during the acute phase

Early Activity Modification

• Rest: Avoid activities that provoke pain
• Avoid immobilization: Complete immobilization is not recommended as it may lead to joint stiffness and delayed recovery 1

Rehabilitation Phase (2-6 weeks)

Exercise Therapy

• Begin as soon as possible: Exercise therapy should be started early to recover joint functionality 1
• Focus areas:
  • Proprioception exercises
  • Gentle ankle eversion against progressive resistance
  • Range of motion exercises
  • Balance training

Progression Criteria

• Evaluate treatment response at 4 weeks:
  • If improving: Continue with progressive exercise program
  • If not improving: Consider advanced imaging (MRI) to reassess tear severity

Advanced Rehabilitation (6-12 weeks)

Progressive Strengthening

• Increase resistance for peroneal strengthening exercises
• Add functional exercises that mimic daily activities and sport-specific movements
• Include coordination and proprioceptive training

Return to Activity Protocol

• Sport resumption: Supervised exercises focusing on proprioception, strength, coordination, and function 1
• Criteria for return to full activity:
  • Pain-free range of motion
  • Restored peroneal strength (at least 90% compared to unaffected side)
  • Ability to perform sport-specific movements without pain

Special Considerations

When to Consider Advanced Treatment

• Persistent symptoms despite 6-8 weeks of conservative management
• Evidence of significant tear progression on follow-up imaging
• Presence of associated pathologies (ankle instability, hindfoot varus)

Monitoring for Complications

• Assess for development of ankle instability
• Monitor for signs of tear progression
• Watch for tendon subluxation

Follow-up Schedule

• 2 weeks: Initial follow-up to assess early response
• 4-6 weeks: Evaluate healing progress and adjust rehabilitation program
• 12 weeks: Assess for return to full activity

Common Pitfalls to Avoid

1. Prolonged immobilization: Can lead to joint stiffness and muscle atrophy
2. Premature return to high-impact activities: May cause re-injury or progression to complete tear
3. Neglecting proprioceptive training: Essential for preventing recurrence and ankle instability
4. Overlooking biomechanical factors: Foot posture and alignment issues should be addressed to prevent recurrence

This treatment algorithm prioritizes functional recovery while allowing appropriate healing time for the injured tendon. The evidence strongly supports early functional treatment over immobilization, with exercise therapy as the cornerstone of rehabilitation 1.