What are the treatment options for peroneal tendinopathy?

Treatment Options for Peroneal Tendinopathy

Conservative management with eccentric strengthening exercises, orthotics, and activity modification should be the first-line treatment for peroneal tendinopathy, with surgery reserved for patients who fail to respond after 3-6 months of appropriate non-operative care. 1, 2

Initial Assessment and Diagnosis

• Clinical Presentation:

  • Lateral ankle pain that worsens with activity
  • Pain may initially subside after warm-up but gradually increases in intensity and duration
  • Pain described as "sharp" or "stabbing" 1
  • May be associated with hindfoot varus 2

• Physical Examination:

  • Well-localized tenderness along the peroneal tendons
  • Swelling and asymmetry may be present
  • Pain reproduced with resisted eversion or passive inversion
  • Check for hindfoot varus alignment (risk factor) 2
  • Assess for lateral ankle instability (often coexists) 3

• Imaging:

  • Plain radiographs to rule out bony abnormalities
  • Ultrasound or MRI for definitive diagnosis of tendon pathology 1

Treatment Algorithm

1. First-Line Conservative Management (0-3 months)

• Relative Rest and Activity Modification:

  • Reduce activities that load the peroneal tendons 1
  • Avoid repetitive ankle eversion exercises initially

• Physical Therapy:

  • Eccentric Strengthening: The cornerstone of tendinopathy treatment 1
    • Progressive loading of the peroneal tendons 2
  • Manual Therapy:
    • Deep transverse friction massage to reduce pain 1
    • Lateral calcaneal glide technique has shown promising results 4
    • Talocrural joint mobilization if restricted dorsiflexion present 4

• Orthotics and Braces:

  • Laterally posted orthotics to reduce stress on peroneal tendons 2
  • Correct excessive foot pronation or pes planus if present 1

• Anti-inflammatory Measures:

  • NSAIDs for short-term pain relief (note: will not affect long-term outcomes) 1
  • Topical NSAIDs may provide relief with fewer systemic side effects 1

2. Second-Line Interventions (if inadequate response after 4-6 weeks)

• Ultrasound-Guided Corticosteroid Injection:

  • Can provide significant pain relief in approximately 37% of patients for >12 weeks 5
  • More effective in patients with shorter duration of symptoms 5
  • Caution: Limited evidence for long-term outcomes; potential complications include tendon weakening 1
  • Low complication rate (1.8%) reported 5

• Other Modalities:

  • Therapeutic ultrasound (limited evidence) 1
  • Extracorporeal shock wave therapy (ESWT) - safe but expensive option 1
  • Iontophoresis with corticosteroids (limited evidence) 1

3. Surgical Management (if failed conservative treatment after 3-6 months)

• Surgical Indications:

  • Persistent pain and dysfunction despite 3-6 months of appropriate conservative care 1, 6
  • Significant tendon tears or degeneration confirmed on imaging

• Surgical Options:

  • Synovectomy
  • Debridement
  • Tendon repair (suture-tubularization)
  • Tenodesis for irreparable tears
  • Valgus osteotomy for patients with hindfoot varus 6

• Surgical Outcomes:

  • High satisfaction rates (94%) reported 6
  • Significant improvement in functional scores 6
  • Mean return to work: 2.5 months
  • Mean return to sport: 8.5 months 6

Special Considerations and Pitfalls

• Commonly Overlooked Diagnosis: Peroneal tendinopathy is frequently misdiagnosed as lateral ankle sprain 2

• Associated Conditions: Always assess for lateral ankle instability, which often coexists with peroneal tendinopathy 3

• Anatomic Risk Factors: Hindfoot varus, enlarged peroneal tubercle, and symptomatic os peroneum may predispose to peroneal tendinopathy 3

• Corticosteroid Injection Caution: While effective for short-term pain relief, injections directly into the tendon substance should be avoided as they may weaken the tendon and increase rupture risk 1

• Rehabilitation Progression: Ensure proper progression from isometric to isotonic to sport-specific exercises before return to full activity

• Surgical Timing: Don't rush to surgery; adequate conservative management should be attempted for at least 3-6 months before considering surgical intervention 1, 2