What is the recommended treatment for chronic ankle pain with suspected tendinopathy and tenosynovitis?

Treatment for Chronic Ankle Tenosynovitis with Multiple Tendon Involvement

MRI is the recommended first-line imaging study for chronic ankle pain with suspected tenosynovitis, followed by a comprehensive treatment approach including NSAIDs, physical therapy, and orthotic devices. 1

Diagnostic Assessment

Your ultrasound findings show:

• Tenosynovitis of multiple tendons (peroneus brevis, longus, tibialis posterior, and FDL)
• Fluid in tendon sheaths
• ATFL sprain
• Possible torn CFL

These findings are consistent with chronic ankle tenosynovitis with ligamentous injury, which explains your 9-month history of medial ankle pain.

Treatment Algorithm

First-Line Treatment (0-6 weeks)

1. Anti-inflammatory therapy:

   • NSAIDs (e.g., ibuprofen 400-600mg three times daily) for pain and inflammation 1
   • Ice therapy for 10-minute periods through a wet towel 1

2. Activity modification:

   • Relative rest with avoidance of aggravating activities
   • No complete immobilization (to prevent muscular atrophy) 1

3. Physical therapy:

   • Eccentric strengthening exercises for affected tendons 1
   • Stretching exercises for calf muscles and ankle joint 1
   • Balance and proprioception training 2

4. Supportive measures:

   • Semi-rigid ankle brace for stability during activities 3
   • Appropriate footwear with adequate support 4
   • Consider orthotic devices to correct biomechanical issues 1

Second-Line Treatment (if no improvement after 6 weeks)

1. Referral to foot and ankle specialist 1

2. Advanced orthotic intervention:

   • Custom orthotic devices to address specific biomechanical issues 1
   • Night splinting to maintain tendon length 1

3. Immobilization options:

   • Consider short-term use of fixed-ankle walker-type device during activities 1
   • Casting may be beneficial in more severe cases 1

4. Injection therapy (with caution):

   • Consider corticosteroid injections around (not into) affected tendons 1
   • Note: Avoid direct injection into tendon substance due to risk of weakening and rupture 1
   • US-guided intrasheath anesthetic injections may be diagnostic and therapeutic 1

Third-Line Treatment (if no improvement after 2-3 months)

1. Advanced imaging:

   • Consider MRI if not previously obtained (sensitivity >90% for tendon tears) 1

2. Minimally invasive interventions:

   • Consider extracorporeal shock wave therapy 5
   • Plasma-rich plasma or hyaluronic acid injections may be beneficial 5

3. Surgical consultation:

   • Synovial debridement may be necessary for persistent tenosynovitis 6
   • Repair of any longitudinal split tears if present 6
   • Ligament repair may be considered for persistent instability 3

Important Considerations

• Tendon evaluation: The undersurface of affected tendons must be carefully inspected for longitudinal split tears during any surgical intervention 6

• Ligamentous instability: Your ATFL sprain and possible CFL tear contribute to ankle instability, which may perpetuate tendon problems if not addressed 7

• Biomechanical factors: Hindfoot varus, lateral ligamentous instability, and other structural components may predispose to peroneal tendon pathology 7

• Monitoring: Regular follow-up is essential to assess treatment response and modify the approach as needed

Pitfalls to Avoid

1. Prolonged immobilization: Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 1

2. Overlooking ligamentous instability: Treating only the tenosynovitis without addressing underlying instability may lead to treatment failure 3

3. Direct tendon injections: Corticosteroid injections directly into tendons can weaken them and increase rupture risk 1

4. Delayed treatment: Persistent tenosynovitis can lead to tendon degeneration and tears if not adequately treated 6

5. Inadequate rehabilitation: Failure to address strength, flexibility, and proprioception deficits can lead to recurrent symptoms 2