What is the treatment for peroneal tendinopathy?

Treatment for Peroneal Tendinopathy

The treatment for peroneal tendinopathy should begin with conservative management including relative rest, activity modification, ice application, and eccentric strengthening exercises for 3-6 months before considering surgical intervention. 1

Initial Conservative Management

Relative Rest and Activity Modification

• Reduce activities that cause pain and overload the affected tendon 1
• Avoid repetitive loading of the damaged tendon
• No clear recommendations exist for the exact duration of rest, but activity should be reduced until pain decreases

Pain Management

• Ice therapy (cryotherapy): Apply melting ice water through a wet towel for 10-minute periods for acute pain relief 1
• NSAIDs: Effective for short-term pain relief but do not affect long-term outcomes 1
  • Use the lowest effective dose for the shortest duration
  • Topical NSAIDs may be effective with fewer systemic side effects
• Corticosteroid injections:
  • May provide more effective acute pain relief than oral NSAIDs 1
  • Ultrasound-guided peroneal tendon sheath injections have shown relative effectiveness with 36.8% of patients experiencing pain relief for more than 12 weeks 2
  • Use with caution due to potential side effects including tendon weakening

Physical Therapy

• Eccentric strengthening exercises: Most effective exercise intervention for tendinopathy 1
  • May reverse degenerative changes in the tendon
  • Should be gradually progressive
• Manual therapy techniques:
  • Lateral calcaneal glide has shown benefit in case reports 3
  • Deep transverse friction massage to reduce pain

Orthotics and Braces

• Laterally posted orthotics for patients with varus hindfoot (a known risk factor) 4
• Supportive devices to correct biomechanical problems such as excessive foot pronation or pes planus 1

Advanced Treatment Options

Other Modalities

• Therapeutic ultrasound: May decrease pain and increase collagen synthesis, though evidence is limited 1
• Extracorporeal shock wave therapy (ESWT): Safe and potentially effective but requires further research 1
• Iontophoresis/phonophoresis: Used to deliver topical medications but lacks strong evidence 1

When to Consider Surgery

• Surgery should be considered after failure of conservative treatment for 3-6 months 1, 4
• Surgical options depend on specific pathology:
  • Synovectomy
  • Debridement
  • Suture-tubularization
  • Fibrous resection
  • Tenodesis
  • Valgus osteotomy for patients with hindfoot varus 5

Monitoring and Follow-up

• Evaluate pain and function every 2-4 weeks
• Most patients (about 80%) fully recover within 3-6 months with conservative treatment 1
• Post-surgical recovery typically involves:
  • Return to work: Average 2.5 months 5
  • Return to sports: Average 8.5 months 5

Special Considerations

• Peroneal tendon disorders are commonly mistaken for or occur alongside lateral ankle sprains 4
• Varus hindfoot is a known risk factor that should be addressed 4
• Patients with chronic lateral ankle instability may have concomitant longitudinal rupture of the peroneus brevis tendon requiring specific surgical approaches 6
• Shorter duration of symptoms before treatment correlates with better outcomes from interventions 2

Common Pitfalls

• Failing to recognize peroneal tendinopathy as a source of lateral ankle pain
• Treating as a simple ankle sprain without addressing the tendon pathology
• Progressing activity too quickly during rehabilitation
• Overlooking biomechanical factors that contribute to ongoing tendon stress