What is the recommended management for a patient with mild peroneus brevis and longus tendinosis and mild fluid deep to the Calcaneofibular Ligament (CFL), with intact Anterior Inferior Tibiofibular Ligament (AiTFL) and Anterior Talofibular Ligament (ATFL)?

Management of Peroneus Brevis and Longus Tendinosis with Mild Fluid Deep to CFL

Conservative management with a structured rehabilitation program is the recommended first-line treatment for mild peroneus brevis and longus tendinosis with mild fluid deep to the CFL, while maintaining intact ATFL and AiTFL ligaments. 1

Initial Management

• Rest and Activity Modification

  • Avoid activities that exacerbate symptoms, particularly those involving repetitive ankle motion
  • Modify technique for athletes to minimize repetitive stress 2
  • Avoid overhead pulleys during initial rehabilitation 2

• Pain Management

  • Acetaminophen (up to 4g/day) as first-line analgesic 2
  • NSAIDs at lowest effective dose for shortest duration if acetaminophen is inadequate
  • Consider topical NSAIDs to reduce tendon pain while avoiding gastrointestinal side effects 2

Rehabilitation Program

• Exercise Therapy - Most critical component

  • Eccentric strengthening exercises targeting the peroneal muscles 2
  • Stretching and mobilization techniques focusing on external rotation and abduction 2
  • Progressive gentle passive and active-assisted range of motion exercises 2
  • Sport-specific or activity-specific exercises as symptoms improve 2

• Supportive Devices

  • Consider ankle brace during activity to reinforce and protect tendons 2
  • Short-term use of sling for protection may help prevent further trauma 2

Advanced Interventions (if conservative management fails after 4-6 weeks)

• Therapeutic Modalities

  • Therapeutic ultrasound may decrease pain and increase collagen synthesis 2
  • Consider Extracorporeal Shock Wave Therapy (ESWT) for recalcitrant cases 2

• Injections

  • Corticosteroid injections may provide short-term relief but should be used with caution as they may inhibit healing 2
  • Consider ultrasound-guided intrasheath anesthetic injections 1
  • Ultrasound-guided percutaneous ultrasonic needle tenotomy may be effective for recalcitrant cases 3

Monitoring and Follow-up

• Re-evaluate after 4-6 weeks of conservative management
• If symptoms persist despite 3-6 months of well-managed conservative treatment, consider surgical referral 2
• Monitor for development of intrasheath subluxation, which may present with painful clicking of the peroneal tendons 4

Special Considerations

• Biomechanical Assessment

  • Evaluate for forefoot striking pattern in runners, which may predispose to peroneal tendinosis 5
  • Assess ankle stability as peroneal tendons contribute to passive stabilization of the ankle joint 6

• Diagnostic Pearls

  • MRI evidence of peroneal tendon pathology should be interpreted with caution as up to 34% of asymptomatic patients may have peroneus brevis tendon tears 1
  • Clinical correlation is essential as MRI evidence of peroneal pathology has only a 48% positive predictive value for clinical findings 1

• Surgical Indications

  • Persistent symptoms despite 3-6 months of conservative treatment
  • Development of intrasheath subluxation confirmed by dynamic ultrasound 4
  • Tears >50% of tendon thickness 2

Pitfalls to Avoid

• Overreliance on corticosteroid injections, which may weaken tendon structure 2
• Delayed progression from conservative to surgical management when appropriate 2
• Failure to address biomechanical factors, particularly in runners 5
• Neglecting the role of peroneal tendons in ankle stability, especially with concurrent ligamentous issues 6

This structured approach prioritizes conservative management while providing clear guidelines for progression to more invasive interventions if initial treatment fails, with the ultimate goal of improving function and preventing recurrence.