What is the treatment for peroneus brevis and peroneus longus tenosynovitis?

Treatment of Peroneus Brevis and Peroneus Longus Tenosynovitis

The treatment of peroneus brevis and peroneus longus tenosynovitis should begin with conservative management including relative rest, NSAIDs, and eccentric strengthening exercises for 3-6 months before considering surgical interventions. 1

Initial Conservative Management

First-Line Treatments

1. Relative Rest and Activity Modification

   • Reduce activities that exacerbate lateral ankle pain
   • Avoid movements that stress the peroneal tendons
   • Duration: No clear recommendations exist, but typically 2-4 weeks 1

2. Cryotherapy

   • Apply melting ice water through a wet towel for 10-minute periods
   • Most effective for acute pain relief 1

3. Medications

   • NSAIDs: First-line medication for pain and inflammation
     • Effective for short-term pain relief but do not affect long-term outcomes
     • Topical NSAIDs may be as effective with fewer systemic side effects 1
   • Acetaminophen: Alternative if NSAIDs are contraindicated

4. Physical Therapy

   • Eccentric strengthening exercises: Highly effective and may reverse degenerative changes 1
   • Deep transverse friction massage
   • Ankle proprioception and stability training

Second-Line Interventions

If symptoms persist after 4-6 weeks of conservative management:

1. Corticosteroid Injections

   • More effective than oral NSAIDs for acute pain relief
   • Limitations:
     • Maximum of 2-3 injections
     • 4-6 weeks between injections
     • Does not alter long-term outcomes 1
   • Caution: Potential risk of tendon weakening with repeated injections

2. Orthotic Devices

   • Lateral heel wedges or custom orthotics to correct biomechanical issues
   • Ankle stabilizers or braces

Advanced Interventions

For cases that fail to respond to 3-6 months of conservative management:

1. Extracorporeal Shock Wave Therapy (ESWT)

   • Consider before surgical intervention 2

2. Surgical Options

   • Tenosynovectomy: Removal of inflamed synovium
   • Tendon repair: For partial tears (<50% of tendon) 3
   • Tenodesis: For more extensive tears (>50% of tendon) 3, 4
   • Tendon reconstruction: For complete ruptures using autografts 5

Monitoring and Follow-up

• Reassess pain and function every 4-6 weeks
• Adjust treatment plan if no improvement after 8-12 weeks
• Most patients (approximately 80%) recover fully within 3-6 months with appropriate conservative management 1

Special Considerations

• Anatomical variations: May affect treatment success
• Concurrent pathologies: Address any underlying ankle instability or foot deformities
• Surgical approach: Minimally invasive techniques may preserve lateral soft tissue integrity 4

Treatment Algorithm

1. Start with relative rest, cryotherapy, NSAIDs, and eccentric exercises for 4-6 weeks
2. If inadequate improvement, add corticosteroid injection and orthotic devices
3. Reassess at 8-12 weeks; if still symptomatic, consider ESWT
4. Consider surgical intervention only after 3-6 months of failed conservative management

Common Pitfalls to Avoid

• Misdiagnosis: Peroneal tendon disorders are often misdiagnosed as ankle sprains 6
• Premature return to activity: Can lead to chronic symptoms or tendon rupture
• Overuse of corticosteroid injections: May weaken tendons and increase risk of rupture
• Delayed surgical intervention: When conservative measures fail, prolonged delay may lead to progression of tendon damage