What is the treatment for peroneal tendonitis?

Peroneal Tendonitis Treatment

The treatment of peroneal tendonitis should begin with conservative measures including NSAIDs, activity modification, physical therapy with eccentric strengthening exercises, and possibly immobilization, with surgery reserved only for cases that fail to respond after 3-6 months of comprehensive non-operative management. 1

Initial Non-Surgical Management

First-Line Interventions

• Activity modification and relative rest: Reduce activities that exacerbate lateral ankle pain
• NSAIDs: First-line medication for pain and inflammation 1
• Immobilization: Short-term immobilization may be beneficial in acute cases 1
• Laterally posted orthotics: Particularly important for patients with varus hindfoot alignment, which is a known risk factor for peroneal tendinopathy 1

Physical Therapy

• Progressive tendon loading exercises: Focus on eccentric strengthening of the peroneal tendons 1
• Manual therapy techniques: May include:
  • Lateral calcaneal glide, which has shown effectiveness in case studies 2
  • Deep transverse friction massage to reduce pain
  • Mobilization of the talocrural joint if hypomobility is present 2

Advanced Interventions

Corticosteroid Injections

• Ultrasound-guided peroneal tendon sheath corticosteroid injections can be considered when initial treatments fail 3
• Evidence shows these injections are relatively safe and effective:
  • 36.8% of patients experience pain relief for more than 12 weeks
  • 25% of patients ultimately progress to surgery despite injections
  • Low complication rate (1.8%), including rare cases of sural nerve irritation 3
• Caution: Shorter duration of symptom relief is associated with longer pre-injection symptom duration 3

Surgical Management

• Surgery should be considered only after failure of 3-6 months of well-managed conservative treatment 1, 4
• Surgical approach depends on specific pathology:
  • Tenosynovitis: Synovectomy and debridement
  • Tendon tears <50%: Primary repair and tubularization
  • Tendon tears >50%: Tenodesis
  • Subluxation: Repair or reconstruction of superior peroneal retinaculum, possibly with groove deepening 4
• Post-surgical outcomes are generally good:
  • Average time to return to work: 2.5 months
  • Average time to return to sport: 8.5 months
  • High satisfaction rates (94.1%) 5

Treatment Algorithm

1. Initial Phase (0-6 weeks):

   • NSAIDs for pain and inflammation
   • Activity modification/relative rest
   • Laterally posted orthotics (especially with varus hindfoot)
   • Possible short-term immobilization for acute cases

2. Intermediate Phase (6-12 weeks):

   • Progressive physical therapy with eccentric strengthening
   • Manual therapy techniques including lateral calcaneal glide
   • Reassess at 8-12 weeks

3. Advanced Phase (if inadequate improvement after 12 weeks):

   • Consider ultrasound-guided corticosteroid injection
   • Continue modified physical therapy program

4. Surgical Consideration (if failed conservative treatment after 3-6 months):

   • Surgical approach based on specific pathology (tenosynovitis, tears, subluxation)

Common Pitfalls and Caveats

• Misdiagnosis: Peroneal tendinopathy is frequently mistaken for lateral ankle sprain 1
• Overlooking biomechanical factors: Varus hindfoot alignment is a significant risk factor that should be addressed with appropriate orthotic intervention 1
• Premature surgical intervention: Conservative management should be thoroughly attempted for 3-6 months before considering surgery 1
• Inadequate rehabilitation: Progressive tendon loading through eccentric exercises is crucial for successful non-operative management 1
• Overuse of corticosteroid injections: While effective, these should not replace comprehensive rehabilitation and may have diminishing returns with multiple injections 3