What is the initial treatment approach for peroneal tendon issues, such as tendonitis or tears?

Initial Treatment Approach for Peroneal Tendon Issues

The initial treatment approach for peroneal tendon issues, such as tendonitis or tears, should focus on conservative management including rest, ice, compression, elevation (RICE protocol), NSAIDs, and targeted exercise therapy before considering surgical intervention. 1, 2

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Imaging:
  • Plain radiographs are recommended as first-line imaging to assess ankle anatomy 1
  • Ultrasound (US) is highly effective for peroneal tendon evaluation with:
    • 100% sensitivity and 90% accuracy in diagnosing peroneal tendon tears 1
    • Ability to perform dynamic assessment for tendon subluxation with 100% positive predictive value compared to surgical findings 1
  • MRI may be considered when US is unavailable, showing sensitivities of 83.9% for tendinopathy and 54.5% for tendon tears 1

Note: Clinical examination remains crucial as MRI evidence of peroneal tendon pathology has only a 48% positive predictive value for clinical findings 1

Conservative Management Algorithm

Phase 1 (0-4 weeks): Pain Control and Protection

1. RICE Protocol:

   • Rest: Reduce activities that cause pain
   • Ice: Apply 15-20 minutes several times daily
   • Compression: Use elastic bandage to reduce swelling
   • Elevation: Keep foot elevated when possible 2

2. Medication:

   • NSAIDs as first-line treatment (ibuprofen 1.2g daily, can increase to 2.4g if needed)
   • Can combine with acetaminophen (up to 4g daily) for inadequate relief 2

3. Protected Range of Motion:

   • Begin pain-free walking as soon as tolerated
   • Initiate pool-based exercises 2

Phase 2 (4-8 weeks): Progressive Strengthening

1. Exercise Therapy:

   • Knee-targeted exercises focusing on quadriceps strengthening
   • Hip-and-knee-targeted exercises (more effective than knee-targeted alone)
   • Low-load strengthening exercises starting with seated calf raises and progressing to bilateral standing heel raises 2

2. Manual Therapy:

   • Focus on the lower quadrant 2

3. Orthotic Support:

   • Consider prefabricated foot orthoses, particularly for patients with hindfoot varus 2, 3

Phase 3 (8-12 weeks): Advanced Rehabilitation

1. Sport-specific or occupation-specific training 2
2. Functional progression based on symptom response

Surgical Considerations

Surgical consultation should be considered if:

• Pain persists despite 3-6 months of well-managed conservative treatment
• Functional limitations significantly impact quality of life 2

Surgical options depend on the extent of tendon damage:

• For tears involving <50% of the tendon: Primary repair and tubularization
• For tears involving >50% of the tendon: Tenodesis 4
• For concomitant tears of both peroneus longus and brevis: Treatment algorithm based on remaining functional tendon, ankle stability, and heel position 3

Return to Activity Criteria

Return to full activity is permitted when the patient demonstrates:

• Complete resolution of pain during and after activity
• Full range of motion compared to uninjured side
• Strength symmetry >90% compared to uninjured side
• Successful completion of sport-specific functional tests 2

Common Pitfalls and Caveats

1. Missed Diagnosis: Peroneal tendon tears are frequently misdiagnosed due to vague lateral ankle pain. Look specifically for swelling along the peroneal tendon sheath, pain with eversion, and subluxing tendons 5

2. Anatomical Variants: Several variants may predispose to peroneal tendon injuries and should be assessed:

   • Flat or convex fibular retromalleolar groove
   • Hypertrophy of the peroneal tubercle
   • Accessory peroneus quartus muscle
   • Low-lying peroneus brevis muscle belly
   • Os peroneum 6

3. Concomitant Conditions: Always evaluate for associated conditions that may require simultaneous treatment:

   • Ankle instability (present in 8 of 28 patients with peroneal tears in one study) 3
   • Hindfoot varus (present in 6 of 28 patients with peroneal tears) 3
   • Cavovarus foot deformity 3

4. Chronic Tears: For chronic tears, particularly when both tendons are involved, conservative management is less likely to be successful, and earlier surgical intervention may be warranted 3