What is the recommended treatment for peroneus tertius or extensor digitorum anterior ankle swelling after hiking?

Treatment for Peroneus Tertius or Extensor Digitorum Anterior Ankle Swelling After Hiking

The recommended treatment for peroneus tertius or extensor digitorum anterior ankle swelling after hiking is the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) combined with NSAIDs and early functional rehabilitation within 48-72 hours of injury. 1

Initial Management (First 48-72 Hours)

• Apply the PRICE protocol:

  • Protection: Use a semirigid or lace-up ankle support (more effective than elastic bandages) 1
  • Rest: Avoid activities that cause pain
  • Ice: Apply cold therapy for 20-30 minutes, 3-4 times daily 1
  • Compression: Apply a compression wrap for comfort (while ensuring circulation isn't compromised)
  • Elevation: Keep the affected ankle elevated to reduce swelling

• Pain Management:

  • NSAIDs (e.g., naproxen, celecoxib) to reduce pain, inflammation, and swelling 1
  • Diclofenac shows superior results compared to ibuprofen for pain during motion 1
  • Topical diclofenac gel can be considered for localized pain relief with fewer systemic side effects 1
  • Alternative: Acetaminophen 1000mg every 6 hours (not exceeding 4000mg daily) 1

• Weight-bearing considerations:

  • Use crutches initially for partial weight-bearing to reduce pain and promote faster healing 1
  • Progress to full weight-bearing as pain and swelling decrease (typically within 5-10 days) 1

Rehabilitation Phase (Beginning within 48-72 Hours)

• Start progressive exercises:

  • Ankle circles and alphabet drawing with toes 1
  • Towel stretches for dorsiflexion 1
  • Resistance band exercises in all directions 1
  • Heel raises (progressing from bilateral to unilateral) 1
  • Balance and proprioception exercises 1

• Support during recovery:

  • Use a semi-rigid ankle support for at least 6 weeks during sports activities to prevent recurrence 1
  • Discontinue crutches when walking without significant pain or limping (usually within 7-14 days for moderate sprains) 1

Special Considerations for Peroneus Tertius

The peroneus tertius is an inconstant muscle (present in about 90% of people) that can be a source of specific pathology 2, 3. If the swelling and pain are specifically related to the peroneus tertius tendon:

• In cases where the peroneus tertius tendon is causing impingement and a typical synovial cyst, surgical removal of the tendon may be necessary if conservative treatment fails 4

When to Consider Advanced Imaging

• Apply the Ottawa Ankle Rules to determine if radiographs are necessary (sensitivity 96%, specificity 98%) 1

  • Inability to bear weight immediately after injury
  • Point tenderness over the malleoli, talus, or calcaneus

• If symptoms persist despite appropriate conservative management:

  • Begin with radiography to evaluate for osteoarthritis, calcified bodies, or evidence of prior trauma 1
  • Consider MRI if radiographs are normal but symptoms persist, to evaluate ligament integrity and identify synovitis or impingement lesions 1

Long-term Management

• Continue proprioceptive and strengthening exercises long-term to help prevent recurrent sprains 1
• Consider a combination of manual therapy and supervised exercise for better recovery outcomes 5

Caution

• Using elastic bandages alone is less effective than semirigid or lace-up supports 1
• While NSAIDs help with pain and inflammation, they may suppress the natural healing process 1
• Ensure compression wraps don't compromise circulation 1