What is the treatment for peroneal tendonitis?

Treatment for Peroneal Tendonitis

The treatment for peroneal tendonitis should begin with conservative management including NSAIDs as first-line medication, physical therapy with eccentric strengthening exercises, and activity modification, progressing to corticosteroid injections if initial treatment fails, with surgery reserved for cases refractory to 3-6 months of conservative treatment. 1

Conservative Management (First-Line Treatment)

Medications

• NSAIDs: Strongly recommended as first-line treatment for tendon pain
  • Ibuprofen 1.2g daily is considered the safest option
  • Can be increased to 2.4g daily if inadequate relief is achieved
  • Can be combined with paracetamol (up to 4g daily) for enhanced pain control 1

Physical Therapy

• Active interventions are conditionally recommended over passive interventions 1
• Recommended program includes:
  • Eccentric strengthening exercises
  • Proprioception training
  • Functional rehabilitation 1
  • Manual therapy techniques (including lateral calcaneal glide) 2

Bracing and Support

• Bracing is preferable to taping due to practical usability and cost considerations 1
• Immobilization may be necessary during acute phase 3

Activity Modification

• Reduce activities that exacerbate symptoms
• Avoid repetitive ankle movements that stress the peroneal tendons

Second-Line Treatment

Corticosteroid Injections

• Ultrasound-guided peroneal tendon sheath corticosteroid injections can be considered if initial conservative measures fail 3
• Benefits:
  • 36.8% of patients experience pain relief for more than 12 weeks
  • Safe with minimal complications (1.8% reported) 3
• Caution:
  • May lead to long-term deterioration of tendon tissue
  • Increased risk of recurrence 1
  • Limit to 2-3 injections with 4-6 weeks between injections 1

Surgical Management

Indications for Surgical Consultation

• Persistent pain despite 3-6 months of well-managed conservative treatment
• Functional limitations significantly impacting quality of life
• Progressive tendon degeneration evident on follow-up imaging 1

Surgical Options Based on Pathology

• For tears involving <50% of the tendon: Primary repair and tubularization
• For tears involving >50% of the tendon: Tenodesis 4
• For cases with hindfoot varus: Consider valgus osteotomy 5

Post-Surgical Rehabilitation

• Critical for optimal outcomes
• Focus on proprioception, strength, coordination, and function 1
• Average time to return to work: 2.5 months
• Average time to return to sport: 8.5 months 5

Diagnostic Considerations

Imaging

• MRI: Highly effective for diagnosing peroneal tendon pathology
  • 83.9% sensitivity for tendinopathy
  • 54.5% sensitivity for tendon tears 1
• Ultrasound: 100% sensitivity and 90% accuracy for diagnosing peroneal tendon tears 1

Return to Activity Criteria

• 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 1

Common Pitfalls and Caveats

• Peroneal tendon disorders are frequently missed and should be considered in all patients with chronic lateral ankle pain 6, 4
• Anatomic variants may predispose to peroneal tendon injuries and should be identified during diagnostic workup 6
• Patients with lower functional demands may do well with conservative treatment, while those with higher demands may benefit from earlier surgical intervention if conservative measures fail 6
• Pre-injection duration of symptoms is associated with post-injection duration of pain relief, with longer-standing symptoms potentially responding less favorably to injections 3