What is the best treatment approach for peroneal tendinitis?

Treatment Approach for Peroneal Tendinitis

The best treatment approach for peroneal tendinitis includes activity modification, NSAIDs for short-term pain relief, eccentric strengthening exercises, and footwear modifications as first-line therapy, with a phased rehabilitation approach over 8-12 weeks. 1

Initial Management (0-4 weeks)

Pain Control and Activity Modification

• Reduce activities that cause pain and implement relative rest 1
• NSAIDs (such as naproxen 500mg twice daily or ibuprofen 1.2-2.4g daily) for short-term pain relief 1
• Footwear modifications:
  • Laterally posted orthotics to reduce stress on peroneal tendons 2
  • Deep heel cups with long lateral flange extensions 3

Early Rehabilitation

• Protected range of motion exercises
• Ice application after activity
• Avoid corticosteroid injections near the tendon due to risk of tendon damage 1

Intermediate Phase (4-8 weeks)

Progressive Strengthening

• Eccentric strengthening exercises (highest evidence-based effectiveness) 1
• Manual therapy techniques:
  • Lateral calcaneal glide has shown effectiveness in case studies 4
  • Talocrural joint mobilization if restricted dorsiflexion is present 4

Supportive Measures

• Customized orthotic devices to correct biomechanical issues 1
• Night splinting may be considered 1
• Immobilization (boot or cast) for more severe cases, but avoid prolonged immobilization beyond 3 weeks 1

Advanced Phase (8-12 weeks)

Functional Rehabilitation

• Occupation-specific training
• Functional exercises
• Progressive return to previous activity levels 1

When to Consider Advanced Interventions

Ultrasound-Guided Corticosteroid Injection

• May be considered for refractory cases
• Studies show varying duration of relief: 36.8% of patients experience >12 weeks of pain relief, while 43.7% experience only 0-1 week of relief 5
• Limited complications reported (1.8%), including sural nerve irritation 5
• Caution: Use only when other conservative measures have failed

Surgical Evaluation

• Consider if pain persists despite 3-6 months of well-managed conservative treatment 1, 6
• Surgical approach depends on specific pathology:
  • Primary repair for tears involving <50% of tendon
  • Tenodesis for tears involving >50% of tendon 6
  • Anatomic repair or reconstruction for tendon subluxation 6

Follow-up and Return to Activity

• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels
  • Range of motion
  • Functional improvement 1
• Return to full activity permitted when:
  • Complete resolution of pain
  • Full range of motion
  • Strength symmetry >90% compared to uninjured side 1

Common Pitfalls to Avoid

• Misdiagnosis: Peroneal tendon disorders are frequently mistaken for lateral ankle sprains 2
• Overuse of imaging: Clinical assessment is sufficient for initial diagnosis 1
• Corticosteroid injections near the tendon: Risk of tendon damage 1
• Prolonged immobilization: Can lead to contractures 1
• Failure to address biomechanical factors: Varus hindfoot is a known risk factor 2
• Delayed referral for surgical evaluation: When conservative measures fail after 3-6 months 1