What is the treatment for peroneal tendonitis?

Treatment for Peroneal Tendonitis

The most effective treatment for peroneal tendonitis is a comprehensive rehabilitation program including NSAIDs for pain relief, eccentric strengthening exercises, and functional support, while avoiding immobilization and limiting corticosteroid injections. 1

Initial Conservative Management (0-4 weeks)

Pain Control

• NSAIDs:
  • Ibuprofen 1.2g daily initially, can be increased to 2.4g daily if needed
  • Naproxen 500mg twice daily is an alternative option
  • May be combined with paracetamol (up to 4g daily) for enhanced pain relief 1

Activity Modification

• Avoid activities that exacerbate symptoms
• Protected range of motion exercises
• Avoid complete immobilization as it may lead to stiffness 1

Physical Therapy

• Gentle stretching exercises
• Ice application for 15-20 minutes several times daily
• Functional support with a brace or taping may help reduce pain during activities 1

Intermediate Phase (4-8 weeks)

Progressive Rehabilitation

• Eccentric strengthening exercises targeting the peroneal muscles
• Proprioceptive and balance training
• Gradual increase in weight-bearing activities 1

Manual Therapy

• Lateral calcaneal glide technique has shown effectiveness in some cases 2
• Mobilization of hypomobile talocrural joint if present 2

Advanced Phase (8-12 weeks)

Functional Rehabilitation

• Occupation-specific training
• Sport-specific exercises if applicable
• Functional exercises that mimic daily activities 1

Injection Therapy

Corticosteroid Injections

• Consider only if conservative measures fail after 4-6 weeks
• Limited use recommended (2-3 injections, 4-6 weeks between injections)
• Provides short-term relief but does not change long-term outcomes 1
• Ultrasound-guided peroneal tendon sheath corticosteroid injection has shown to be relatively safe and effective, with 36.8% of patients experiencing pain relief for more than 12 weeks 3

Injection Technique

• Must be performed using aseptic technique
• Ultrasound guidance improves accuracy and safety
• Avoid injection if there are signs of infection at the site 1

Diagnostic Imaging

• Ultrasound has shown 100% sensitivity and 90% accuracy in diagnosing peroneal tendon tears
• MRI can be used with reported sensitivities and specificities of 83.9% and 74.5% for tendinopathy 1
• Note that MRI findings should be interpreted carefully as up to 34% of asymptomatic patients may have peroneus brevis tendon tears 1

Surgical Intervention

• Consider only when conservative measures fail after 3-6 months of well-managed treatment 1
• Indications include:
  • Persistent pain and dysfunction despite appropriate conservative management
  • Peroneal tendon tears involving >50% of the tendon (tenodesis recommended)
  • Tears involving <50% of the tendon (primary repair and tubularization) 4
  • Peroneal tendon subluxation requiring repair or reconstruction of the superior peroneal retinaculum 4

Return to Activity Criteria

• Complete resolution of pain
• Full range of motion
• Strength symmetry >90% compared to the uninjured side
• Successful completion of occupation-specific functional tests 1

Follow-up Schedule

• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels
  • Range of motion
  • Functional improvement
  • Signs of recurrent instability 1

Common Pitfalls and Caveats

• Peroneal tendinopathy is often underdiagnosed and should be considered in all cases of chronic lateral ankle pain 5
• Avoid overuse of corticosteroid injections as they may weaken tendons and lead to rupture
• Patients with hindfoot varus may require additional interventions such as valgus osteotomy to address biomechanical factors 5
• Don't rely solely on imaging findings, as asymptomatic individuals may have abnormal MRI findings 1
• Failure to address underlying biomechanical issues may lead to recurrence