What is the treatment for Peroneal Tendinitis?

Treatment for Peroneal Tendinitis

The treatment of peroneal tendinitis should begin with conservative measures including NSAIDs, activity modification, physical therapy with eccentric strengthening exercises, and possibly immobilization, with surgery reserved only for cases that fail to respond after 3-6 months of well-managed conservative treatment. 1

Initial Conservative Management

Medication

• NSAIDs (such as naproxen 500mg twice daily or ibuprofen 1.2g daily) for short-term pain relief 2
• Acetaminophen can be used as an alternative if NSAIDs are contraindicated 2

Activity Modification

• Relative rest from aggravating activities
• Avoid activities that exacerbate lateral ankle pain
• Gradual return to activity only when symptoms improve

Supportive Measures

• Laterally posted orthotics to correct varus hindfoot alignment (a known risk factor) 1
• Bracing may provide symptomatic relief but should support rather than replace rehabilitation 2

Physical Therapy

Physical therapy is a cornerstone of treatment, focusing on:

1. Initial Phase (0-4 weeks):

   • Pain control
   • Protected range of motion
   • Activity modification

2. Intermediate Phase (4-8 weeks):

   • Progressive strengthening exercises
   • Eccentric training of the peroneal muscles
   • Gradual loading of the tendon

3. Advanced Phase (8-12 weeks):

   • Occupation-specific training
   • Functional exercises
   • Return to pre-injury activities

Advanced Interventions

Injection Therapy

• Ultrasound-guided peroneal tendon sheath corticosteroid injection may be considered when initial conservative measures fail
• This approach has shown to be relatively safe and effective, with 36.8% of patients experiencing pain relief for more than 12 weeks 3
• Proper technique is essential, including aseptic technique with surgical gloves and skin preparation 2
• Potential complications include sural nerve irritation and possible tendon tear progression (reported in 1.8% of cases) 3

Immobilization

• Short-term immobilization may be beneficial in acute cases
• Can be achieved through walking boot, brace, or cast depending on severity

Surgical Management

Surgery should only be considered when:

• Conservative measures have failed after 3-6 months of well-managed treatment 1
• Significant functional limitation persists
• Specific conditions are present such as:
  • Peroneal tendon tears involving >50% of the tendon (requiring tenodesis) 4
  • Peroneal tendon subluxation (requiring repair or reconstruction of the superior peroneal retinaculum) 4
  • Recurrent instability

Approximately 25% of patients with peroneal tendinopathy ultimately require surgical intervention despite conservative management 3.

Follow-up and Monitoring

• Regular assessment at 2,6, and 12 weeks to evaluate:

  • Pain levels
  • Range of motion
  • Functional improvement
  • Signs of recurrent instability 2

• Consider referral to a specialist if no improvement occurs after 6-8 weeks of conservative treatment 2

Important Considerations

• Peroneal tendon disorders are often mistaken for or occur alongside lateral ankle sprains 1
• Patients with shorter duration of symptoms before treatment tend to have better outcomes with conservative management 3
• Manual therapy techniques, including lateral calcaneal glide, may be beneficial when combined with exercise therapy 5
• Return to full activity should only be permitted when the patient demonstrates complete resolution of pain, full range of motion, and strength symmetry >90% compared to the uninjured side 2