How is peroneal tendonitis treated?

Treatment of Peroneal Tendonitis

The treatment of peroneal tendonitis should focus on relative rest, ice application, eccentric strengthening exercises, and analgesics for pain relief, with bracing as a supportive measure to prevent recurrence and promote healing. 1

Initial Conservative Management

• Relative Rest: Reduce activities that aggravate symptoms while avoiding complete immobilization to prevent muscle atrophy and deconditioning. Allow patients to continue activities that do not worsen pain 1

• Ice Therapy: Apply ice through a wet towel for 10-minute periods to provide short-term pain relief and reduce swelling, especially in acute inflammatory phases 1

• Analgesics: NSAIDs are effective for short-term pain relief and may offer additional benefit in acute inflammatory tendonitis. Topical NSAIDs can also be used to reduce pain while minimizing gastrointestinal side effects 1

• Eccentric Strengthening Exercises: These have proven beneficial in treating tendinopathies by stimulating collagen production and guiding normal alignment of newly formed collagen fibers 1

• Stretching Exercises: Generally thought to be helpful and widely accepted as part of rehabilitation 1

Supportive Devices

• Bracing: A brace is preferable to tape for supporting the ankle and peroneal tendons due to practical usability and cost considerations. Braces help reinforce, unload, and protect tendons during activity 1

• Orthotics: May be helpful in correcting biomechanical problems such as excessive foot pronation that could contribute to peroneal tendonitis 1

Advanced Treatment Options

• Corticosteroid Injections: Should be used with caution. Ultrasound-guided peroneal tendon sheath corticosteroid injections may provide pain relief, but there's a risk of tendon weakening and potential rupture. These injections may be more effective than oral NSAIDs for acute pain relief but do not alter long-term outcomes 1, 2

• Therapeutic Modalities: Ultrasonography, extracorporeal shock wave therapy, and iontophoresis may be used, though evidence for their effectiveness is limited 1

• Technique Modification: For athletes and manual laborers, modifying movement techniques can minimize repetitive stresses on tendons 1

Surgical Management

• Surgery: Should be reserved for patients who have failed 3-6 months of conservative therapy. Surgical options depend on the extent of tendon damage 1, 3:
  • Primary repair and tubularization for tears involving <50% of the tendon
  • Tenodesis for tears involving >50% of the tendon
  • Debridement or reconstruction in other cases

Treatment Algorithm

1. First 2-4 weeks: Relative rest, ice application, NSAIDs, and gentle stretching 1
2. Weeks 4-8: Progressive eccentric strengthening exercises, continued use of bracing during activities 1
3. Weeks 8-12: Return to normal activities with continued strengthening and possible technique modification 1
4. If no improvement after 3 months: Consider advanced interventions like corticosteroid injections or referral for surgical evaluation 1, 3

Special Considerations

• Diagnostic Imaging: If symptoms persist despite treatment, consider MRI or ultrasound to evaluate for tendon tears or other pathology. MRI has high sensitivity (>90%) for diagnosing ankle tendon tears 1, 4

• Rehabilitation Focus: For athletes, rehabilitation should include proprioception, strength, coordination, and functional exercises to prevent recurrence 1

• Common Pitfalls:

  • Misdiagnosis is common with peroneal tendinopathy, which can lead to chronic lateral ankle pain and instability 5, 4
  • Complete immobilization should be avoided as it can lead to muscle atrophy 1
  • Injecting corticosteroids directly into the tendon substance should be avoided due to risk of tendon rupture 1

Most patients with overuse tendinopathies (approximately 80%) fully recover within three to six months with appropriate conservative treatment 1.