What is the initial management approach for a peroneal tendon injury?

Initial Management of Peroneal Tendon Injury

The initial management approach for a peroneal tendon injury should consist of relative rest of the affected area, icing, and analgesics, followed by a progressive rehabilitation program including eccentric strengthening exercises. 1

Diagnosis and Assessment

• Peroneal tendon injuries are an under-appreciated source of lateral ankle pain that can be difficult to distinguish from lateral ankle ligament injuries 2
• Common symptoms include lateral ankle pain, swelling, clicking, tenderness along the peroneal tendon track, and potential ankle instability 3, 4
• Physical examination should include:
  • Assessment of foot type (cavus or planovalgus)
  • Palpation of the peroneal tendons in the retromalleolar groove during resisted ankle dorsiflexion and eversion
  • Testing of lateral ankle ligament stability 2
• Imaging is helpful when diagnosis remains unclear:
  • Ultrasound has shown 100% sensitivity and 90% accuracy in diagnosing peroneal tendon tears 1
  • MRI demonstrates sensitivities of 83.9% for tendinopathy and 54.5% for tendon tears 1

Initial Conservative Management

Relative Rest

• Prevent ongoing damage and promote tendon healing by reducing activities that worsen pain 1
• Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 1
• Allow continuation of activities that do not exacerbate symptoms 1

Cryotherapy (Ice)

• Apply ice through a wet towel for 10-minute periods to reduce pain and swelling 1
• Icing helps slow tissue metabolism and blunt the inflammatory response in acute cases 1

Pain Management

• Nonsteroidal anti-inflammatory drugs (NSAIDs) effectively relieve tendinopathy pain 1
• Topical NSAIDs may be used to reduce pain while avoiding gastrointestinal side effects 1

Bracing

• A brace is preferable to tape for initial support based on practical usability and cost considerations 1
• Workers with peroneal tendon injuries should preferably be treated with a brace to speed up work resumption 1

Rehabilitation Program

• Begin eccentric strengthening exercises once acute pain subsides 1
• Include proprioceptive training to address potential deficits in ankle stability 1
• Incorporate strength training for eversion and other ankle muscles 1
• Gradually phase out supportive devices (brace or tape) as strength and function improve 1

When to Consider Advanced Interventions

• Most patients with overuse tendinopathies (about 80%) fully recover within three to six months with conservative treatment 1
• Consider surgical consultation if symptoms persist despite 3-6 months of appropriate conservative management 5
• Surgical options depend on the specific pathology:
  • Tenosynovitis may require synovectomy
  • Tendon tears <50% may be treated with debridement and tubularization
  • Tears >50% may require tenodesis or tendon transfer 5, 6

Pitfalls and Caveats

• Peroneal tendon disorders are frequently misdiagnosed as lateral ankle ligament injuries 2, 6
• Up to 40% of patients with ankle sprains experience chronic ankle pain, with peroneal tendon injuries being a potential cause 6
• MRI evidence of peroneal tendon pathology should be interpreted cautiously as up to 34% of asymptomatic patients may have peroneus brevis tendon tears 1
• Low-demand patients typically do well with conservative management, while high-demand patients may benefit from earlier surgical intervention 6