Initial Treatment for Peroneal Tendon Subluxation
The initial treatment for peroneal tendon subluxation should include immobilization with a below-knee cast or brace, followed by functional rehabilitation, though surgical intervention is often necessary for recurrent cases due to the high failure rate of conservative management. 1
Diagnosis and Assessment
- Peroneal tendon subluxation is often misdiagnosed as a lateral ankle sprain due to similar injury mechanisms and lower frequency of occurrence 2, 1
- Diagnosis relies primarily on clinical examination with tenderness along the peroneal tendons posterior to the lateral malleolus 1
- Ultrasound is particularly valuable for diagnosis as it allows dynamic assessment of tendon subluxation with a reported positive predictive value of 100% compared with surgical findings 3
- MRI can detect peroneal tendinopathy but has only 66% accuracy for assessing tendon subluxation compared to ultrasound's superior capability in this specific condition 3
Conservative Management
Initial Treatment Protocol
- Immobilization in a below-knee non-weight-bearing cast in semi-equinus position for 2-4 weeks 4
- Following immobilization, transition to a brace for continued support during rehabilitation 3
- Supervised rehabilitation focusing on:
- Proprioceptive training
- Peroneal muscle strengthening
- Coordination exercises
- Functional activities 3
Important Considerations
- Conservative treatment has a low success rate for preventing recurrent subluxation 1
- High-demand individuals and athletes may benefit from earlier surgical consideration 5
- Return to work and sports should follow a structured progression based on functional recovery 3
Surgical Management
Surgical intervention is indicated when:
- Conservative treatment fails
- Patient experiences recurrent subluxation
- Patient is a high-demand individual or athlete 5, 6
Surgical Options
- Retinaculoplasty (repair of the superior peroneal retinaculum) is considered the preferred soft tissue procedure with fewer complications 5, 2
- Peroneal groove deepening combined with retinaculum repair shows excellent outcomes for stabilizing the tendons 4, 6
- For tears involving <50% of the tendon, primary repair and tubularization is indicated 6
- For tears involving >50% of the tendon, tenodesis is recommended 6
Post-Treatment Rehabilitation
- Following conservative treatment or surgery, a structured rehabilitation program is essential 3
- Supervised exercises provide better outcomes than non-supervised training 3
- Focus on proprioception, strength, coordination, and function to facilitate faster return to sport 3
- Gradual return to activities based on functional recovery rather than arbitrary timeframes 3
Clinical Pitfalls to Avoid
- Misdiagnosing peroneal tendon subluxation as a simple lateral ankle sprain 2, 1
- Relying solely on MRI for diagnosis when ultrasound provides superior dynamic assessment 3
- Prolonged conservative management in high-demand individuals when surgical outcomes are more reliable 5
- Failing to address anatomical variations that may contribute to recurrent subluxation 2
- Not recognizing intrasheath subluxation, a unique subtype requiring specific diagnostic approaches 2