What is the procedure for repairing a longus muscle or tendon injury, including postoperative care and rehabilitation?

Peroneus Longus Tendon Repair

For peroneus longus tendon injuries requiring surgical repair, perform direct tendon repair or tenodesis to the peroneus brevis using suture anchors, followed by early protected mobilization at 2-4 weeks with progressive weight-bearing and rehabilitation over 3-6 months. 1

Surgical Approach

Repair Technique

• Direct surgical repair is indicated for complete tears or avulsions to restore function and prevent progressive deformity 1
• Use suture anchors (typically 3 anchors with high-strength suture material) for osseous avulsions or proximal tears to achieve secure fixation 2
• When both peroneus longus and brevis are torn, tenodesis of the longus to the brevis is an effective option if at least one functioning tendon remains 1
• Address any contributing factors including chronic ankle instability, hindfoot varus deformity, or peroneal subluxation at the time of repair 1

Surgical Considerations

• Make a longitudinal incision along the posterior border of the fibula, approximately 2 cm above the fibular tip 3
• Preserve the superior peroneal retinaculum as it provides primary restraint against tendon subluxation 3
• Identify anatomical landmarks carefully: the peroneus longus is more rounded and free of muscle attachment compared to the brevis 3

Postoperative Management

Immobilization Phase (0-2 Weeks)

• Immobilize the ankle and foot for the first 2 weeks to protect the repair 4
• Apply cryotherapy through a wet towel for 10-minute periods to reduce acute postoperative pain 5
• Use local cold therapy as consensus supports its benefit for pain relief after tendon surgery 6

Early Mobilization Phase (2-4 Weeks)

• Begin mobilization by 2-4 weeks using a protective device (walking boot or brace) 7
• The protective device must limit dorsiflexion to protect the healing tendon 7
• Initiate gentle range-of-motion exercises during this period 4

Progressive Weight-Bearing (4-6 Weeks)

• Commence full weight-bearing at 6 weeks if healing progresses appropriately 4
• Weight-bearing should only be tolerated with correct gait pattern, no pain, no effusion, and no temperature increase 6
• Use crutches if necessary to maintain proper biomechanics 6

Strengthening Phase (6 Weeks - 3 Months)

• Implement eccentric strengthening exercises as they are effective for tendinopathy treatment and may reverse degenerative changes 5
• Begin isometric exercises when they provoke no pain to reactivate the muscle 6
• Progress to active resistance exercises as tolerated, though specific timing remains based on clinical assessment 6

Expected Outcomes and Timeline

Recovery Milestones

• Most patients (80%) fully recover within 3-6 months with appropriate treatment 5
• Return to full preinjury function typically occurs at 3 months following surgical repair 8, 2
• Manual muscle strength testing should demonstrate 5/5 strength with resisted movements equal to the contralateral side by 3 months 2
• 91% of patients achieve normal or moderate peroneal muscle strength with appropriate surgical management 1

Functional Assessment

• At 3-month follow-up, expect active extension with full range of motion and no discomfort during daily activities 4
• Long-term follow-up (mean 4.6 years) shows mean AOFAS ankle scores of 82 points for concomitant peroneal tendon repairs 1

Important Caveats

Pain Management

• NSAIDs (topical or systemic) provide short-term pain relief but have no effect on long-term outcomes 5
• Avoid peritendinous corticosteroid injections as they may inhibit healing and reduce tensile strength, predisposing to spontaneous rupture 6
• If corticosteroids are used, apply them with extreme caution and only for acute pain relief 5

Monitoring for Complications

• Watch for sural nerve injuries, which can occur with surgical approaches 7
• Monitor for deep vein thrombosis during the immobilization period 7
• Patient compliance with the prescribed protocol is crucial to prevent rerupture 7

Relative Rest Principle

• Relative rest of the affected area is essential to prevent further damage and promote healing 5
• Continue rehabilitation for 9-12 months depending on return-to-work or return-to-sport goals 6
• Surgery should be reserved for patients who have failed conservative therapy of at least 3-6 months 6