What is the treatment for tendinitis on the lateral aspect of the foot?

Treatment of Lateral Foot Tendinitis

Begin with a structured 3-6 month conservative treatment program consisting of relative rest, eccentric strengthening exercises, NSAIDs, and cryotherapy before considering any invasive interventions. 1

Initial Conservative Management (First-Line Treatment)

Activity Modification and Rest

• Implement relative rest by allowing patients to continue activities that do not worsen pain while avoiding complete immobilization, which causes muscle atrophy and deconditioning 1
• Tensile loading of the tendon through controlled activity stimulates collagen production and guides proper alignment of newly formed collagen fibers 1

Eccentric Strengthening Exercises

• Eccentric exercises are the cornerstone of treatment and have proven beneficial in multiple tendinopathies, including Achilles and patellar tendinosis 1, 2
• These exercises can reverse degenerative changes in the tendon and should be initiated early 1
• Stretching exercises are widely accepted and generally helpful 1

Cryotherapy

• Apply ice through a wet towel for 10-minute periods for short-term pain relief 1
• Ice reduces tissue metabolism, slows release of blood and proteins from surrounding vasculature, and blunts the inflammatory response in acute cases 1

NSAIDs

• Topical NSAIDs are preferable to oral NSAIDs as they eliminate the increased risk of gastrointestinal hemorrhage while effectively relieving tendon pain 1
• Oral NSAIDs provide effective pain relief and may offer additional benefit in acute inflammatory tendonitis 1
• Important caveat: NSAIDs provide only short-term pain relief and do not affect long-term outcomes 1

Orthotics and Bracing

• Shoe orthotics are safe, widely used, and often helpful in correcting biomechanical problems such as excessive foot pronation or pes planus deformity 1
• These devices reinforce, unload, and protect tendons during activity, though definitive evidence for their effectiveness is limited 1
• For lateral foot tendinitis specifically, orthotics can address underlying biomechanical issues contributing to peroneal tendon overload 2

Expected Outcomes

• Approximately 80% of patients with overuse tendinopathies recover completely within 3-6 months with appropriate conservative treatment 1

Second-Line Treatments (If No Improvement After 6-8 Weeks)

Corticosteroid Injections

• Use with extreme caution and only for peritendinous injection - never inject directly into the tendon substance 1
• May be more effective than oral NSAIDs for acute phase pain relief, but do not alter long-term outcomes 1
• Critical pitfall: Corticosteroids may inhibit healing, reduce tensile strength of tissue, and predispose to spontaneous rupture when injected into tendon substance 1

Immobilization

• Consider cast immobilization or fixed-ankle walker-type device in particularly acute or refractory cases 1
• Should be time-limited to avoid muscle atrophy 1

Additional Modalities (Weak Evidence)

• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify optimal treatment strategies 1
• Therapeutic ultrasonography may decrease pain and increase collagen synthesis, but evidence for consistent benefit is weak 1
• Iontophoresis and phonophoresis are widely used but lack well-designed RCTs to permit reliable recommendations 1

Surgical Management

Indications

• Surgery is warranted only if pain persists despite 3-6 months of well-managed conservative treatment 1
• Referral to a podiatric foot and ankle surgeon is appropriate when conservative measures fail 1

Surgical Approach

• Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1
• The mechanism of surgical healing promotion is not entirely understood, but surgery is effective in carefully selected patients 1

Important Considerations for Lateral Foot Tendinitis

Peroneal Tendinopathy Specifics

• Peroneal tendinopathy is often misdiagnosed and can lead to chronic lateral ankle pain and instability 2
• Should be suspected in any patient with chronic lateral ankle pain or instability 2
• Treatment involves physical therapy and close monitoring for surgical indications 2

Technique Modification

• For athletes and manual laborers, modify techniques to minimize repetitive stresses placed on tendons to eliminate pain and promote healing 1

Common Pitfalls to Avoid

• Never inject corticosteroids directly into the tendon substance - only peritendinous injections should be considered 1
• Avoid complete immobilization for prolonged periods as it leads to muscle atrophy and deconditioning 1
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 1
• Do not rely on NSAIDs alone for long-term management - they provide only short-term symptom relief 1