From the Guidelines
The best treatment for peroneal tendinopathy is a combination of rest, physical therapy, and anti-inflammatory measures, with a focus on eccentric strengthening exercises and ankle mobility, as recommended by the American Family Physician 1. The initial management should include reducing activities that cause pain and following the RICE protocol (rest, ice, compression, elevation) to manage acute symptoms. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg three times daily with food) or naproxen (500mg twice daily) can help reduce pain and inflammation for short periods, typically 1-2 weeks, as they are effective for short-term pain relief but have no effect on long-term outcomes 1. Some key points to consider in the treatment of peroneal tendinopathy include:
- Relative rest and reduced activity to prevent further damage and promote healing and pain relief, as generally accepted practice 2, 1
- Cryotherapy, such as icing, for acute relief of tendinopathy pain, with repeated applications of melting ice water through a wet towel for 10-minute periods being most effective 1
- Eccentric strengthening exercises as an effective treatment of tendinopathy, which may reverse degenerative changes, and should be performed 3-5 times weekly for 6-12 weeks 1
- Proper footwear with adequate support and temporary use of lateral heel wedges or custom orthotics to reduce stress on the peroneal tendons
- Avoidance of corticosteroid injections, as they may weaken the tendon and increase rupture risk, and consideration of platelet-rich plasma injections for chronic cases
- Surgery typically reserved for cases that don't respond to 3-6 months of conservative treatment, as it is an effective option in carefully selected patients who have failed conservative therapy 1. Recovery time varies, but most patients see improvement within 6-12 weeks with appropriate management, addressing both symptom management and underlying biomechanical issues that contribute to peroneal tendinopathy.
From the Research
Treatment Options for Peroneal Tendinopathy
- Nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and immobilization are traditionally used as the initial treatment for symptomatic peroneal tendinopathy and tears 3
- Ultrasound-guided peroneal tendon sheath corticosteroid injection is an additional nonoperative modality that has been shown to be safe and relatively effective in patients with symptomatic peroneal tendon tears or tendinopathy, including those who had undergone prior surgery 3
- Conservative measures, such as physical therapy and activity modification, are often used as the first-line treatment for peroneal tendinopathy in athletes 4
- Surgery is typically reserved for those failing nonoperative treatment, and is often immediately indicated in cases of recurrent symptomatic subluxation or dislocation 3, 4
Factors Influencing Treatment Outcomes
- Preinjection duration of symptoms has been associated with postinjection duration of pain relief, with longer symptom duration potentially leading to longer pain relief 3
- The effectiveness of treatment may also depend on the underlying diagnosis, with some patients responding better to certain treatments than others 3, 4
Potential Complications and Risks
- Ultrasound-guided peroneal tendon sheath corticosteroid injection has been shown to have a low complication rate, with only 2 reported complications (1.8%) in one study, including self-limited sural nerve irritation and peroneus longus tear progression 3
- Surgical treatment also carries potential risks and complications, although most procedures have a high success rate 4