What are the guidelines for managing tenosynovitis of the ankle?

Management of Ankle Tenosynovitis

For ankle tenosynovitis, initiate conservative treatment with rest, NSAIDs, and physical therapy for 6-12 weeks; if symptoms persist despite conservative measures or if associated with seronegative spondyloarthropathies, proceed to surgical synovectomy with tendon inspection and repair of any longitudinal tears.

Initial Conservative Management

• Start with tendon rest and NSAIDs to reduce pain and inflammation 1, 2
• Prescribe physical therapy focusing on controlled range of motion and strengthening exercises 1, 2
• Modify footwear to reduce mechanical stress on the affected tendon 2
• Continue conservative treatment for 3 months in mechanical/overuse cases (true stage I disease) 1

Diagnostic Evaluation

• Perform late physical examination to accurately assess the severity of tendon involvement 3
• Consider ultrasound imaging as an inexpensive and accurate method to confirm tenosynovitis and detect tendon pathology 1
• Evaluate for underlying systemic conditions including seronegative spondyloarthropathies and rheumatoid arthritis through clinical assessment and hematologic analysis 1
• Identify the specific tendon involved (posterior tibial, peroneal, flexor hallucis longus, or tibialis anterior) as this guides treatment approach 1, 4, 5, 2

Surgical Intervention Criteria

Proceed to surgery earlier (6 weeks) if:

• Seronegative spondyloarthropathy is present (enthesopathic disease requires early synovial débridement) 1
• Symptoms persist despite 3 months of conservative treatment in mechanical/overuse cases 1
• Infectious tenosynovitis is suspected (requires prompt surgical drainage to avoid complications) 3

Surgical Technique Components

When surgery is indicated, the procedure must include:

• Synovectomy to remove inflamed synovial tissue 1, 4, 2
• Thorough inspection of the tendon undersurface for longitudinal split tears 1
• Repair of any longitudinal tears with nonabsorbable suture, burying the knots 1
• Deepening of constricted grooves if stenosing tenosynovitis is present 4
• Fashioning new pulleys from available sheath and retinaculum 4
• Construction of new sheath from regional deep fascia if needed 4
• Intraoperative assessment of tendon excursion to ensure adequate decompression 1

Consider tendoscopic approach for tibialis anterior tenosynovitis to preserve extensor retinaculum integrity 2

Postoperative Management

• Non-weightbearing for 1 month with soft bandages 4
• Initiate home exercise therapy immediately focusing on gentle range of motion 4
• Progress to intensive muscle strengthening after the first month 4
• Provide orthoses as needed for support during rehabilitation 4

Critical Pitfalls to Avoid

• Do not confuse ankle tenosynovitis with ankle sprain - tenosynovitis requires specific treatment and has distinct pathophysiology 1
• Do not delay surgery in seronegative disease - waiting beyond 6 weeks increases risk of tendon rupture 1
• Do not perform isolated tenosynovectomy without evaluating for structural deformity in stage I disease, as this leads to surgical failure 1
• Do not miss longitudinal split tears during surgery - failure to repair these results in persistent symptoms 1
• Do not use immobilization as it is contraindicated and delays recovery 3

Special Considerations by Tendon Location

Posterior tibial tendon: Pain typically localizes to the hypovascular zone 40mm proximal to insertion; evaluate carefully for pre-existing flatfoot deformity 1

Flexor hallucis longus: Most common in ballet dancers but can occur in runners; presents as posteromedial ankle pain worsened by plantarflexion 5

Tibialis anterior: Usually overuse injury from repetitive dorsiflexion; tendoscopic approach preferred to preserve retinaculum 2

Peroneal tendons: May require groove deepening if stenosing component present 4