What is the recommended treatment for a patient with peroneal tendinitis?

Treatment of Peroneal Tendinitis

Begin with a structured conservative approach combining relative rest, NSAIDs, cryotherapy, and eccentric strengthening exercises for 3-6 months before considering any invasive interventions. 1

Initial Conservative Management (First-Line Treatment)

Activity Modification and Rest

• Reduce repetitive loading activities that stress the peroneal tendons while maintaining activities that don't worsen pain 1
• Avoid complete immobilization—this causes muscular atrophy and deconditioning 1
• Allow patients to continue activities that do not reproduce their pain 1

Pain Management

• NSAIDs (oral or topical) are recommended for short-term pain relief, though they provide no long-term benefit 1
• Topical NSAIDs are preferable as they eliminate gastrointestinal hemorrhage risk while providing equivalent pain relief 1
• Apply cryotherapy through a wet towel for 10-minute periods for acute pain relief 1

Rehabilitation Exercises

• Eccentric strengthening exercises are the cornerstone of treatment and can reverse degenerative tendon changes 1, 2
• Progress to sport-specific and work-specific functional exercises as tolerated 3, 2
• Address proprioception deficits and delayed peroneal muscle response time, which commonly occur after lateral ankle injuries 1

Orthotic Support

• Consider laterally posted orthotics to unload the peroneal tendons 2
• Correct varus hindfoot deformity if present, as this is a known risk factor for peroneal tendinopathy 2

Secondary Treatment Options (If Conservative Fails After 6-8 Weeks)

Corticosteroid Injections

• Ultrasound-guided peroneal tendon sheath corticosteroid injection may provide pain relief, with 37% of patients experiencing >12 weeks of relief 4
• Injections are more effective than oral NSAIDs for acute-phase pain relief but do not alter long-term outcomes 1
• Critical pitfall: Never inject directly into the tendon substance—only into the tendon sheath—as this inhibits healing, reduces tensile strength, and may predispose to rupture 1
• Patients with shorter preinjection symptom duration experience longer postinjection pain relief 4
• Complication rate is low (1.8%) but includes sural nerve irritation and potential tendon tear progression 4

Advanced Manual Therapy

• Lateral calcaneal glide technique combined with talocrural joint mobilization may provide benefit when standard approaches fail 5
• Address any concurrent talocrural joint hypomobility 5

Surgical Management

Surgery is reserved exclusively for patients who fail 3-6 months of well-executed conservative therapy 1, 2

Surgical Indications and Techniques

• Operative treatment is frequently required for peroneal tendon subluxation, involving anatomic repair or reconstruction of the superior peroneal retinaculum 6
• For tendon tears <50% of tendon width: primary repair and tubularization 6
• For tendon tears >50% of tendon width: tenodesis to the adjacent intact tendon 6
• Surgical debridement of degenerative tissue with longitudinal tenotomies to release scarring 1

Critical Pitfalls to Avoid

• Do not inject corticosteroids into the tendon substance itself—only the tendon sheath 1, 4
• Avoid multiple corticosteroid injections as they weaken tendon structure despite providing short-term relief 1
• Do not proceed to surgery without a minimum 3-6 month trial of conservative treatment 1, 2
• Peroneal tendon disorders are frequently mistaken for lateral ankle sprains—maintain high clinical suspicion 2
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease 1
• Complete immobilization must be avoided 1

Expected Outcomes

Approximately 80% of patients with overuse tendinopathies recover completely within 3-6 months with appropriate conservative treatment 1. Following ultrasound-guided corticosteroid injection, 37% of patients experience pain relief lasting >12 weeks, though 44% experience only 0-1 weeks of relief 4.