What is the best course of treatment for a young female patient with a history of motor vehicle accident (MVA) and persistent pain over multiple ligamentous areas in the ankle, with MRI findings showing moderate ankle effusion, thickening of the anterior syndesmotic ligament, and attenuation of the peroneus brevis tendon?

Management of Post-MVA Ankle Injury with Syndesmotic and Peroneal Tendon Pathology

This patient requires immediate referral to physical therapy for functional rehabilitation with proprioceptive training, combined with orthopedic consultation for the attenuated peroneus brevis tendon, as this combination of syndesmotic ligament injury and peroneal tendon pathology typically requires coordinated conservative management with surgical evaluation. 1, 2, 3

Immediate Management Steps

Primary Treatment Pathway

• Initiate structured physical therapy immediately focusing on graded exercise regimens with proprioceptive elements such as ankle disk training to address the chronic ligamentous injury and prevent recurrent instability 1, 2
• Prescribe semirigid or lace-up ankle supports for use during all weight-bearing activities, particularly given the history of multiple ligamentous injuries and ongoing pain 1, 2
• Avoid cryotherapy as sole treatment as it shows minimal benefit for pain, swelling, or function in chronic ankle conditions 1

Concurrent Orthopedic Evaluation

• Obtain orthopedic consultation specifically for the peroneus brevis tendon attenuation, as this finding frequently coexists with lateral ligament injuries and may require surgical intervention if conservative management fails 3, 4
• The combination of lateral ankle instability (evidenced by thickened anterior syndesmotic ligament) and peroneus brevis pathology is a recognized pattern that often requires addressing both components surgically if symptoms persist 3, 5

Critical Clinical Considerations

Understanding the Pathology

• The thickened anterior syndesmotic ligament represents sequelae of prior injury and indicates chronic instability that predisposes to ongoing symptoms 6, 1
• Peroneus brevis tendon attenuation is frequently missed in patients with lateral ankle instability and presents with atypical posterolateral or retromalleolar pain 3, 4
• The moderate ankle effusion suggests ongoing inflammation from chronic instability rather than acute injury 6

Red Flags Requiring Earlier Surgical Consideration

• Monitor for increased swelling, inability to bear weight, or new mechanical symptoms (clicking, catching, or giving way) during the rehabilitation period 1, 2
• Retromalleolar pain that persists beyond 6-8 weeks of physical therapy strongly suggests the peroneus brevis tendon requires surgical repair 3, 4
• Peroneus brevis tears associated with lateral ligament instability typically require débridement and tubularization for less extensive tears, or tenodesis to the peroneus longus for more severe cases 4, 5

Structured Rehabilitation Protocol

Weeks 1-6

• Functional rehabilitation with controlled motion produces superior outcomes compared to prolonged immobilization 2
• Progressive weight-bearing as tolerated with ankle support
• Proprioceptive training emphasizing balance and coordination exercises 1, 2
• NSAIDs for pain management during the rehabilitation phase 2

Re-evaluation at 6-8 Weeks

• Mandatory reassessment to determine response to conservative management 1
• If retromalleolar pain persists or mechanical symptoms develop, proceed with surgical consultation for combined ligament reconstruction and peroneal tendon repair 3, 5
• Repeat MRI is NOT indicated unless new trauma occurs, symptoms significantly worsen, or there is clinical suspicion for osteochondral lesion 1, 2

Common Pitfalls to Avoid

Diagnostic Errors

• Do not dismiss retromalleolar pain as simple ankle sprain - this is the hallmark of peroneus brevis pathology that is frequently misdiagnosed 3, 4
• Avoid repeat imaging without clinical indication as the ACR recommends against repeat imaging in chronic conditions without new trauma or clinical deterioration 1

Treatment Mistakes

• Do not rely on immobilization - early functional treatment is superior 2
• Do not delay orthopedic referral beyond 8 weeks if symptoms persist, as surgical outcomes for combined peroneus brevis tears and lateral ligament instability are excellent (91% good/excellent results) when both pathologies are addressed 5
• In surgical series, 98% of patients achieved stability when both the tendon rupture and ligamentous insufficiency were corrected simultaneously 3, 5

Surgical Timing

• If conservative management fails by 8-12 weeks, surgical reconstruction addressing both the lateral ligament instability and peroneus brevis tendon pathology is indicated 3, 5
• Surgical repair typically involves tendon débridement/tubularization, superior peroneal retinaculum reconstruction, removal of sharp posterior fibular edge, and lateral ligament reconstruction 3, 5