What are the treatment options for os peroneum pain?

Os Peroneum Pain: Treatment Algorithm

For os peroneum pain, begin with conservative management including restricted weightbearing, NSAIDs or acetaminophen, and physical therapy, reserving surgical excision only for cases that fail conservative treatment after 6-8 weeks. 1, 2

Initial Conservative Management (First-Line Treatment)

Conservative treatment should be attempted first for all patients with os peroneum pain, regardless of activity level. 1

Immediate Interventions (Weeks 0-2)

• Restrict weightbearing for 2 weeks to allow acute inflammation to subside 1
• Prescribe acetaminophen as first-line analgesic for mild to moderate pain due to favorable safety profile 3, 4
• Add NSAIDs (ibuprofen or naproxen) for inflammatory pain if acetaminophen provides insufficient relief, though monitor for GI, renal, and cardiovascular side effects 3, 4
• Consider topical NSAIDs (diclofenac gel) applied 3-4 times daily to minimize systemic exposure while providing local anti-inflammatory effect 3, 5

Rehabilitation Phase (Weeks 2-8)

• Initiate physical therapy after the initial 2-week restricted weightbearing period focusing on peroneal tendon strengthening and ankle stabilization 1
• Progress gradually to full weightbearing activities over 4-6 weeks based on pain response 1
• Apply local heat before exercise to enhance joint mobility and pain control 5
• Use fixed-interval dosing of analgesics rather than as-needed for more consistent pain relief during rehabilitation 4, 5

Diagnostic Imaging Considerations

Obtain radiographs to identify os peroneum fracture, multipartite ossicle, or displacement. 6, 7, 8

• Use musculoskeletal ultrasound for initial diagnosis to assess peroneus longus tendon integrity and tenosynovitis 7
• Order MRI if ultrasound suggests peroneus longus tendon tear to classify tear location relative to os peroneum (proximal, at level, or distal) 8
• Recognize that os peroneum position changes indicate tendon disruption: proximal migration suggests distal tendon tear, while distal migration suggests proximal tear 8

Surgical Indications (After Failed Conservative Treatment)

Reserve surgery for patients who fail 6-8 weeks of conservative management. 1, 2

Surgical Options

• Excision of the os peroneum with direct tendon repair is the standard surgical approach for symptomatic multipartite or fractured os peroneum 2, 7
• Consider tenodesis of peroneus longus to peroneus brevis in cases of complete tendon disruption 1
• Avoid fixation of os peroneum fractures as excision provides superior symptomatic relief 2

Expected Outcomes and Return to Activity

High-level athletes can return to full activity 8 weeks after injury with conservative treatment alone when fractures are minimally displaced 1

• Radiographic healing occurs by 7 years post-injury with full strength and motion restoration 1
• Surgical excision provides symptomatic relief when conservative measures fail after appropriate trial 2

Critical Clinical Pitfalls

Do not assume all active patients require surgery – even high-level athletes with minimally displaced fractures respond well to conservative management 1

Avoid premature return to activity before completing 8-week rehabilitation protocol as this increases risk of chronic pain and tendon complications 1

Do not overlook peroneus longus tendon tears – painful os peroneum syndrome frequently involves associated tenosynovitis or tendon disruption requiring MRI evaluation 7, 8

Monitor elderly patients on NSAIDs closely for fluid retention, renal dysfunction, and GI bleeding, as they are at higher risk for adverse effects 3, 4