What is the best management approach for a patient with recurring peroneal pain without signs of infection or swelling?

Management of Recurring Peroneal Pain Without Infection or Swelling

For recurring peroneal pain without infection or swelling, initiate conservative management with functional rehabilitation focusing on proprioception, muscle strength, and coordination exercises, combined with appropriate bracing if needed. 1

Initial Assessment and Diagnosis

The evaluation should focus on identifying the specific peroneal pathology causing symptoms:

• Obtain detailed history regarding mechanism of injury (sudden inversion or repetitive activities), presence of clicking, lateral ankle instability, and functional limitations 2, 3
• Physical examination should assess for tenderness along the peroneal tendon track, pain with resisted eversion, and signs of tendon subluxation with ankle motion 3, 4
• Check for predisposing factors including chronic lateral ankle instability, cavovarus foot deformity, or history of ankle sprains (up to 40% develop chronic pain) 2, 4

Imaging Strategy

Ultrasound is the preferred initial imaging modality for peroneal tendon evaluation, as it demonstrated 100% sensitivity and 90% accuracy for diagnosing peroneal tendon tears, potentially superior to MRI 5. Additionally, ultrasound allows dynamic assessment of tendon subluxation with 100% positive predictive value compared to surgical findings 5.

• MRI should be reserved for cases where ultrasound is inconclusive or when comprehensive evaluation is needed, though MRI has limitations (sensitivity 83.9% for tendinopathy, 54.5% for tears) 5
• Important caveat: Up to 34% of asymptomatic patients may have peroneus brevis tears on MRI, so imaging must be correlated with clinical findings 5

Conservative Treatment Protocol

Most peroneal tendon disorders respond to conservative therapy and should be attempted before surgical intervention 2, 3, 4:

• Supervised functional exercises targeting proprioception, muscle response time, strength, coordination, and function to accelerate recovery 1
• Bracing for immediate functional support, which speeds return to work and activities 1, 6
• Activity modification and supportive therapy with analgesics as needed 6
• Duration: Low-demand patients typically do well with nonsurgical approaches 4

Indications for Advanced Intervention

Surgical treatment is indicated when conservative therapy fails after an appropriate trial (typically several months) 2, 3:

For Peroneal Tenosynovitis:

• Operative treatment reserved for refractory cases not responding to conservative management 3
• US-guided intrasheath anesthetic injection can be both diagnostic and therapeutic 5

For Peroneal Tendon Tears:

• Tears involving <50% of tendon: Primary repair and tubularization 3
• Tears involving >50% of tendon: Tenodesis to adjacent tendon 3
• Minimally invasive tendoscopic approach allows synovectomy, assessment of tear extent, and tenodesis with reduced soft tissue complications 7

For Tendon Subluxation/Dislocation:

• Anatomic repair or reconstruction of the superior peroneal retinaculum, with or without deepening of the retromalleolar groove 3

Treatment Algorithm

1. Initial phase (0-3 months): Conservative management with functional rehabilitation, bracing, and activity modification 1, 6, 4
2. Persistent symptoms: Consider US-guided diagnostic/therapeutic injection 5
3. Refractory cases (>3-6 months): Surgical consultation for definitive treatment based on specific pathology 2, 3

Critical Pitfalls to Avoid

• Do not rely solely on imaging: Clinical correlation is essential, as MRI has only 48% positive predictive value for clinical findings in peroneal pathology 5
• Avoid delayed diagnosis: Peroneal tendon injuries are frequently missed in patients with chronic lateral ankle pain and should always be considered 3, 4
• Do not overlook predisposing factors: Address underlying biomechanical abnormalities (instability, cavovarus deformity) to prevent recurrence 2
• Recognize that untreated disorders can lead to persistent pain and substantial functional deficits, particularly in patients with anatomical predisposition 2

Special Considerations

High-demand patients (athletes, physically active individuals) may benefit from earlier surgical intervention compared to low-demand patients who typically respond well to conservative measures 4.