From the Guidelines
For a split tear of the peroneus brevis with mild posterior tibialis and Achilles tendinosis, I strongly recommend a conservative treatment approach combining rest, physical therapy, and anti-inflammatory measures as the first line of treatment, given the mild nature of the tendinosis and the potential for significant improvement with non-surgical interventions 1.
Initial Treatment
Initially, reduce weight-bearing activities and use a walking boot or ankle brace for 2-4 weeks to stabilize the ankle. This will help in reducing further strain on the affected tendons. Take NSAIDs like ibuprofen (400-600mg three times daily with food) or naproxen (500mg twice daily) for 1-2 weeks to reduce inflammation and pain, as suggested for similar conditions 1. Apply ice for 15-20 minutes several times daily, especially after activity, to help reduce pain and inflammation.
Physical Therapy
Begin physical therapy focusing on eccentric strengthening exercises, ankle proprioception, and gradual return to function. Specific exercises should include heel raises, resistance band work for the peroneal muscles, and balance training. Eccentric strength training, as mentioned in the context of Achilles tendinopathy 1, can be particularly effective for tendon healing and strengthening. Custom orthotics may help correct biomechanical issues contributing to tendon stress, similar to the approach for treating anatomic misalignment in Achilles tendinopathy 1.
Considerations for Surgery
While surgery is an effective treatment option in carefully selected patients with persistent pain despite conservative treatment 1, it should not be considered as the initial approach for this patient given the mild nature of the tendinosis. The mechanism of surgical healing promotion is not entirely understood, but it typically includes excision of abnormal tendon tissue and performance of longitudinal tenotomies to release areas of scarring and fibrosis 1.
Expected Outcome
Most patients see significant improvement within 6-12 weeks with consistent therapy, though complete healing may take 3-6 months depending on tear severity and individual factors. This comprehensive approach addresses both the acute tear and chronic tendinosis by reducing inflammation while promoting healing and strengthening the affected tendons.
From the Research
Peroneus Brevis Split Tear
- A split tear of the peroneus brevis tendon can be a challenging diagnosis, as it may present with non-specific symptoms such as lateral ankle pain and swelling 2.
- The condition can be associated with tendinopathy, and the presence of tenosynovitis, changes in tendon shape, and multiple subtendons can indicate a complete multifragmenting split tear 2.
- Magnetic resonance imaging (MRI) and ultrasound (US) can be used to diagnose peroneus brevis split tears, but may sometimes miss the condition 2.
- Dynamic US assessment is especially valuable for detecting instability and split tears 2.
Treatment Options
- Surgical treatment is primarily recommended for peroneus brevis tendon tears, and must address both the split tendon and the subluxation that caused it 3.
- Debridement and repair are recommended for grade 1 tendons, which have damage to less than 50% of the cross-sectional area, while excision of the damaged segment and tenodesis to the peroneus longus are recommended for grade 2 tendons, which have destruction of greater than 50% of the cross-sectional area 3.
- Non-operative treatment, such as peroneus brevis targeted physical therapy, can also be effective in managing peroneal split syndrome, particularly in lower-demand middle-aged patients 4.
Associated Conditions
- Peroneus brevis split tears can be associated with other conditions, such as posterior tibialis and Achilles tendinosis, which can contribute to ankle pain and dysfunction 5, 6.
- Achilles tendon ruptures can be treated with peroneus brevis tendon transfer, which can provide a secure reconstruction of the tendon 6.