From the Guidelines
For a longitudinal tear of the peroneus brevis tendon, the most appropriate initial treatment is conservative management, including relative rest, icing, and eccentric strengthening exercises, as recommended by the American Family Physician in 2005 1. This approach is supported by the fact that most patients with overuse tendinopathies (about 80 percent) fully recover within three to six months with conservative treatment 1. The treatment plan should include:
- Relative rest to reduce activity and decrease repetitive loading of the damaged tendon 1
- Icing to reduce pain and inflammation, with applications of ice through a wet towel for 10-minute periods being most effective 1
- Eccentric strengthening exercises to stimulate collagen production and guide normal alignment of newly formed collagen fibers 1
- Physical therapy focusing on ankle strengthening and proprioception exercises to be initiated once acute pain subsides, usually after 1-2 weeks
- A walking boot or ankle brace may be prescribed for 3-4 weeks to immobilize and protect the tendon during initial healing If symptoms persist beyond 3-6 months despite conservative treatment, surgical intervention may be necessary, which typically involves debridement of the torn tendon, repair of the tear with sutures, and sometimes addressing any anatomical factors contributing to the tear 1. It's worth noting that imaging techniques such as MRI can be useful in diagnosing ankle tendon tears, including peroneal tendinopathy and tendon tears, with sensitivities and specificities of 83.9% and 74.5%, respectively, for tendinopathy and 54.5% and 88.7%, respectively, for tendon tears 1.
From the Research
Treatment Options for Longitudinal Tear of Peroneus Brevis
- Surgical treatment is primarily recommended for longitudinal tears of the peroneus brevis tendon, as it addresses both the split tendon and the subluxation that caused it 2.
- 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 2.
- Non-operative treatment, such as peroneus brevis targeted physical therapy, can also be considered, especially in lower-demand middle-aged patients 3.
- Other surgical options include primary repair with tenodesis, primary repair without tenodesis, FDL tendon transfer, FHL tendon transfer, and allograft reconstruction 4, 5.
Outcomes of Treatment
- The average postoperative AOFAS score was 85, and return to maximum function is prolonged, but good-to-excellent results were found in the majority of patients 2.
- A systematic review of clinical studies reported a weighted mean postoperative AOFAS score of 88.82, and a weighted mean postoperative VAS score of 1.2, indicating significant improvement in symptoms and function 5.
- The average overall complication rate was 38.7%, with ankle pain being the most commonly reported minor complication 5.
Diagnostic Considerations
- Persistent swelling along the peroneal tendon sheath is a reliable diagnostic sign for longitudinal tears of the peroneus brevis tendon 2.
- Magnetic Resonance Imaging (MRI) can be used to diagnose longitudinal splitting of the peroneus brevis tendon 3.
- Diagnostic diligence is required to direct treatment to the diseased peroneus brevis tendon and avoid prolonged morbidity 3.