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Peroneal Tendon Syndromes Treatment & Management

  • Author: Steven J Karageanes, DO, FAOASM; Chief Editor: Craig C Young, MD  more...
 
Updated: Jun 25, 2015
 

Acute Phase

Rehabilitation Program

Physical Therapy

In the acute phase, most ankle injuries are managed with rest, ice, compression, and elevation (RICE), with or without a short period of no weight bearing. Nonsteroidal anti-inflammatory drugs (NSAIDs) can also be prescribed to reduce inflammation and pain. Once the swelling and pain have decreased, a more extensive examination can be performed. If the symptoms are minimal and if no significant instability is present, a rehabilitation program can be started. This program should include an ankle strengthening, flexibility, and proprioception regimen.

In cases of peroneal tendinosis in which the tendon is degenerated but not ruptured, acute care may include 2-6 weeks of cast immobilization, particularly if the symptoms are recurrent.

Physical therapy must evaluate core biomechanics as previously discussed in this article. Patients with peroneal injuries can limp or favor that side, and many patients develop dysfunctions in the lumbosacropelvic region that inhibit muscle firing, shift functional leg lengths, and lead to problems in other regions, such as the lower back and knee. A comprehensive rehabilitation program must evaluate core stability and include core exercises in the rehabilitation program.

Medical Issues/Complications

Complications of conservative treatment are continued symptoms that worsen and instability of gait that leads to falls or further injury to the ankle.

Surgical complications vary depending on the procedure. They may include sural nerve injury, continuation of symptoms, chronic lateral ankle pain, and restricted range of motion.

Surgical Intervention

Surgery is indicated in the acute phase for peroneus brevis tendon rupture, acute dislocation, anomalous peroneal brevis muscle hypertrophy, and in peroneus longus tears that are associated with diminished function.[22, 23, 24] Tears can be horizontal or longitudinal. The repair for subluxation usually involves the peroneal retinaculum, the lateral ankle ligaments, and possibly the peroneal tendons. A procedure to deepen the fibular groove is also performed in many cases.[12] Patients had excellent long-term functional outcomes with debridement and primary operative repair of peroneal tendon tears.[25]

Consultations

An orthopedic surgeon, or a foot and ankle surgeon, should be consulted for surgical repair or if an associated fracture is identified.

Other Treatment

Cast immobilization with a short leg non–weight-bearing cast for 4-6 weeks with the foot in plantarflexion and inversion is an alternative treatment for acute peroneal tendon dislocation.

Injection with corticosteroid is not recommended for the peroneal tendons. The peroneal tendons are very superficial and are in close approximation with the sural nerve. Injecting in this area can cause fat necrosis and a sural neuroma, making it painful for the patient to wear a shoe.[26]

Osteopathic manipulative treatment

This treatment has been demonstrated to provide significant pain relief in acute ankle injuries.[27] The seeds of peroneal tendinopathy can be sown in ankle injuries that cause significant dysfunction to talar and subtalar motion. Dysfunctions along the kinetic chain from the foot through the sacroiliac joint and lumbar spine can alter gluteus medius firing and core stability, which then can lead to increased impingement of the peroneus longus and brevis laterally. Restoring normal biomechanics in the acute phase reduces the chance for peroneal impingement.

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Recovery Phase

Rehabilitation Program

Physical Therapy

In the recovery phase, steps are taken to restore ankle strength and flexibility and to return the patient to their activity.[28, 29]

With respect to surgical/casting intervention, there is a period of cast immobilization from 2-6 weeks, depending on the procedure. Then, the patient wears a walking boot for another 2-3 weeks.

Once the cast is removed after either surgical or nonsurgical treatment, a physical therapy regimen is started with light range of motion progressing to stretching exercises. Once the boot is removed, therapy continues to progress until the patient has 80-90% of their strength and function as compared with the nonaffected ankle. The patient then may participate in activities with a brace or ankle taping. Bracing and taping has been recommended for as long as 6 months, depending on the surgical repair.

Proprioceptive rehabilitation is crucial because recurrent ankle sprains are related to poor muscle firing and balance. Every sprain can stretch and damage the peroneus tendon fibers, loosen the lateral supports, and create further instability. Athletes need to be aware that recurrent injury without proper rehabilitation can destabilize the ankle supports and create further problems.

Surgical Intervention

For persistent symptoms with peroneal tendinitis, a tenosynovectomy is the procedure of choice.

Chronic tears of the peroneal tendons with persistent pain and instability require surgical repair. Tendinosis may cause nodules or scar tissue that may need debridement. Longitudinal tears that fail treatment with immobilization may be present.

Consultations

An orthopedic surgeon, or a foot and ankle surgeon, should be consulted in cases of continued ankle pain or instability.

Other Treatment (Injection, manipulation, etc.)

Osteopathic manipulative treatment should be used throughout the recovery process to monitor and correct biomechanical dysfunctions that can lead to peroneal disorders, as previously mentioned in the Acute Phase section. Osteopathic manipulative treatment should be used in concert with physical therapy to minimize the number of times it is used by stabilizing the alignment through improvement in pain, core stability, and gait biomechanics.

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Maintenance Phase

Rehabilitation Program

Physical Therapy

The maintenance phase should be grounded in good preexercise and postexercise ankle stretching and continued use of strengthening techniques learned in physical therapy. Bracing and taping should not be necessary if the ankle is fully rehabilitated. Proprioceptive physiotaping can be used to speed recovery.

Consultations

An orthopedic surgeon, or a foot and ankle surgeon, should be consulted in cases of continued ankle pain or instability.

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Contributor Information and Disclosures
Author

Steven J Karageanes, DO, FAOASM Director of Sports Medicine, St Mary Mercy Hospital Livonia; Regional Assistant Dean, Kansas City University of Medicine and Biosciences; Clinical Assistant Professor, Michigan State University College of Osteopathic Medicine

Steven J Karageanes, DO, FAOASM is a member of the following medical societies: American Medical Association, American Osteopathic Academy of Sports Medicine, American Osteopathic Association, Michigan State Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Kathleen Sharp, MD, CAQSM Staff Physician, Parkland Homes Program

Kathleen Sharp, MD, CAQSM is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, National Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

References
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Lateral ankle anatomy demonstrates the peroneal tendons as they course beneath the superior retinaculum. The anterior talofibular, calcaneofibular, and posterior talofibular ligaments are also shown.
Anterior drawer test, which assesses anterior talofibular ligament stability. The top hand stabilizes, while the lower hand translates the calcaneus and talus directly toward the operator. From Karageanes SJ. Principles of Manual Sports Medicine, Lippincott Williams & Wilkins, 2005.
Tilt test. The operator tilts the talus and calcaneus, not the forefoot. This assesses the integrity of the calcaneofibular ligament. From Karageanes SJ. Principles of Manual Sports Medicine, Lippincott Williams & Wilkins, 2005.
Dislocated peroneal tendons. Left, Note the course of the tendons anterior to the lateral malleolus. Right, Image demonstrates manual relocation of the displaced tendons.
Peroneal stability test. The patient pushes the foot laterally against resistance, while the operator monitors the tendon. From Karageanes SJ. Principles of Manual Sports Medicine, Lippincott Williams & Wilkins, 2005.
 
 
 
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