eMedicine Specialties > Sports Medicine > Lower Limb
Peroneal Tendon Syndromes: Treatment & Medication
Updated: Sep 2, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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.
Related eMedicine topic:
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
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.20 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
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.
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.
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.
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.
Medication
In the acute phase of any ankle injury, the medications of choice are NSAIDs. In cases of severe pain, narcotics may be used for a short period.
Related eMedicine topics:
Toxicity, Acetaminophen
Toxicity, Narcotics
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Resource Center Opioids: A Guide to State Opioid Prescribing Policies
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Nonsteroidal Anti-inflammatory Drugs
NSAIDs have anti-inflammatory properties and reduce pain.
Ibuprofen (Advil, Motrin, Excedrin IB, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when patient is taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when patient is taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
Analgesics
Narcotics are used for pain reduction. Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries. Many analgesics have sedating properties, which are beneficial for patients who experience pain.
Acetaminophen (Tylenol, Feverall, Tempra, Aspirin Free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce the analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity is possible in patients with chronic alcoholism at various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; many OTC products contain acetaminophen, and combined use may result in cumulative doses that exceed the recommended maximum dose.
Acetaminophen and codeine (Tylenol-3)
Indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose PO based on codeine content q4-6h or 1-2 tab PO q4h; not to exceed 4 g/d of acetaminophen
Pediatric
0.5-1 mg/kg/dose PO based on codeine q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
The toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAOIs, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics; rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase the hepatotoxicity of acetaminophen.
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who are dependent on opiates because substitution may result in acute opiate-withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction; hepatotoxicity with acetaminophen is possible in patients with chronic alcoholism at various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; many OTC products contain acetaminophen, and combined use may result in cumulative doses that exceed the recommended maximum dose.
Hydrocodone and acetaminophen (Lorcet-HD, Vicodin, Lortab, Norcet)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Coadministration with phenothiazines may decrease the analgesic effects; the toxicity increases with CNS depressants or tricyclic antidepressants.
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates, because this substitution may result in acute opiate-withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction
Propoxyphene and acetaminophen (Darvocet-N, Darvocet-N 100, Propacet, Wygesic)
Drug combination indicated for mild to moderate pain.
Adult
1-2 tab PO q4h prn; not to exceed 600 mg/d propoxyphene
Pediatric
Not established
May increase the serum concentrations of MAOIs, tricyclic antidepressants, carbamazepine, phenobarbital, and warfarin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who are dependent on opiates, because this substitution may result in acute opiate withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction
More on Peroneal Tendon Syndromes |
| Overview: Peroneal Tendon Syndromes |
| Differential Diagnoses & Workup: Peroneal Tendon Syndromes |
 Treatment & Medication: Peroneal Tendon Syndromes |
| Follow-up: Peroneal Tendon Syndromes |
| Multimedia: Peroneal Tendon Syndromes |
| References |
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Further Reading
Keywords
peroneal tendon syndromes, peroneal tendon, ankle sprain, ankle instability, peroneal tendonitis, peroneal tendinitis, peroneal tendon tears, peroneal tendon subluxation, peroneal tendon dislocation, peroneal tendon strain, peroneal tenosynovitis, peroneal retinaculum tear, peroneal tendon pathology, peroneus brevis disorders, disruptions of the peroneus longus, disruptions of the peroneus brevis, fractured os peroneum, fragmented os peroneum, longitudinal tears of the peroneus longus, peroneus brevis tears, longitudinal tears of the peroneus brevis tendon, primary peroneus longus tendinopathy, peroneus longus rupture, ankle pain, foot pain, tendon rupture, lateral ankle ligament tear, inversion injury
