Peroneal Tendon Syndromes Treatment & Management

Updated: Dec 22, 2017
  • Author: Steven J Karageanes, DO, FAOASM; Chief Editor: Craig C Young, MD  more...
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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.

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, and anomalous peroneal brevis muscle hypertrophy and for peroneus longus tears that are associated with diminished function. [18, 19, 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] Patients have had excellent long-term functional outcomes with debridement and primary operative repair of peroneal tendon tears. [27]

A literature review by van Dijk et al found good outcomes following surgery for peroneal tendon dislocation, as well as a fast postsurgical return to sports. The study also found that the sports-return rate was significantly greater in patients who underwent a combination of groove deepening and superior peroneal retinaculum repair than in those managed with superior peroneal retinaculum repair alone. [28]

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. [29]

Osteopathic manipulative treatment

This treatment has been demonstrated to provide significant pain relief in acute ankle injuries. [30] 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. [31, 32]

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.

A literature review by van Dijk et al of studies addressing rehabilitation following surgery for peroneal tears and ruptures found a possible trend toward shorter postsurgical immobilization periods and earlier initiation of range-of-motion (ROM) exercises, with ROM activity begun within 4 weeks postsurgery in 41% of the studies that discussed commencement of these exercises. The report found no consensus regarding optimal rehabilitation practices after peroneal tendon tear or rupture surgery. [33]

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. [34] 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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