Peroneal Tendon Syndromes Treatment & Management

Chronic peroneal tendinopathy usually appears as tendinosis or tearing of varying degrees of severity. The pathology develops over time, with repetitive stress combined with dysfunctional mechanics to cause collagen breakdown.  

Overuse is rarely an actual cause, as many patients with most peroneal tendon syndromes developing from levels of exercise not too dissimilar from their peers. This is better explained as "repetitive use with biomechanical dysfunction." When treating this condition, one must find and treat the causes that lead to the tendinosis.

Acute peroneal tendon injuries require aggressive conservative treatment immediately in order to minimize functional loss, scarring, and atrophy. The typical mechanism of injury is inversion ankle injury, with an eccentric load on peroneal muscles that concentrically contract to prevent the inversion. Therefore, a complete ankle exam should be performed, and any injuries should be treated concomitantly. Any residual instability should be rehabilitated to prevent further inversion injuries.

Acute management

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.

Short-term use of weight-bearing immobilization (walking boot) are effective in allowing ambulation while decreasing stress on the tendon structures. Cast immobilization with a short leg non–weight-bearing cast for 4-6 weeks with the foot in plantar flexion and inversion is an alternative treatment for acute peroneal tendon dislocation.

Physical Therapy

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.

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. ^{[19, 20, 21]} 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. ^[13] Patients have had excellent long-term functional outcomes with debridement and primary operative repair of peroneal tendon tears. ^[29]

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. ^[30]

Other Treatment

Corticosteroids

Injection with corticosteroid is not recommended for the peroneal tendons, especially in the acute phase. 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. ^[31]

Osteopathic manipulative treatment

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

Physical Therapy

In the recovery phase, steps are taken to restore ankle strength and flexibility and to return the patient to their activity. ^{[33, 34]}

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. ^[35]

Immobilization

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.

Regenerative biologic agents

These treatments include such procedures as platelet-rich plasma, amniotic fluid, and stem cell from bone marrow aspirate concentrate show promise in healing tears and tendinosis. These are all considered experimental and not covered by major insurance carriers. However, these treatments are likely to become more commonplace as patients look to restore tissue health without invasive surgical disruption. ^{[36, 37, 38, 39]}

Percutaneous tenotomy

Percutaneous ultrasonic tenotomy is a procedure whereby ultrasonic energy is transmitted through a slender probe to debride tendinotic disease. This shows significant promise in restoring tendon function without an open surgical debridement, which has a longer recovery and larger price tag. This procedure is covered by most major insurances. Although the procedure is most successful treating the common extensor tendon origin (lateral epicondylitis) and plantar fasciitis, peroneal tendinopathy. ^[40]

Osteopathic manipulative treatment

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.

Surgical Intervention

Chronic tears of the peroneal tendons with persistent pain and instability that fail conservative treatment should have a surgical evaluation. ^[41] Tendinosis may cause nodules or scar tissue that may need debridement. Longitudinal tears that fail treatment with immobilization may be present.

An orthopedic surgeon, or a foot and ankle surgeon, should be consulted in cases of ankle pain or instability that is unresponsive to conservative treatment. Conditions that would warrant surgical evaluation include talar instability, peroneal subluxation or dislocation, distal fibular fracture or nonunion, and full-thickness peroneal tendon tear. A systematic review and meta-analysis by Lootsma et al found that surgical treatment results in excellent outcomes in patients with chronic peroneal instability; however, insufficient high-quality data are available to determine which approach is superior in this setting. ^[42]

For persistent symptoms with peroneal tendinitis, a tenosynovectomy is the procedure of choice.  ^[43]

Rehabilitation Program

Physical Therapy

The maintenance phase should be grounded in good pre-exercise and post-exercise ankle stretching and strengthening techniques. Bracing and taping should not be necessary if the ankle is fully rehabilitated. Proprioceptive physiotaping, such as KT taping, can be used to speed recovery and enhance stability. 

Performance training

Patients need to continue training the stability of the ankle long-term, especially with those who stress their ankles repetitively. ^[44]

If surgery and/or casting is not required for a peroneal tendon injury, the patient can usually return to activity in 1-2 weeks with ankle bracing or taping until strength and function are back to 90-100% of the nonaffected ankle.

If surgery is performed, return to play with bracing or taping is usually allowed once the strength and function of the ankle has been rehabilitated to 90% of that in the nonaffected ankle. Once the ankle is close to 100%, the bracing/taping is usually not necessary but permitted.

In most sports injuries, return to play should be allowed when the ankle has a painless range of motion, normal or improved balance, preinjury muscle strength, and no pain with sport-specific functional testing.

Several measures can be taken to prevent peroneal tendon injuries: (1) Good preexercise and postexercise stretching of the ankle, (2) a gradual increase in the level of activity or training, and (3) full rehabilitation of the ankle after any type of injury. These measures decrease the occurrence of ankle injury and, in turn, prevent peroneal tendon injury. Other interventions, such as attempting to correct foot abnormalities (eg, pes planus), also play an integral part in prevention.

Educating patients about the importance of ankle rehabilitation after an injury is the cornerstone in the prevention of peroneal tendon injuries. Further, stressing the need to stretch before and after exercise is also important.