Peroneal Tendon Rehab Protocol

Applies to: peroneal tendon debridement/repair, tubularization, tenosynovectomy, SPR work (if performed, be more conservative with eversion/subluxation risk), without major tendon transfer/graft/osteotomy.

Phase 0: Protection and Recovery (0 to 2 weeks)

Immobilization / WB

• Posterior splint (or short leg splint) with ankle in neutral to slight plantarflexion per surgeon preference.
• Non-weight-bearing (NWB) with crutches/knee scooter.

Goals

• Protect the repair, reduce swelling, control pain.
• Maintain conditioning (core/hip/knee), maintain toe motion.

Therapeutic exercise

• Toe AROM, gentle intrinsic foot      activation (within dressing limits).
• Knee ROM, hip strengthening,      contralateral limb conditioning.
• No active ankle eversion.

Precautions

• Keep incision dry, elevate      aggressively.
• Avoid inversion/eversion stresses      and resisted peroneal activation.

Evidence note: A commonly reported pattern is splinting briefly followed by ~2 weeks NWB casting/splinting, then transition to boot/cast with progressive WB depending on surgeon preference. 

Phase 1: Early Motion in Boot (2 to 6 weeks)

At ~2 weeks

• Wound check, suture removal.
• Transition to CAM boot.

Weight-bearing

• Begin progressive weight-bearing in boot as tolerated (typical: partial → full by 4–6      weeks if swelling/pain allow and fixation/repair quality supports it). 

ROM

• Start gentle ankle AROM/PROM for:
  • Dorsiflexion / plantarflexion
  • Inversion (gentle), and avoid combined inversion + plantarflexion stress
  • NO aggressive active eversion (your preference: avoid until 6 weeks)
• Begin active inversion / dorsiflexion / plantarflexion at 2 weeks (as you outlined),      emphasizing smooth, low-load motion.

Strength

• Proximal strengthening (hip/core), closed-chain work only as allowed by WB status.
• No resisted eversion and no peroneal strengthening yet.

Manual therapy

• Scar mobilization once incision healed.
• Gentle joint mobilizations as needed (avoid stressing lateral ankle/peroneals).

Criteria to progress

• Minimal swelling, pain controlled.
• Tolerating progressive WB in boot.
• DF/PF ROM improving without lateral tendon pain.

Phase 2: Strength Initiation and Gait Normalization (6 to 12 weeks)

Weight-bearing / bracing

• Wean boot to supportive shoe when:
  • You can walk pain-minimized in boot with normalized gait and minimal swelling.
• Consider a lace-up ankle brace for transition and higher-demand walking.

ROM

• Progress to full ROM in all planes as tolerated.
• Start gentle stretching (gastroc/soleus) but keep it symptom-guided.

Strength (start peroneals now)

• Begin active eversion (unresisted → light band) starting at ~6 weeks.
• Progress to:
  • Eversion isometrics → isotonic       bands
  • Heel raises (double → single)
  • Balance/proprioception       (single-leg stance, foam, perturbations)

Functional

• Stationary bike / elliptical as      tolerated.
• Pool running once wounds healed      and gait mechanics are safe.

Evidence note: Many published pathways initiate formal PT and strengthening around ~6 weeks once protective immobilization ends, then restore ROM/strength progressively. (PMC)

Phase 3: Return to Running and Sport (3 to 6 months)

Advanced strengthening

• Single-leg heel raises endurance,      lateral step-downs, controlled hopping progressions.
• Eccentric calf strengthening and      peroneal endurance.

Running progression (typical)

• Begin treadmill walk-jog      progression when:
  • Pain minimal, no reactive       swelling
  • Near-symmetric ROM
  • Good single-leg balance/control
• Advance to cutting/pivoting and      sport-specific drills later.

Return-to-sport criteria (practical)

• Pain-free functional hopping      progressions.
• Symmetric single-leg heel raises      and balance testing.
• Surgeon clearance.

Applies to: peroneal tendon reconstruction with graft, tenodesis/transfer, or combined realignment osteotomy where you prefer casting until 6 weeks.Phase 0: Protection (0 to 6 weeks)Immobilization / WB

• Splint initially, then short-leg      cast (your preference: cast through 6 weeks).
• NWB for 6 weeks (unless your osteotomy/fixation      construct and soft-tissue quality support earlier progression—your call).

ROM

• Typically no ankle      inversion/eversion during this period.
• If you allow any motion: limit to      gentle DF/PF only, low amplitude.

Key precaution supported by graft-reconstruction literature

• Avoid inversion-eversion early to prevent stretching/elongation      of the healing reconstruction and loss of strength. (PMC)

Phase 1: Transition to Boot + Protected Motion (6 to 10 weeks)

• Convert cast → boot.
• Start progressive WB in boot      (often partial → full).
• Begin DF/PF AROM/PROM; introduce      inversion/eversion gradually only when you feel the construct is ready.

Phase 2: Strengthening (10 to 16+ weeks)

• Initiate peroneal strengthening      later than the standard track.
• Proprioception and gait      retraining.
• Sport progression often shifts      later depending on osteotomy healing and tendon quality.

Evidence note: Reviews describing tenodesis/complex repairs frequently use longer casting/immobilization windows (6+ weeks) before transitioning to boot and delaying formal PT. (PMC)

Red Flags / When to Slow Down

• Increasing lateral ankle pain      that persists >24–48 hours after therapy sessions
• Reactive swelling, warmth, or      wound drainage
• “Popping” sensation or recurrent      subluxation feeling
• Calf pain/swelling (rule out DVT      urgently)

• Systematic review of post-op      rehab after operative peroneal tendon tears/ruptures (summarizes common      immobilization + timing patterns). (PubMed)
• Operative treatment review with a      more conservative tenodesis pathway (splint then prolonged casting      in some tenodesis cases). (PMC)
• Peroneus brevis reconstruction      with tendon graft: 2 weeks NWB cast → boot WBAT; PT focuses DF/PF;      inversion/eversion prohibited early (supports your “no aggressive      eversion early,” especially for graft cases). (PMC)