A very common problem among athletes is leg and ankle pain that originates from tendons of these organs. It is a matter of debate what the mechanism of these pathologies is – whether overuse or inflammation and what the proper treatment for tendon disease of the foot and ankle should be. These tendon problems are collectively known as tendinopathies.
Mechanism of tendon injury in the foot and ankle
Generally, tendinopathies are not proven to be inflammation. The pathology is actually tendinitis, peri-tendinitis or tendinosis. Tendinopathies are most likely to occur after a change in activity pattern, most commonly, when more activity is performed. This is most likely because of too little recovery time and resultant microscopic tissue breakdown.
Normally, when a tendon is injured there is inflammation (i.e. tendinitis) and then recovery through deposition of collagen. Abnormal collagen deposition and abnormal structure causes tendinosis.
Risk factors for foot and ankle tendon disease
- Wrong exercise
- Smoking
- Obesity
- Inappropriate equipment
- Anatomical disorders of the foot and ankle
- Older age
- Poor blood supply to the foot and ankle
Ankle anatomy
The ankle anatomy can be seen in the following diagram (showing the ankle-foot complex from the lateral view):
Ankle anatomy - Lateral view
An important anatomical landmark to know when discussing ankle and foot tendon disease is the tarsal tunnel. The tarsal tunnel is a medial anatomical space that contains (from the medial malleolus and posteriorly): The tendons of the tibialis posterior, flexor digitorum longus, flexor hallucis longus, posterior tibial artery (which pulse can be felt) and the tibial nerve.
An important anatomical landmark in the foot are the foot arches. The foot contains three arches: Lateral, medial and transverse. The arches are supported by keystone bones (central bones of each arch), ligaments and muscles.
Clinical presentation of ankle and foot tendon disease
People complain of pain over the affected tendon area during the inciting exercise. The pain can be dull (at rest) or sharp (during activity). At first, a warm-up decreases pain, but as disease progresses, the pain is felt with less activity and even during rest. A thorough physical examination is mandatory, including an assessment of foot biomechanics during rest and the gait cycle.
Imaging for foot and ankle tendon disease
On the one hand, a plain radiograph for a tendon problem does not make sense. However, it may reveal anatomical malalignment, osteoarthritis, calcifications or osteochondritis dissecans. Ultrasonography in the hands of an experienced, dedicated ultrasonographer, may reveal tendon tears and swelling. If surgery is considered then MRI may offer great anatomical images of the tendons.
Treatment for foot and ankle tendon disease
The treatment of foot and ankle tendon disease ranges from rest to surgical debridement. No matter what the choice, conservative treatment should be the start. Surgery should only be considered after 6 months of rehabilitation. Another universal treatment is the elimination of intrinsic or extrinsic causative factors (see ‘risk factors’ above). PRICEMR is an acronym that symbolyzes the treatments for all tendon problems of the foot and ankle:
Protection, Relative rest, Ice, Compression, Elevation, Medication, Rehabilitation (stretching of tendons and eccentric muscle exercises).
Because inflammation is lacking (outside the very first acute phase), NSAIDS are probably not warranted; they may even lessen healing. Acetaminophen is actually a good option for pain relief.
Surprisingly, perhaps, orthotics have not been proven to help all people with tendinopathies.
Specific tendon disease of the ankle and foot
Posterior tibial tendon tendinopathy
The posterior tibial tendon serves to stabilize the medial longitudinal arch of the foot:
Medial view of the posterior tibial tendon
Injury to the posterior tibial ligament causes a painful, flatfooted deformity. Because of its location, posterior tibial ligament injury can be misdiagnosed to be medial ankle sprain. Left untreated, this deformity progresses and causes pain in the lateral tarsal area (sinus tarsi). It is more common in women.
Physical examination should include comparison of the patient’s feet from behind. The affected foot will be more pronated and too many toes will be showing laterally. The flat foot deformity causes no heel varus when tiptoeing:
Normal heel varus
Treatment for posterior tibial tendon disease starts with rest and if needed an immobilizing cast for 2-3 weeks. If all fails, surgery might be needed. It is not recommended to disregard this problem, as it may progress.
Peroneal tendon disease
Peroneal tendon injury may cause lateral ankle pain and instability (“fibular popping”). Diagnosis is made by peroneal tunnel compression – dorsiflexion and eversion of the foot against resistance:
Lateral view of the peroneal tendon
Treatment consists mainly of rest and physiotherapy meant to gain strength and proprioception.
Achilles tendon disease
The achilles tendon inserts posteriorly into the calcaneous. About 4-6 cm above this insertion is the so called “watershed” area, with the least blood supply. This is the area most inflicted by achilles tendinitis and peri-tendinitis. If the achilles tendon is hurt enough, a palpable nodular mass will be felt. If a gap is felt and the Thompson test is negative, then an achilles tendon tear should be suspected. In this case the history is usually acute and an injury and / or “pop” can be elicited.
Differential diagnosis of achilles tendon disease includes retrocalcaneal bursitis and superficial achilles tendon bursitis.
Treatment for achilles tendinosis includes PRICEMR as usual, but also eccentric exercise of calf muscles. Stretching the gastrocnameous-soleus complex helps. Keeping the area warm is also helpful.
Read more about achilles tendon disease.
Flexor hallucis longus tendon disease
Flexor hallucis longus tendon disease is common in… ballet dancers because of the en pointe maneuver:
En pointe ballet dancers by Edgar Degas
Symptoms of flexor hallucis longus tendon disease are pain behind the medial malleolus or on the medial aspect of the subtalar joint. Diagnosis is done by eliciting pain while the foot is in plantar flexion and the great toe is flexed against resistance.
Prevention of flexor hallucis longus tendon disease actually involves improving balance and strengthening the body core (back, abdomen etc.).
Treatment of flexor hallucis longus tendon disease involves rest and sometimes an immobilization boot.
Anterior tibial tendon disease
The anterior tibial muscle is the major dorsiflexor of the foot. It also causes adduction and inversion. Therefore, tear of the anterior tibial tendon causes drop-foot and “slapping gait“.
Anterior tibial tendon disease is caused by overuse and is typical of older adults, distance runners and football players. Symptoms of anterior tibial tendon include weakness during dorsiflexion and anterior ankle pain.
Treatment for anterior tibial tendon disease includes rest, immobilization with a walking cast for 3 weeks and then partial use of the cast for 3 more weeks during ambulation.
Plantar fasciitis
Plantar fasciitis is an inflammation of the plantar aponeurosis of the foot. On MRI there is usually thickening at the calcaneal insertion (the heel area). Symptoms include pain in the foot, mostly near the heel, but not only. Pain is more severe after prolonged rest periods and improves after walking. On the other hand rest is needed for healing of plantar fasciitis.
The tenderness is usually antero-medial
Who suffers from plantar faciitis? Obese (women), runners, people with arthritis.
Further reading about foot and ankle tendon disease
- American family physician. 2009; 80(10): 1107-1114.
- Common problems in endurance athletes. American family physician. 2007; 76(2): 237-244.
