Background & Etiology (Cause)

There are over 30 joints in the foot. The joints in the foot include the subtalar, talonavicular, calcaneocuboid, the metatarsocunieform joints, and the metatarsophalangeal joints. The precise movement of these joints as they work together is what enables us to run, walk, and jump. Tendons are connective tissues that attach muscle to bone. They are strong, fibrous structures that transfer the forces generated by the muscle to the bone, producing movement at the joint. When a tendon becomes irritated or inflamed it becomes painful, especially with movement. Inflammation of the tendon is called tendinitis.

Tendinitis

Tendinitis in the foot occurs when the tendons that attach muscles in the lower leg and ankle to the bones in the foot joints become inflamed. The tendons in the foot that commonly experience tendinitis are the Achilles tendon, the posterior tibialis tendon, and the peroneal tendons. Any of these structures can experience inflammation and subsequent pain.

Achilles Tendinitis

The Achilles tendon is the largest tendon in the body. It runs from the calf muscles to the heel bone. The Achilles tendon plays a significant role in the ability to walk, run, and jump. Because the Achilles tendon is used for activities that can put great stress on the tendon, it can be prone to the inflammation resulting in Achilles tendinitis. Pain from Achilles tendinitis commonly occurs along the back of the leg and in the vicinity of the heel and back of the foot. Individuals will experience pain, swelling and possible weakness of the tendon. Pain may be present first thing in the morning, after sitting, with running, jumping and any activities involving pushing off with the foot.

Posterior Tibialis Tendinitis

The posterior tibialis tendon is located along the inner side of the ankle, running into the foot. It connects the posterior tibial muscle (located at the back of the shin bone) to the foot. Problems with this tendon typically occur underneath the prominence of the medial malleolus (inner ankle bone) because this area is prone to having a compromised or decreased blood supply. Decreased blood supply makes this tendon prone to injury and overuse injuries are common. Healing time is also greater because of circulation issues. Pain with this type of tendinitis typically occurs along the inside of the foot and ankle. The posterior tibialis muscle helps support the medial arch of the foot. Tendinitis or dysfunction of this muscle may result in a drop in the arch of the foot.

Peroneal Tendinitis

There are two peroneal tendons, the peroneus longus and the peroneus brevis. These tendons run along the outside of the foot and ankle and are subject to the repetitive forces created by walking and standing. Pain with this condition is typically located along the posterolateral area on the outside of the foot and ankle. Peroneal tendon injuries are rarely isolated and more likely associated with lateral ankle sprains. Individuals with ankle instability and arthritis may be more likely to have peroneal tendinitis. These tendons are also susceptible to subluxation and tendon rupture in extreme cases.

Turf Toe

Inflammation of the tendons in the metatarsalphalangeal joint of the big toe causes a condition called turf toe. These tendons include the flexor hallucis longus and the extensor hallucis longus. Turf toe occurs when these tendons become inflamed causing redness, pain and swelling in the big toe joint. This condition typically occurs due to acute traumatic incidents where the toe is stretched too far backward in the direction of the shin. This injury is common those participating in rugby, soccer, beach volleyball, and football. Playing on rigid surfaces such as artificial turf can make one more susceptible to this injury. With this injury activities involving quick acceleration, running, and cutting need to be curtailed.

Tendinitis is most often caused by an overuse repetitive strain injury (RSI). Other high risk activities or conditions that can lead to the development of foot tendinitis include:

  • Participating in athletic activities that strain the foot, like soccer, football or running.
  • Sudden changes in athletic training schedules increasing workload and stress on tendons.
  • The use of artificial turf can increase the incidence of tendinitis or turf toe injuries.
  • Repetitive strain injuries (RSI) at work occur in people who have jobs that require performing activities of a repetitive or forceful nature, like running, cutting or sudden acceleration.
  • Sudden trauma or an accident, like a fall where an individual lands on their foot off-balance, or where the toes are forced backward.
  • Patients with rheumatoid or osteoarthritis may be susceptible to tendinitis
  • In the case of Posterior Tibial Tendinitis, flat feet or fallen medial arches may be a contributing factor adding stress to the tendon.
  • Foot pain or tenderness directly over the injured tendon that can radiate through out the foot, heel, and ankle
  • Difficulty walking, running or performing sporting activities
  • Pain or burning sensation during activities
  • Difficulty performing activities of daily living
  • Weakness may occur as the inflammation gets worse
  • Feeling of tightness or loss of motion due to discomfort
  • Swelling of the tendon
  • Loss of motion of the foot

If an individual suspects they have tendinitis, the initial treatment should consist of avoiding the positions and activities that produce the pain. A course of conservative treatment is usually recommended that would include rest and immobilization, possible splinting, ice, physical therapy and non-steroidal medications to reduce inflammation.

If symptoms persist, treatment by your physician may be necessary. This may include steroidal medication or injections, use of taping, orthotics or foot supports in conjunction with therapy. In severe cases surgical intervention may be needed to correct any mechanical causes of the tendon irritation.

Physical Therapists are professionals, educated and trained to administer interventions. As stated in The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and goal of the patient or client. Common interventions in the treatment of Foot Tendinitis include:

  • Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, deep friction massage, manual stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the foot and tendon.
  • Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen the foot and effected muscle.
  • Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity, and improve movement technique and mechanics (for example, running, jumping, kicking, or stepping) in daily use of the involved lower extremity.
  • Modalities that can include the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation at the foot and tendon.
  • Home program that includes strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.

Procedures that your physician may recommend and perform in addition to physical therapy may include:

  • REST and ICE
  • The use of NSAIDS (Non Steroidal Anti-Inflammatory Drugs)
  • Steroidal injections to reduce inflammation
  • Pain medication to reduce the discomfort and allow the patient to perform the recommended exercises
  • Orthotics, arch supports and taping
  • Surgery to correct underlying pathology or the cause of the tendinitis. This may include debridement of the involved tendon.
  • Splinting to rest or immobilize the ankle and effected tendons.

Prognosis

Most people recover full function following a course of conservative care that includes physical therapy, medication and/or injections. It is important that once the pain and inflammation is reduced, and motion and strength are restored, the patient gradually returns to full activities. Instruction in daily activities or sport performance is helpful for reducing a reoccurrence of tendinitis.

Prevention

It is easier to prevent tendinitis than to treat it. Below are some tips to reduce the risk of tendinitis.

  • Warm up lightly before activity to improve circulation and lubricate the muscle and tendon. Warm up should be performed to the area that will be used.
  • Stretch the tendons and muscles you will be using after your warm up, prior to the activity and after it. Do not bounce when stretching. Instead, hold the stretch for 15-20 seconds.
  • Strengthen the muscles and tendons that you need to use for your activity. A regular strengthening program three times a week will keep muscles prepared for the job you are asking them to perform.
  • Do not work through pain. Listen to your body. Avoid the “no pain, no gain” philosophy.

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