Ankle Foot Tendonitis Treatment
Four major types of tendonitis can occur in the ankle.
Achilles tendonitis is discussed on another page on this website.
The posterior tibial tendon runs from the calf of the leg down behind the medial malleolus of the ankle (inside bump) and attaches to a bone in the foot called the navicular.
The posterior tibial tendon is essential to the normal functioning of the foot by maintaining the navicular bone in the proper position. By doing so, the arch of the foot is maintained. If the posterior tibial tendon fails to function properly, the navicular bone begins to drop, the arch falls and a flatfoot deformity begins to develop. When this occurs, the foot hurts with weight bearing.
Predisposing factors to degenerative posterior tibial tendonitis include are diabetes mellitus, hypertension, obesity, trauma or surgery to the medial aspect of the ankle and steroid injections.
In addition, other inflammatory conditions such as arthritis may also lead to degeneration.
The chronic degenerative tear of the posterior tibial tendon usually occurs in a patient who is a female over the age of 40 who does a lot of standing and walking.
The diagnosis is made clinically and supported by either magnetic resonance imaging or diagnostic ultrasound. Without proper treatment, or sometimes, even with proper treatment, the damage is so advanced that healing fails to occur and the tendon ruptures.
Initially, treatment often consists of physical therapy, icing, NSAID, and activity restriction. Sometimes orthotics are used. Occasionally, it is necessary to use a cast. In more severe situations, or if the problem fails to improve with non-operative treatment, then surgery may be indicated.
Another tendon, the flexor hallucis longus, runs parallel to the posterior tibial tendon and may produce pain similar to that from posterior tibial tendonitis.
The distinction is made by magnetic resonance imaging.
The anterior tibial tendon, located in the front of the ankle, helps control the front of the foot with walking and running. When this tendon becomes inflamed, there is swelling and pain with weight-bearing located at the area where the ankle meets the foot.
The peroneal tendon runs from the outside of the calf down behind the lateral malleolus of the ankle (outside bump) and attaches to the outside of the foot. With tendonitis, the patient may feel pain with weight-bearing and “pushing off” the foot. Pain and swelling may be present. Patients with inflammatory forms of arthritis such as rheumatoid arthritis are at increased risk for this problem.
The most common form of tendonitis in the foot is plantar fasciitis. The plantar fascia is a thick, broad band of fibrous tissue that runs along the bottom of the foot. It is attached to the calcaneus (heel bone) and fans out to attach to the bottom of the ball of the foot. In this position, the plantar fascia acts like a bowstring to maintain the arch of the foot. Plantar fasciitis refers to an inflammation of the plantar fascia. The inflammation in the tissue is the result of injury to the plantar fascia.
Typically, plantar fasciitis results from repeated trauma to the tissue where it attaches to the calcaneus. This repeated trauma often results in microscopic tearing of the plantar fascia at or near the point of attachment of the tissue to the calcaneus. The result of the damage and inflammation is pain.
Plantar fasciitis typically starts as a dull, intermittent pain in the heel and may progress to sharp, constant pain. Often, it is usually worse in the morning or after sitting, and then decreases as the patient begins to walk around.
In addition, the pain usually increases after standing or walking for long periods of time, and at the beginning of a sporting activity. Often people who develop plantar fasciitis have several risk factors for doing so. They include:
- Flat feet
- High arched, rigid feet
- Increasing age and family tendency
- Running on toes, hills or very soft surfaces (sand)
- Poor arch support in shoes
- Rapid change in activity level
Most cases of plantar fasciitis respond to non-surgical treatment. The recovery time varies from patient to patient. While some patients may be healed after 6 weeks of treatment, others may require 6 months or longer for recovery.
Treatments include anti-inflammatory medication, icing, stretching, activity modification, and heel inserts. It is necessary to avoid activities that aggravate the fasciitis. This includes any activity that involves repeated impact of the heel on a hard surface, such as running. Sometimes, cortisone injections are necessary.
If the pain persists, it may be necessary to run additional diagnostic studies to rule other, less common, causes of heel pain such as stress fractures or nerve compression injuries.
Rarely, surgical treatment is necessary.
As mentioned in other sections, the use of ultrasound-guided percutaneous tenotomy with autologous tissue grafting is an excellent approach for chronic tendonitis that has failed conservative measures. It certainly can prevent the need for surgery in many cases. This procedure should be strongly considered in the patient who would prefer to avoid surgery.