Tendinitis is a condition whereby there is inflammation and pain to a tendon. This condition is typically caused by overuse. As there are many tendons in the foot, there are many different types of tendinitis that can result. The three most common types of tendinitis seen in podiatry are Achilles tendinitis, Posterior tibial tendinitis and peroneal tendinitis.
The Achilles tendon is the strongest tendon in the body. Its function is to push off during the gait cycle to transition your body forward. In athletics, the Achilles tendon is used in jumping. It attaches to the back of the heel bone in the foot. Achilles tendinitis can happen in children as well as in adults. Often the culprit is being tight and overusing the tendon.
In children, Achilles tendonitis is often associated with Sever’s disease – or calcaneal apophysitis. What is happening mechanically is that the Achilles tendon is pulling against the portion of the heel where it inserts. Around the age of 10, children’s growth plate in the heel is beginning to fuse and attach to the larger portion of the heel bone. With overuse, the Achilles tendon pulls and creates inflammation in the growth plate as well.
In adults, Achilles tendinitis occurs due to tightness and overuse of the tendon as well. Treating Achilles tendinitis involves providing relief of inflammation as well as providing support and immobilization and correcting the tightness through increasing range of motion. Decreasing inflammation (the source of pain) is addressed with icing and oral anti-inflammatories. In order to support the tendon and allow it a bit of rest and relief, an ankle brace is recommended. The brace helps to stabilize the tendon, which allows most people to perform their normal daily activities without constantly re-aggravating the tendon. Stretching exercises are used to increase range of motion. In addition, we often recommend a device that helps to passively stretch the tendon while you rest and sleep.
Posterior tibial tendinitis is most frequently seen in patients who have a low arch (flatfoot). The posterior tibial tendon originates within the lower leg and inserts on a bone called the navicular which is on the inside aspect of the foot, typically near the high point of the arch. Its function is to support the arch. In patients with a flat foot, whether rigid or flexible, the posterior tibial tendon becomes stretched over time and can become very inflamed. This condition can also be seen in younger patients as well as adults and the geriatric population.
Posterior tibial tendonitis responds best to similar treatment as the Achilles tendon. Anti-inflammatories (both oral and through icing) help to reduce the painful inflammation. An ankle brace is recommended for this condition as well, though a slightly different brace than is used with Achilles tendonitis provides additional strapping and support through the arch and inside part of the ankle. Just as with other types of tendinitis, bracing provides rest to the tendon as it recovers and heals. Ultimately, posterior tibial tendinitis is treated with custom orthotic inserts. Whether the condition has improved or resolved, the custom orthotics provide more long-standing support to reduce to overstrain of the tendon which reduces recurrences.
Peroneal tendinitis is pain and inflammation of the tendon on the outer aspect of the foot and ankle. This tendon is the antagonist to the posterior tibial tendon. Patients with a higher arch foot structure tend to experience peroneal tendinitis more often. As in high arched feet, the foot and heel typically turn more inward, which puts strain on the peroneal tendon. There are even some patients with an arch structure so high that the peroneal tendon may sublux (or move out of its normal position) behind the outer ankle bone. Peroneal tendinitis is treated with bracing and anti-inflammatories, though the supportive strap is on the opposite side of the foot from posterior tibial tendinitis. Because this condition is also linked with a particular foot structure, custom orthotics are recommended in this case as well, in order to balance the foot in a way to equalize the tendon pull which reduces recurrent overuse.
Any of the above types of tendinitis can occur suddenly or over a period of time. In either case, if the pain is suddenly very severe or pain does not improve with bracing, there may be other conditions at play. While the tendons themselves are most often inflamed, in some cases, there is even inflammatory fluid that develops around the tendon within the sheath that encompasses the tendon. This is a condition called tenosynovitis. Certain oral anti-inflammatories work better than others in tenosynovitis and in some instances of peroneal and posterior tibial tendinitis, steroid injections may be what is needed to alleviate the condition.
Another possible extension of these types of tendinitis is a tear of the tendon. While this sounds traumatic, tears are often not associated with an injury. Over a period of time while the tendon is inflamed, the body develops collagen and scar tissue to heal the area. Scar tissue that develops in a chronic condition does not remodel to become as flexible and resilient as healthy tendon tissue which means it is essentially more brittle. If the strain that caused the tendinitis is not addressed, the areas where scar tissue has developed can result in an interstitial tear. This is a tear that occurs between the fibers of the tendon rather than end-to-end. If your doctor is concerned about a tendon tear, this merits more immobilization (often with a walking boot) and advanced imaging. While x-rays give us clues into the foot structure and rules out most conditions associated with the bones and joints, we cannot visualize the tendons themselves unless MRI or diagnostic ultrasound is used.
Some tendon tears will heal on their own if given enough support and immobilization, but others may necessitate surgical repair. In these cases the tendon is sewn up with medical suture and typically the surgery allows your doctor to remove some of the disease tissue which may have been inhibiting healing in the first place.
Tendinitis in general is painful more so with activity and in some cases is worse when getting up from a resting position, due to the tightness that builds while you are resting. If you are experiencing pain around the ankle and/or foot that doesn’t resolve within a week of diligent icing and consistent use of sturdy athletic shoes, calling a foot doctor is in your best interest. The longer tendinitis continues, the more damage can result. Call our office for an evaluation and don’t let that tendinitis get you down!