Extensor Tendonitis (Top of Foot) : All You Need to Know

Think you might have extensor tendonitis (top of foot) ? Looking for reliable and comprehensive information on the topic?

Based on my experience as a physical therapist and thorough exploration of scientific literature, I have put together this article for you.

Happy reading! 🙂

(Have any questions, remarks, or experiences to share? Feel free to use the comments section at the end of the article! Your input is greatly appreciated! 🙏)

What are the different types of tendonitis on the top of the foot?

There are 3 types of tendonitis (or tendinopathies) on the top of the foot. I list them in order of frequency:

1. tendonitis affecting the tendon of the tibialis anterior muscle (or anterior shin muscle);
2. tendonitis of the extensor hallucis longus muscle of the big toe (also called the extensor of the big toe);
3. tendonitis of the extensor digitorum longus muscle (also called the extensor of the toes).

I estimated their order of frequency based on the number of scientific studies available for each of them (accessible on the PubMed search engine).

What are the symptoms of tendonitis on the top of the foot?

All tendon pathologies on the top of the foot share a common symptom of causing pain on the top of the foot. Let’s now explore the specific symptoms of each.

Symptoms of tibialis anterior tendonitis

For tibialis anterior tendonitis, the pain may be localized differently in sedentary individuals and athletes:

• for sedentary individuals, it is usually located in the middle of the foot, on the side of the big toe;

• for athletes, it is typically located near the front of the ankle, or even directly on the front of the ankle.

It’s worth noting that following increased tendon stress, the pain may even manifest at rest (without any activity).

Other symptoms include:

• pain or tenderness when palpating the insertion of the tendon on the foot (see image below). In other words, when pressure is applied.
• Sometimes swelling, i.e., a swollen area, around the same insertion point.
• Pain when attempting to raise the tip of the foot; this pain intensifies with resistance to the movement.
• Increased pain when stretching the tibialis anterior muscle.

Symptoms of big toe tendonitis

I have written a comprehensive article on big toe tendonitis (or extensor hallucis longus tendonitis). However, here is a condensed version of the section on its symptoms.

In addition to pain that may occur even at rest after activity, the symptoms of long extensor hallucis tendonitis are:

• pain upon palpation of the tendon ;
• pain during resisted movement to lift the big toe ;
• pain when stretching the big toe downwards ;
• swelling (edema) or redness may be present on the tendon of the big toe.

Symptoms of long extensor digitorum tendonitis

Long extensor digitorum tendonitis is rare, with only three cases detailed in the scientific literature. Let’s examine the symptoms for each of these cases:

🏃‍♂️ Ultramarathon runner (after a 100 km run):

• pain and swelling at the front of the ankle (so in this case, not exactly above the foot) ;
• feeling of crepitus (crackling) when walking or during movements of the foot up and down ;
• increased mobility of the joint between the talus and navicular bones (ankle bones) at 30° of plantar flexion ;
• in the same position as above, the head of the talus pushes the long extensor digitorum tendon to the side (little toe side) ;
• slight weakness and pain when lifting the big toe.

🌊 Windsurfer (1st case):

• painful swelling on the top of the foot, at the level of the metatarsophalangeal joints.

🌊 Windsurfer (2nd case):

• painful swelling on the top of the foot ;
• sensitivity on the back of the metatarsals ;
• hard lump (cyst) on top of the 4th metatarsophalangeal joint.

Sources : Hetsroni, 2006 ; Kobayashi, 2007

What should these tendon issues not be confused with?

There are several types of issues that are not tendonitis and can cause pain on the top of the foot. These include:

• fractures resulting from trauma ;
• stress fractures ;
• complications from a poorly healed fracture ;
• rheumatological conditions.

Consulting with a professional remains one of the best ways to avoid being misled by a misdiagnosis.

How are these tendinopathies caught?

There are three main categories of reasons, which can combine to lead to one or another of these tendon issues:

1. overuse: using the tendons excessively during any activity ;
2. aging: as we age, our tendons have more difficulty self-repairing, especially after 40 years ;
3. genetics: we all have different predispositions to developing tendonitis in response to activity.

Let’s examine more precisely what these reasons entail for each of these tendinopathies.

Causes of tibial anterior tendonitis

Tibial anterior tendonitis can occur particularly in two contexts:

⚫ among overweight women: being a woman increases the risk of developing tendonitis. Moreover, excess weight plays a role in two ways:

1. higher mechanical stress on the tendons during walking ;
2. a different biological function, which favors the occurrence of tendonitis.

⚫ among athletes, especially long-distance runners with significant variations in elevation.

Sources: Harkin, 2017

Causes of big toe tendonitis

The typical development context for this tendonitis includes overuse (such as running) combined with wearing overly tight shoes.

For more information on this, refer to my article dedicated to big toe extensor tendonitis.

Causes of long extensor toe tendonitis

This tendonitis is rare. The only three cases reported in the scientific literature are:

• In an ultramarathon runner.
• In two windsurfers, due to excessively tight bindings on the feet.

Sources: Hetsroni, 2006; Kobayashi, 2007

What is the duration of tendonitis on the top of the foot?

The required duration for recovering from tendinitis on the top of the foot can vary based on three factors:

• the chosen therapeutic modalities (discussed in the next section);
• biological differences between individuals: everyone’s tendon healing abilities differ based on their constitution;
• what each individual considers “healing” to entail, for example, being able to run a marathon versus being able to take a one-hour walk on Sundays.

That being said, assuming you have managed your treatment well, the duration can be roughly:

➡️ up to a few weeks if you do not have overly demanding requirements and your tendon healing capabilities are good;

➡️ up to several months (even up to a year) if you have substantial requirements and your tendon healing capabilities are poor.

Sources: Thomopoulos, 2015

What to do with this type of tendinitis? What treatment?

Firstly, it’s important to note that there are no studies evaluating the effectiveness of therapeutic options for tendinitis on the top of the foot.

Among these options, there are those aimed at short-term and long-term improvements.

Short-term treatment options

The short-term treatment modalities for tendinitis on the top of the foot are:

☑️ The PRICE protocol for:

• P for “protection“

For tibial anterior tendinitis, some suggest immobilizing the ankle with a plaster cast (allowing for walking) for 2 or 3 weeks.

For other tendinitis, it involves removing or adapting the external source of irritation. Loosening shoelaces, for example!

• R for “relative rest“

Applicable to all tendinitis on the top of the foot (and more).

The goal is to not stop walking altogether. Find the right balance so that the pain is bearable and gradually decreases over the days.

• I for “ice“

Applying an ice pack can help relieve pain in the very short term.

Especially useful if there is difficult-to-bear resting pain (“resting pain” = pain without doing anything special). See also: Cold or Heat for Tendonitis?

• C for “compression“

Wearing compression stockings can alleviate pain and reduce swelling in the short term.

• E for “elevation“

Like compression, elevating the foot when sitting or lying down can alleviate pain and reduce swelling in the short term (with a cushion, stool, etc.).

☑️ Paracetamol and non-steroidal anti-inflammatory drugs to reduce pain in the short term.

☑️ A single corticosteroid injection (no more) to reduce pain in the short term as well.

⚠️ Caution ⚠️ Injecting corticosteroids carries a risk of tendon weakening in the long term.

Sources: Simpson, 2009; Deu, 2022

Long-term treatment options

For the long term, the best therapeutic options are:

✅ Protection

If one of the factors explaining the tendinitis is, for example, poor footwear or shoes that are too tight, it is essential to remedy this.

✅ Progressive re-loading

This involves:

1️⃣ Adapting or temporarily replacing the activity causing the problem until the pain subsides.

It is always preferable to adapt the activity rather than completely eliminate it.

By “adapting,” I mean, for example, if it’s running, reducing the distance and speed of running, as well as the frequency of sessions.

2️⃣ Gradually increasing the activity again until the desired level.

⚠️ Caution: excessive rest is bad for tendon healing. Tendons need a certain amount of activity to heal properly.

While these principles may seem simple, they can sometimes be quite challenging to implement. For this, a physical therapist can help you.

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You could also like :

Big toe tendonitis : all you need to know!

Most common causes of top of foot pain

📚 SOURCES

📗 Sources cited in the post:

Harkin E, Pinzur M, Schiff A. Treatment of Acute and Chronic Tibialis Anterior Tendon Rupture and Tendinopathy. Foot Ankle Clin. 2017 Dec;22(4):819-831. doi: 10.1016/j.fcl.2017.07.009. Epub 2017 Sep 28. PMID: 29078830.

Hetsroni I, Mann G, Ayalon M, Frankl U, Nyska M. Extensor digitorum longus tendonitis in windsurfing due to footstrap fixation. Clin J Sport Med. 2006 Jan;16(1):74-5. doi: 10.1097/01.jsm.0000181434.95526.a4. PMID: 16377981.

Kobayashi H, Sakurai M, Kobayashi T. Extensor digitorum longus tenosynovitis caused by talar head impingement in an ultramarathon runner: a case report. J Orthop Surg (Hong Kong). 2007 Aug;15(2):245-7. doi: 10.1177/230949900701500226. PMID: 17709872.

Thomopoulos S, Parks WC, Rifkin DB, Derwin KA. Mechanisms of tendon injury and repair. J Orthop Res. 2015 Jun;33(6):832-9. doi: 10.1002/jor.22806. Epub 2015 Mar 2. PMID: 25641114; PMCID: PMC4418182.

Simpson MR, Howard TM. Tendinopathies of the foot and ankle. Am Fam Physician. 2009 Nov 15;80(10):1107-14. PMID: 19904895.

Deu RS, Coslick AM, Dreher G. Tendinopathies of the Foot and Ankle. Am Fam Physician. 2022 May 1;105(5):479-486. PMID: 35559641.

📙 Sources consulted to construct this post:

Beischer AD, Beamond BM, Jowett AJ, O’Sullivan R. Distal tendinosis of the tibialis anterior tendon. Foot Ankle Int. 2009 Nov;30(11):1053-9. doi: 10.3113/FAI.2009.1053. PMID: 19912714.

Cignetti C, Peng J, McGee A, Lehtonen E, Abyar E, Patel HA, He JK, Naranje S, Shah A. Tibialis anterior tendinosis: Clinical characterization and surgical treatment. Foot (Edinb). 2019 Jun;39:79-84. doi: 10.1016/j.foot.2019.02.006. Epub 2019 Feb 13. PMID: 30978661.

Lemmens L, van Beek N, Verfaillie S. Postoperative results of distal tibialis anterior tendinosis. Foot Ankle Surg. 2020 Dec;26(8):851-854. doi: 10.1016/j.fas.2019.11.005. Epub 2019 Dec 12. PMID: 31870617.

📷 Image sources :

BodyParts3D CC – By SA

Was a bee CC – By SA

Beischer AD, Beamond BM, Jowett AJ, O’Sullivan R. Distal tendinosis of the tibialis anterior tendon. Foot Ankle Int. 2009 Nov;30(11):1053-9. doi: 10.3113/FAI.2009.1053. PMID: 19912714.