The tibialis anterior tendon is a large tendon that starts at the front of the shin and moves across the ankle and inside the medial mid-foot. It attaches to the inner mid-foot. The tendon lifts the foot up and inwards. During walking, it is a pivotal tendon to stop us from tripping over. Sometimes, we develop overuse of this tendon, also known as anterior tibial tendonitis. How does anterior tibialis tendonitis present, and what do we do about it?
Causes of anterior tibial tendonitis
Several factors can cause swelling or tendonitis of the anterior tibialis tendon. First, tight shoe laces can compress the tendon. Second, excessive training combined with abnormalities such as a flat foot can overload the tendon. This combination can lead to swelling and tendonitis from overuse. Other risks are obesity and middle-aged females.
Symptoms of anterior tibialis tendonitis
Generally, anterior tibialis tendonitis causes gradual pain inside the mid-foot. Usually, pain starts at the beginning and end of the exercise. As the swelling increases, pain can occur during training and last for days after activity. Also, we may see swelling at the medial mid-foot, stiffness, and foot deformity.
Sometimes, prolonged tendonitis can cause arthritis in the ankle, subtalar joint, or mid-foot.
Other possible medial mid-foot causes include mid-foot arthritis, stress fractures of the mid-foot or metatarsus, navicular stress fracture, Os naviculare, or ganglion in the foot.
If you suspect anterior tibialis tendonitis, we suggest an ultrasound or MRI to confirm the diagnosis of tendon swelling. Imaging also excludes a partial tear and other pain causes, such as a stress fracture or mid-foot arthritis.
Treatment for anterior tibialis tendonitis
Generally, we start with simple treatments such as modifying activity (walking or running). Anti-inflammatory therapies can also help and include regular ice, topical Voltarol cream, and oral ibuprofen.
Physical therapy to strengthen the calf and foot muscles can help. Focussed exercise for the anterior tibialis tendon using therabands is useful. Your therapist will also mobilise a stiff ankle and subtalar joint.
Finally, seeing a podiatrist to help correct abnormal foot posture can offload the tendon and allow it to heal.
Other treatments for anterior tibial tendonitis
GTN patches help reduce pain in chronic tendonitis. They are placed onto the skin over the tendon and left for 12 hours. They contain nitric oxide, an essential metabolite in tendon healing. Overall, GTN patches are suitable for anterior tibialis tendonitis.
Shockwave therapy uses sound waves to heal tendons and desensitise pain fibres. It can be performed weekly for up to five sessions and has shown promise in lower limb tendons, including the Achilles tendon.
Injection therapy is generally discouraged for foot tendons. Cortisone should be avoided because of the risk of complete tendon rupture. Although there is little evidence for use in anterior tibial tendonitis, we sometimes use PRP injections to help with tendon healing without the risk of tendon rupture.
Surgery for anterior tibialis tendonitis
Surgery is necessary for a complete tendon tear from the attachment. In these cases, we use grafts such as the hamstring tendon to reconstruct the tendon and reattach it to the bone. Generally, surgery should only be reserved for patients who have failed all simple treatments.
(Your author was unfortunate to develop anterior tibialis tendonitis. Against (his own) medical advice, he had a cortisone injection, leading to a tendon rupture. As a result, he needed surgical reconstruction of the tendon. While he is now back running and playing sports, he would not wish the experience on anyone!).
Final word from Sportdoctorlondon about anterior tibialis tendonitis
Anterior tibialis tendonitis is an uncommon cause of medial mid-foot pain caused by overuse and posture abnormalities. Treatment should generally be simple, including medication, physical therapy, and podiatry. GTN patches and shockwave therapy might help. Avoid surgery at all costs.
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