The tibialis anterior tendon is a large tendon that starts at the front of the shin, crosses the ankle, and attaches to the inner mid-foot. It lifts the foot up and inwards, and during walking, it’s a pivotal tendon that helps prevent us from tripping over. Overuse of this tendon is known as anterior tibial tendonitis. So, how does tibialis anterior tendon pain 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:
- Tight shoelaces, which compress the tendon across the front of the ankle
- Excessive training combined with a foot abnormality, such as a flat foot, which overloads the tendon
- Other risk factors, including obesity and being a middle-aged woman
This combination can lead to swelling and tendonitis from overuse.
Symptoms of tib anterior tendonitis
Anterior tibialis tendonitis causes gradual pain at the front of the ankle and inner mid-foot. Pain usually starts at the beginning and end of exercise. As the swelling increases, pain can occur during training and last for days afterwards. There may also be swelling at the inner mid-foot, stiffness, and foot deformity.
Sometimes, prolonged tendonitis can lead to arthritis in the ankle, subtalar joint, or mid-foot.
Other possible causes of inner mid-foot pain include mid-foot arthritis, a stress fracture of the mid-foot or metatarsus, a navicular stress fracture, os naviculare (accessory navicular), or a ganglion in the foot.
If we suspect anterior tibialis tendonitis, we suggest an ultrasound or MRI to confirm tendon swelling. Imaging also excludes a partial tear and other causes of pain, such as a stress fracture or mid-foot arthritis.
Treatment for anterior tibialis tendonitis
We start with simple treatments — modifying activities such as walking or running. Anti-inflammatory measures also help, including regular ice, topical Voltarol cream, and oral ibuprofen.
Physical therapy to strengthen the calf and foot muscles helps, and focused exercises for the anterior tibialis tendon with resistance bands are useful. Your therapist will also mobilise the stiff ankle and subtalar joint.
Seeing a podiatrist to correct abnormal foot posture can help offload the tendon and allow it to heal.
Other treatments for tib anterior tendonitis
GTN patches
GTN patches reduce pain in chronic tendonitis. They’re placed on the skin over the tendon and left for 12 hours. They contain nitric oxide, an essential metabolite in tendon healing, and are suitable for anterior tibialis tendonitis.
Shockwave therapy
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.
Injections — and an important caution
Injection therapy is generally discouraged for foot tendons. Cortisone should be avoided in the anterior tibialis tendon because of the risk of complete tendon rupture. Although there’s little evidence for its use here, we sometimes use a PRP injection to promote tendon healing without the rupture risk associated with cortisone.
Surgery for anterior tibialis tendonitis
Surgery is necessary for a complete tendon tear from the attachment. In these cases, we use a graft — such as the hamstring tendon — to reconstruct the tendon and reattach it to the bone. Surgery should only be reserved for people who’ve failed all simple treatments.
A personal note from Dr Masci: Your author was unfortunate enough to develop anterior tibialis tendonitis. Against his own medical advice, he had a cortisone injection — which led to a tendon rupture. As a result, he needed surgical reconstruction of the tendon. While he’s now back running and playing sport, he wouldn’t wish the experience on anyone — and it’s exactly why he cautions so strongly against cortisone in this tendon.
Frequently asked questions about anterior tibialis tendonitis
Where does tib anterior tendonitis hurt?
At the front of the ankle and the inner midfoot, along the tendon line. The pain typically comes on gradually and is worse at the start and end of exercise, and in more advanced cases during and after activity.
Can you have a cortisone injection for anterior tibialis tendonitis?
No — cortisone is best avoided in this tendon because it carries a real risk of complete tendon rupture. This is a case where a cortisone injection can do more harm than good (as Dr Masci’s own experience shows). Where an injection is considered, PRP is the cautious alternative, as it supports healing without the rupture risk.
What’s the difference between anterior and posterior tibial tendonitis?
The anterior tibialis tendon runs down the front of the ankle and lifts the foot up and inwards. The posterior tibialis tendon runs behind the inner ankle bone and supports the arch. They cause pain in different places and are managed slightly differently, so it’s worth confirming which is involved.
How long does tibialis anterior tendon pain take to heal?
Like most tendon problems, it’s often slow — weeks to several months — and responds best to load management and a progressive strengthening programme rather than complete rest. Correcting footwear and foot posture helps it settle and stops it from returning.
Can you run with tibialis anterior tendon pain?
Often, with modification — reducing mileage and impact, loosening tight laces, and keeping training below the level that flares the pain, while building tendon strength. Pain that continues to worsen despite these changes warrants assessment to exclude a tear.
Final word from Sport Doctor London about anterior tibialis tendonitis
Tib Anterior tendonitis is an uncommon cause of inner mid-foot pain, often due to overuse and foot posture abnormalities. Treatment should be simple — medication, physical therapy, and podiatry — with GTN patches and shockwave therapy as useful additions. Above all, avoid cortisone in this tendon.
If you have persistent pain at the front of the ankle or inner mid-foot, Dr Masci can assess you in London, including an ultrasound in the clinic. Contact the team here or call +44 (0) 203 488 0350.
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