Tibialis anterior tendonitis: a cause of mid-foot pain

The tibialis anterior tendon is a large tendon that starts at the front of the shin and moves across the front of the ankle and inside the medial mid-foot. It attaches to the medial cuneiform and base of the first metatarsal bone. The primary function of the tendon is to lift the foot up [...] The post Tibialis anterior tendonitis: a cause of mid-foot pain appeared first on Sport Doctor London.

Nov 2, 2022 - 13:28

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The tibialis anterior tendon is a large tendon that starts at the front of the shin and moves across the front of the ankle and inside the medial mid-foot. It attaches to the medial cuneiform and base of the first metatarsal bone. The primary function of the tendon is to lift the foot up and inwards. It is a pivotal tendon during walking to keep the ankle and foot upwards and stop us from tripping over. Sometimes, we develop overuse of this tendon, also known as tendonitis. How does tibialis anterior tendonitis present, and what do we do about it?

Causes

Several factors can cause swelling or tendonitis of the anterior tibialis tendon. First, tight shoe laces can compress the tendon leading to tendon swelling at the front of the ankle. Second, excessive training combined with biomechanical abnormalities such as a flat foot. This combination can lead to swelling and tendonitis from overuse. Other risk factors are obesity and middle-aged females.

Symptoms of tibialis anterior tendonitis

Generally, tibialis anterior tendonitis causes gradual pain at the inside of the mid-foot. Usually, pain starts at the beginning and the end of an activity, such as running. As the swelling increases, pain can occur during exercise and last for days after any workout, such as running. Other symptoms include swelling at the medial mid-foot, stiffness, and foot deformity.

Sometimes, prolonged standing tendonitis can cause arthritis in the ankle, subtalar joint, or mid-foot.

Other possible causes of medial mid-foot pain 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 tibialis anterior tendonitis, we suggest either an ultrasound or MRI to confirm the diagnosis of tendon swelling close to the attachment at the medial cuneiform. Imaging also excludes a partial tear and other causes, such as a stress fracture or mid-foot arthritis.

Treatments

Generally, we start with simple treatments such as modifying or eliminating the offending activity (walking or running). Also, anti-inflammatory therapies include regular ice, topical Voltarol cream, and oral ibuprofen.

Physical therapy to strengthen the calf and intrinsic foot muscles can help. Focussed rehab for the anterior tibialis tendon using therabands, starting with exercises sitting and progressing to standing help. Your therapist will also assist in mobilisation of the stiff ankle and subtalar joint.

Finally, seeing a podiatrist to help correct abnormal foot biomechanics can offload the tendon and allow it to heal.

Adjuncts for tibialis anterior tendonitis

GTN patches are effective in reducing pain with chronic tendonitis. Patches are placed onto the skin on top of the tendon and left for 12 hours. They contain a substance called nitric oxide, which is an essential metabolite in tendon healing.

Shockwave therapy uses sound waves to remodel tendons and desensitise pain fibres. The procedure is performed every week for up to five sessions and has shown promise in lower limb tendons, including the Achilles tendon.

Injection therapy is generally discouraged for weight-bearing tendons. Cortisone should be avoided because of the risk of complete rupture of the tendon. PRP has shown little effectiveness for lower limb tendons and is not recommended.

Surgery for tibialis anterior tendonitis

Surgery is necessary for a complete avulsion of the tendon from the attachment to the medial mid-foot. 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 cases that have failed all conservative management in tendonitis.

(Your author was unfortunate to develop tibialis anterior tendonitis. Against (his own) medical advice, he had a cortisone injection leading to a complete tendon rupture. As a result, he needed surgical reconstruction of the tendon using a hamstring graft. While he is now back running and playing sports, he would not wish the surgical experience on anyone!).

Final word from Sportdoctorlondon about tibialis anterior tendonitis

This condition is an uncommon cause of medial mid-foot pain caused by overuse combined with biomechanical abnormalities. In general, treatment should be conservative, including medication, physical therapy, and podiatry. GTN patches and shockwave therapy might help. Avoid surgery at all costs.