achilles tendonitis :: posterior tibial tendonitis :: peroneal tendonitis 

Tendon Terms & Anatomy:

Tendon: a band of connective tissue that connects muscle  to bone that functions to transmit force created in the muscle to the bone and allow for joint movement. Paratenon: a very thin outer layer of the tendon, which functions as an elastic sleeve. Not all tendons have a paratenon. Also called a peritendinous sheet.

Tendon sheath: A canal like structure that surrounds the tendon and creates a lubricated low-friction environment for the tendon to glide. The tendon sheaths are mostly grouped around the ankle and may partially or completely surround the tendon. Tendinopathy: a general term used to describe a painful, overuse tendon injury. Tendinitis: painful inflammation of the tendon, generally associated with microscopic tearing and subsequent degeneration within the tendon.

Tendonitis: the inflammation of a tendon resulting from small microscopic tears within the tendon caused by chronic overuse. The small tears weaken the area and cause inflammation. Swelling may be noticeable and the area is typically painful and weak. Common symptoms with tendonitis:

• Dull achy pain and soreness at rest
• Sharp pain with certain activities
• Tenderness to the touch and swelling
• Pain and stiffness in the morning Inflammation and swelling generally characterize the initial stages of the tendonitis.

Tendonitis will last about 2-4 weeks. Tendonitis progress to tendonosis sometime between 1 - 3 months. The exact period of time is not well defined and may vary by individual.

Tendinosis: non-inflammatory degeneration of a tendon which may or may not be painful. Tendinosis is the degeneration (deterioration) of the tendon. The collagen fibers which make up the tendon become disorganized and infiltrated with small blood vessels, which results in a weakened tendon. Tendonosis is not an inflammatory condition, it is a degenerative condition.

Paratenonitis: an inflammatory process with associated thickening of the paratenon. This process may constrict the underlying tendon and prevent gliding. This condition commonly occurs in areas where the tendon is changing direction or lying over a bony prominence. Also known are peritendinitis or tenosynovitis.

Achilles Tendonitis / Tendinosis

Achilles tendonitis is the most common type of tendonitis in the foot and ankle. The pain is generally about 2 inches above the heel bone in the area which many refer to as the heel cord. Pain is accompanied by stiffness, especially at the first step in the morning, or rising after long periods of rest. There may be some swelling and extreme tenderness to the touch. Achilles tendonitis can also occur at the insertion of the tendon on the heel bone (calcaneus). This type of tendonitis is termed insertional Achilles tendonitis. Pain is located directly on the back of the heel and the area may be very tender  to the touch. Stiffness upon rising may also accompany this type of Achilles tendonitis. As the condition progresses out of the inflammatory phase (first 2-4 weeks) and into the degenerative phase, the swelling and intense tenderness will decrease and can be replaced with what looks like a lump or nodule on the back of the heel. This is Achilles tendinosis (tendonosis) and can take months and even up to a year to heal.

Achilles tendonitis typically develops after an increase or change in a certain activity. Many runners will develop tendonitis when they return to their training routine. Adding hills or stairs to a running routine or running on uneven surfaces or trail running can contribute to the development of tendonitis. Sports which involve quick sprints like basketball, soccer or tennis can contribute to the developed of Achilles tendonitis. The Achilles tendon is under the most stress when running or walking up steep hills, and this activity continues to be one of the most common aggravating activities. Changing to a new pair of shoes, especially a pair of shoes without a wedge at the heel or lift at the heel can add to the stress on the Achilles tendon. Starting a new job that requires a specific type of shoes, climbing up and down stairs or squating can cause tendonitis.

Treating Achilles Tendonitis

It is important to recognize the aggravating activity so that it can be eliminated during the healing process. Recognizing the problem and treating the tendonitis as soon as it develops will prevent progression to tendon degeneration. The initial treatments focus on taking the stress off of the achilles tendon, resting and decreasing inflammation.

1. Eliminate the aggravating activity: 
If you are a runner or a walker, switch to biking or swimming for 2-4 weeks during the healing process. If you are a cyclist, avoid hills, steep climbs and don't drop your heel while pedaling.
   
    
2. Ice massage: 
Ice the back of the heel and tendon for at least 20 minutes twice a day (3-4 times a day if possible). The most effective icing method is to place ice directly on the heel and massage the heel with the ice for 20 minutes. This will cause discomfort and possibly some pain, but should eventually lead to some numbness. Extended periods with ice directly on the skin could result in mild frostbite, so always keep the ice moving and don't leave the ice directly on the skin for long periods of time. If the direct ice massage is too painful, rest your heel directly on an ice pack or a bag of frozen peas. 

   
    
3. Wear shoes with a heel:The best shoes to take stress off of the Achilles tendon is a shoe with a wedge or heel (1 inch), a rigid midsole and a rocker on the bottom. The best example of this shoe is a Dansko. Those with insertional Achilles tendonitis may find the rigid heel counter on the Dansko shoe uncomfortable.
   
   This is not the only acceptable shoe, but the Dansko shoe is a good example. A true rocker bottom sole is not necessary, but a rocker at the toe area as demonstated in this picture, helps with push off during walking and decreases the stress on the Achilles tendon. Avoid flexible, soft shoes and don't go barefoot. More on shoes.
   
    
4. Try heel lifts:Heel lifts can be placed in any shoe and will lift the heel, effectively taking stress off the Achilles tendon. The concept is the same as wearing a shoe with a wedged heel.
   
   To better understand the concept behind heel lifts, look at the images o n the right. When foot is forced up at the ankle (when walking uphill) the tendon is placed on stretch. There is a considerable amount of tension on the calf muscle and the Achilles tendon. It's like taking a cord and pulling it at both ends until it becomes taut.
   
   When the foot flexes down at the ankle (plantar flexion) the tension is taken off of the Achilles tendon and the calf muscle. It would be like giving the cord in the example above more slack. The less tension and less stress on the tendon, the faster the tendon will heal. A heel lift is used or wedged heel shoe takes stress off of the Achilles tendon.
   
   
5.  Calf Stretching: Start with gentle stretching during the initial stages of tendonitis. When seated, take a belt or a towel and place it around the ball of  your foot. Keep the knee extended and gently pull the foot towards you. You should start to feel a stretch in the calf muscle. Continue to gently pull the foot toward you until you feel some pain. Back off a little and then hold the stretch for 60 seconds. Repeat this stretch 10 times, twice a day. Try to stretch before getting out of bed in the morning, or before you get up after long periods of rest. This stretch should not be painful. Aggressive stretching during the initial phases of tendonitis can aggravate the condition.
   
    
6. Take anti-inflammatory medications: Ibuprofen and Naproxen are two common anti-inflammatory medications which can be bought over the counter. They will reduce pain and decrease inflammation. Used in combination with the other treatments mentioned, they can be an effective therapy. But, it is also important to realize that they can mask the pain and they are not addressing the cause of the problem. 
   

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Treating Achilles Tendinosis

If the tendonitis has not improved within 2 - 4 weeks, an appointment with your doctor is recommended. After 4 weeks, the condition has most likely progressed to tendonosis. At this point, the treatment regimen will change slightly and a referral to physical therapy is recommended. Icing can still be done because this will help decrease the number of new blood vessels formed within the area and act as an analgesic. But, it is no longer necessary as an anti-inflammatory. Anti-inflammatory medications are not necessary at this point either, although they can help reduce the pain. This is something to be discussed with your doctor and may vary on an individual basis.

1. Continue wearing rigid shoes with a wedge heel.
   
   
2. Continue wearing a heel lift.
   
   
3. Return to exercise. Although it is important to avoid the aggravating activities that caused the problem (for example, running up hills), full rest at this point is not beneficial. A return to running or walking on flat surfaces is ok. Start with about half the mileage and make sure to add stretching to your exercise routine. Warm up for about 10 minutes initially, stop and stretch the calf for 2-3 minutes and then continue with your exercise routine. At the end of the activity, stretch the calf again for about 5 minutes. Ice immediately after the activity. Do not continue if the pain worsens. 

   
   
4. Friction rub: A friction rub is performed by taking your index and middle finger and placing them perpendicular to the achilles tendon. Press down firmly and then move your fingers back and forth across the tendon (not up and down). Pressure should be firm and it is generally a little painful. Continue this for 5 minutes and then ice the area. One theory behind the friction rub is that the deep tissue massage helps to break up the fibers and reorganize them. Others believe it stimulates the inflammatory process and accelerates healing.
   
   
5. Calf stretching: Add more calf stretching to your daily routine. Increase the amount of stretching and the type. Perform the following routine twice a day. Start with the seated calf stretch shown above each morning before getting out of bed. Stretch for at least 60 seconds. Once up and out of bed, peform each stretch shown below. Hold each stretch for 60 seconds and repeat three times. This will take about 10 minutes. Do not bounce when stretching and don't stretch through pain.    
   



 

6. Start strengthening: Once the pain starts to decrease, strengthening exercises should be started. Heel raises are one of the best exercises to help strengthen the calf muscles without aggravating the tendon. Perform the heel raises slowly, going up onto the toes and then back down in a slow, controlled motion, 10 times and then rest for a minute. Repeat this series 3 times, twice a day. This should not be painful, but there may be some achiness the first few times the exercise is performed.
   
   

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Posterior Tibial Tendonitis

The posterior tibial tendon starts at the inside of the leg and runs down the inside of the ankle and attaches in the middle of the arch. The main attachment point is at a bone called the navicular, but the tendon fans out to attach to other bones in the bottom of the foot. The posterior tibial tendon is one of the main structures which maintains and supports the arch. When the posterior tibial tendon is not functioning properly, the arch is not maintained and will collapse. When there is too much force, tension or stress on the posterior tibial tendon, the tendon becomes overworked. The result is microtears, inflammation and the development of tendonitis. The two most common locations of pain are at the insertion of the tendon on the navicular and inside the ankle. Just as with Achilles tendonitis, the first 2-4 weeks are inflammatory and after this period of time, the tendon will gradually start to degenerate and progress towards tendonosis.

Posterior tibial tendonitis is generally associated with flatfeet. But, the cause is not simply an arch collapse. The development of posterior tibial tendonitis and the associated flatfoot (adult aquired flatfoot) is due to abnormal foot biomechanics. Most individuals with posterior tibial tendonitis have an abnormal amount of pronation. In the image to the  right, the foot is pronating. The foot is flexing up at the ankle, the forefoot is turning out away from the midline of the body and the heel is rotating out, away from the midline of the body. This is pronation when the foot is not bearing weight.

In the image to the left, a view from behind shows a pronated foot in stance. The heel is rotating away from the midline of the body, which forces the midfoot and ankle to rotate in, towards the midline of the body. The navicular can be seen and is very prominent at the inside of the arch. This position puts an abnormal amount of stress on the posterior tibial tendon and leads to the development of tendonitis. The image below shows a pronated foot in an individual with posterior tibial tendonitis and tibial tendon dysfunction (also called adult acquired flatfoot).

It's important to note the rotation of the heel (eversion). The posterior tibial tendon controls eversion and the amount of pronation while walking. Once the heel rotates in, the midfoot starts to collapse and excess stress is placed on the posterior tibial tendon at the ankle area and at the insertion. Chronic overuse of the posterior tibial tendon leads to tendonitis. For individuals with abnormal pronation, the tendon is constantly under abnormal stress and something as simple as a shoe change or a weekend warrior event can stimulate the development of tendonitis. In some individuals, it is only a matter of time before the tendon will become irritated, inflamed and painful. Treatments for posterior tibial tendonitis The treatments are essentially the same for posterior tibial tendonitis as they are for Achilles tendonitis.

The first 2-4 weeks are more inflammatory and treatment should be directed as decreasing inflammation and taking stress off the tendon.

1. Eliminate the aggravating activity: Posterior tibial tendonitis more commonly develops from walking or running on uneven surfaces (for example trail running, hiking or running on a slanted or banked road). Sports with side to side motion, like tennis or soccer, are also common activities which can lead to posterior tibial tendonitis. If a specific routine or running or walking, soccer or other sporting activity contributed to the development, take a break for 2-4 weeks and try biking or swimming.

   
   
2. Ice massage: Ice the area of pain (arch or ankle) for at least 20 minutes twice a day (3-4 times a day if possible). The most effective icing method is to place ice directly on the heel and massage the heel with the ice for 20 minutes. This will cause discomfort and possibly some pain, but should eventually lead to some numbness. Extended periods with ice directly on the skin could result in mild frostbite, so always keep the ice moving and don't leave the ice directly on the skin for long periods of time. If the direct ice massage is too painful, place a bag of frozen peas or ice pack directly on the area.
   
   
3. Wear rigid, supportive shoes with a heel: This is probably the most important step for posterior tibial tendonitis. A soft flexible shoe will aggravate the tendon and no matter what other treatments are done, the tendonitis will never improve. The shoe should be rigid at the midfoot and bend only at the toes. A Dansko type shoe, as mentioned above, is also a good choice, but in many cases individuals with this condition will need an orthotic, which will not fit in most Dansko type shoes. Having a wedged heel is important with posterior tibial tendonitis as well. Avoid flexible sandals and don't go barefoot, even around the house.
   



4. Wear orthotics: Depending on the amount of overpronation (which should be evaluated by a podiatrist) you may need custom made orthotics. Custom made orthotics are made from a mold of your foot. They are rigid devices which fit into the shoe and control abnormal motion. A soft insert will do nothing for your foot except to add cushion. Custom orthotics can be expensive, but many insurances do cover them for this condition. If you can't afford custom made orthotics, a prefabricated orthotic in a good shoe is a reasonable substitute. Prolab orthotics are one of the best prefabricated orthotics because it is rigid and designed to control pronation. Superfeet insoles are less rigid and have a soft cover and are also designed to control motion. Arch Molds, a heat moldable, semi-rigid insole, is another good option. Don't buy the inserts at a drug store, if you are looking for an insert to control motion, go to your local sporting goods store and look for an insert which has some rigidity to it and doesn't flex in the arch area.

   
   
5. Anti-inflammatory medications: Ibuprofen and Naproxen are two common anti-inflammatory medications which can be bought over the counter. They will reduce pain and decrease inflammation. Used in combination with the other treatments mentioned, they can be an effective therapy. But, it is also important to realize that they can mask the pain and they are not addressing the cause of the problem.
   
   
6. Calf stretching: Most individuals with posterior tibial tendonitis and flat feet have a very tight calf muscle. When the calf muscle is tight, the it is difficult for the foot to flex up (dorsiflex) when walking. This forces the foot to rotate out (pronate) and places excess stress on the posterior tibial tendon. For this reason, calf stretching is extremely important in the treatment of posterior tibial tendonitis. Follow the routine for calf stretching for Achilles tendonosis outlined above. More aggressive calf stretching can be started earlier for posterior tibial tendonitis, since the Achilles tendon is not injured.

   

Treating Posterior Tibial Tendinosis

Between 4-12 weeks posterior tibial tendonitis progresses to posterior tibial tendinosis. This means the condition changes from an inflammatory condition to a degenerative condition. The time period is variable and not well defined. Posterior tibial tendinosis tends to be a more chronic condition and even when healed, has a tendency to recur over and over again, unless the abnormal motion has been controlled. It is not recommended to treat posterior tibial tendonosis on your own, a visit to a podiatrist is recommended and a referral to physical therapy may be beneficial. Posterior Tibial Tendon Dysfunction (PTTD) is the compromise of the tendon unit and complex group of structures which support the arch, resulting in severe collapse of the foot. In the past, the posterior tibial tendon was thought to be the main structure responsible for a collapsed arch. The term posterior tibial tendon dysfunction has lost some favor become it implies that the posterior tibial tendon is the main cause of a progressive flatfoot, when really the tendon is just one structure within a group of structures in the foot and ankle contributing to arch collapse. Although the posterior tibial tendon may be injured, elongated and/or deteriorated, significant ligament rupture also occurs as this deformity progresses. This is why PTTD is more commonly called Adult Acquired Flatfoot.
 
The Spring ligament is one of the most important structures maintaining the arch. The Spring ligament is also called the plantar calcaneonavicular ligament because it originates on the calcaneus and inserts on the navicular. The main function of the Spring ligament is to support the head of the talus and prevent excess rotation of the talus resulting from over pronation.

Abnormal mechanical stresses can cause stretching and lengthening of the Spring ligament, even rupture. Although the Spring ligament is only one of the ligaments supporting the arch, it is extremely important. When the Spring ligament cannot function to support the talar head, loss of arch height results.

Stages of PTTD

• Stage 1: peritenonitis with possible tendon degeneration (deterioration). Alignment of the foot is normal with normal flexibility and mild dscomfort and weakness. Treatment is conservative.
  
  
• Stage 2: tendon is attenuated (elongated/stretched) with some degeneration (deterioration) and the foot is in a valgus position (see pronated image above) but the foot is still flexible. There is considerable weakness of the tendon and moderate pain. Treatment starts with conservative therapies but may result in surgery (tendon transfers vs joint fusions).
  
  
• Stage 3: tendon is attenuated (elongated/stretched) with marked degeneration (deterioration) or even completely ruptured. The foot is no longer flexible and is in a valgus position (see pronated image above). Pain is moderate and tendon weakness is considerable. Treatment is usually surgical (generally involves joint fusions).
  
  
• Stage 4: tendon is attenuated (elongated/stretched) with marked degeneration (deterioration) or even completely ruptured. Rigid valgus foot position (see pronated image above) and the ankle is in a valgus position as well. The pain encompasses the entire ankle and there is considerable weakness. Treatment is surgical and generally involves both foot and ankle fusions. The treatment for PTTD vary based on the stage, stage 1 can be treated conservatively and in many cases, stage 2 can also be treated without surgery. The biggest issue is recognizing the problem and initiated early treatment. Although tendonitis responds to ice and anti-inflammatory medications, tendinosis generally does not. The doctor may recommend a short course with a cast boot and physical therapy and will almost always recommend custom made orthotics.
  
  In stage 2, an AFO (seen in the image to the right) may be very beneficial. An AFO (ankle foot orthosis) can help support the foot and the ankle during the long healing process. Although those with PTTD will almost always wear custom orthotics throughout the course of their lives, the AFO may only be necessary during the healing process. This is not a condition which can be self-treated with over the counter orthotics and icing, a visit to your doctor is necessary.
  

Peroneal Tendonitis

Peroneal tendonitis is another common tendonitis in the foot. The peroneal tendons are located on the outside of the ankle and insert on the midfoot. These tendons function to balance and stabilize the foot while walking. The most common type of pain is a dull pain on the outside of the foot. Many will notice what they think is a lump. It is actually the bone which one of the peroneal tendons attaches called the styloid process, located at the base of the 5th metatarsal. The peroneus brevis tendon is the more common of the two tendons to develop tendonitis. The pain generally occurs with walking and standing, but there can also be stiffness at the first step in the morning, similar to Achilles tendonitis. It is not as common to develop peroneus longus tendonitis. The pain is similar in quality, but is in a different location. Although it can also be at the outside of the ankle, the pain may extend under the arch. The treatment for peroneal tendonitis is very similar to the treatment for Achilles tendonitis. Follow the regimen listed above. Identifying the cause of the tendonitis is important and it's essential to eliminate aggravating activities like walking on uneven terrain or walking in worn out shoes. These are the two most common problems resulting in peroneal tendonitis. Daily icing, contrasting between hot and cold water for 20-30 minutes a day and stretching exercises may help.

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last updated 6/23/10

Disclaimer: The advice on this website is not intended to substitute for a visit to your health care provider. We will not be held liable for any diagnosis made or treatment recommended. Consult your doctor if you feel you have a medical problem.