The ankle consists of three bones that are attached by muscles, tendons, and ligaments that connect the foot to the leg. The lower leg are two bones called the tibia (shin bone) and the fibula. These bones articulate (connect) to the ankle bone at the tibiotalar joint (ankle joint) allowing the foot to move up and down. Overall, the foot and ankle in the human body work together to provide balance, stability, movement, and propulsion.
The tibial nerve is a mixed nerve with both motor and sensory function, and part of the peripheral nervous system. Mixed motor and sensory nerves enable electrical impulses to travel between muscle cells and the spinal cord. Impulses from the tibial nerve then travel to the brain to help provide sensory information and manage the voluntary and involuntary movement of your lower limbs. Branches of the tibial nerve connect to muscles in the back of the leg.
This enables you to move your leg, foot, and toes. Furthermore, the tibialis anterior muscle arises from the front of your shin bone. It travels down your shin and turns into a tendon that attaches to the top inner portion of your foot. The function of the anterior tibialis is to dorsiflex your foot and ankle, the action of pulling your foot and toes up towards the front of your shin. When walking, the tibialis anterior contracts to lift your foot and toes, helping them clear the floor. The muscle also serves to pull your toes and foot inwards, a movement called inversion.
Tibialis anterior tendonitis is a condition that causes inflammation of the tendon, or sheath surrounding the tendon of the tibialis anterior muscle. However, tendinopathy is a more accurate term to use in most long-term cases as it describes wear and tear, as opposed to acute inflammation. In some cases, the terminology of tendon disorders may be confusing. Although it is acceptable to use “tendinopathy” as an all-encompassing term denoting a disease of the tibialis tendon, it may be helpful to think of the three distinct disorders, such as:
- Tendonitis – Also known as tendinitis, refers to a painful clinical condition where there is acute pain and swelling due to micro-tearing of the tendon and the resulting inflammatory response.
- Tendonosis (or tendinosis) – is a chronic degenerative condition in which repetitive overuse and aging lead to a non-inflammatory degeneration of the tendon’s collagen over time.
- Paratenonitis – This condition is an inflammation of the lining of the thin lining of connective tissue that surrounds many tendons allowing the tendon to glide more easily.
Causes & Symptoms
Activities that place inordinate pressure on the tendon can result in injury, either due to degeneration of the tendon over time, or, rarely, because of a single incident in which the tendon is accidentally rubbed.
This rarer cause is provoked by actions such as very tight tying of a bandage, guard, shoelaces, or other material directly over the tendon. More commonly, tendonitis is caused through repeated strain as caused in movements including quick walking or sprinting on hills or uneven ground (or even excessively on flat surfaces), wearing very tight footwear, kicking a football with your shin, or kneeling for an extended period of time. Several fast-paced sports that require running and kicking can lead to tibialis anterior tendonitis.
As for symptoms, pain may be felt near the front of the foot or ankle, especially during or after a physical activity in which much strain is put on the tibialis anterior tendon. The pain may not be immediately felt, and it is common to experience the pain the next morning or after rest. It is also likely to become sharper over time if physical activities involving the affected foot continue to feel pain. In worse cases, pressing on the area of the tendon itself may result in replicating the pain.
Overall, tibialis anterior tendonitis is usually classified into three stages. Depending on what stage you are in determines how much or how little you must practice your sport or physical activity:
- Stage 1 tendonitis – There is pain only after participating in an activity. For instance, playing a sporting event that involves excessive use of your ankle (such as soccer). At this stage, there are no limitations in activities.
- Stage 2 tendonitis – There is pain at the beginning and after an activity. Once the ankle has warmed up, there is no pain, and it does not affect the way you play. However, on completion of playing, the ankle pain has returned to be presented. At this point, participation is not limited, but it is important to identify why the tendonitis has started.
- Stage 3 tendonitis – There is pain beginning, during, and after participating in an activity, but play is not affected nor has the person altered how he/she is playing. An example would be a basketball player with lingering tibialis anterior pain every time he or she is running. At this stage, it is important to limit play to 50% participation.
Who gets Tibialis Anterior Tendonitis?
Anyone can hurt their tibialis anterior tendon, but some people are more prone than others. Certain risk factors that increase the likelihood of tibialis anterior tendonitis and other tendon problems include the following:
- Increasing age – People over 30 years of age contribute to the decreased blood supply to tendons, making them more prone to injury.
- Wearing high heels – Regularly can shorten the tibialis tendon, making it more prone to injury.
- Tight or weak calf muscles – Having tight/weak calf muscles can be overstretched, resulting in soft-tissue damage.
- High-arched feet – These are associated with a higher risk of developing tibialis anterior tendonitis.
- Chronic ankle instability – or a recurrent “giving way” or rolling of the ankle are causes that can lead to the condition.
- A sudden in playing surface – such as when a tennis player shifts from playing on grass courts to clay courts, or when the athlete changes footwear.
- Certain medications – such as ciprofloxacin, gemifloxacin, or levofloxacin, put a person at temporary risk of tendon injury.
How does it affect you? How serious is it?
In worse cases, tibialis anterior tendonitis can become serious if it is ever left untreated, thus leading to the requirement of it being surgically repaired, known as an anterior tibialis tendon repair. This treatment is a surgery performed to repair a torn or ruptured anterior tibialis tendon.
Therefore, the main objective of the anterior tibialis tendon repair is to reduce pain, correct foot deformity, and restore the normal ankle and foot function and walking pattern by reattaching the torn tendon to its regular anatomical position. Even though repairs have a higher success rate, certain complications can be present during the process. Some of these complications include:
- Persistent ankle pain – Some patients tend to continue to have persistent ankle pain after an anterior tibialis tendon repair. When this happens, your doctor will work with you to create a treatment plan, which may include additional physiotherapy, cognitive behavioral therapy, or medicines to help you recover regularly.
- Nerve or blood vessel damage – During surgery, there is a minimal chance that the nerves, veins, or tissue around your knee can be damaged. Damaged nerves or blood vessels can cause numbness, pain, or lower blood flow around the ankle.
- Blood clots – Because an anterior tibialis tendon repair affects the way blood flows around your ankle, it can increase your risk of developing blood clots.
Recommended Treatment & Rehabilitation
During a diagnosis for tibialis anterior tendonitis, a physician will begin by performing a physical exam, alongside acquiring a detailed medical history, and if needed, diagnostic imaging tests:
Physical exam
Your doctor will examine the foot and lower leg and look for signs of the condition. He or she will probably conduct a series of clinical assessments to test the tibialis anterior tendon. Your doctor may also ask you to do a series of exercises such as leg lifts, hops, or jumps to gauge the level of activity-related pain, as well as exactly where it occurs.
Medical history
In addition to a physical exam, your doctor will ask you to describe the pain, what makes you feel better or worse, describe any changes in your lifestyle, and recent sports involvement.
Medical imaging is typically not required to arrive at a tibialis anterior tendonitis. However, in some cases, your doctor may order imaging to get a detailed view of the tendon or to rule out other conditions, such as magnetic resonance imaging (MRI) and an ultrasound. X-rays aren’t normally used to diagnose tibialis anterior tendon damages or tears but are helpful in identifying associated contributors to pain.
Rehabilitation
Rehabilitation of a damaged tibialis anterior tendon typically begins at approximately three or four weeks after injury. You may benefit from working with a physiotherapist during your rehabilitation. Your physiotherapist can assess your condition and guide you during your recovery. Therefore, your therapist may provide the following recommendations below:
Muscle-strengthening exercises
Strengthening activities for any muscles affected by tibialis anterior tendonitis in the front of your lower leg, can help alleviate further pain linked to this condition.
- Nerve gliding activities – Gentle exercises that move and glide the nerves may help reduce symptoms and improve function.
- Balance and coordination activities – Work to improve your balance and coordination, which are often affected by tibialis anterior tendonitis.
- Supporting equipment – It is recommended to apply ankle taping, a custom orthotic, or bracing to position the foot to decrease stress on the anterior tibial nerve.
Although there are no proven strategies for preventing tibialis anterior tendonitis, there are certain ways to minimize stress to the foot and ankle, such as choosing appropriate footwear, wearing custom shoe inserts, minimizing the amount of time spent standing on hard surfaces, and improving and maintaining strength in the muscles of your legs, ankles, and feet. In addition, early detection of tibialis anterior tendonitis signs will help you and your medical providers start the best management of the condition, which may increase your long-term well-being.
Below are a few exercises you can perform to help boost your recovery from the condition:
Heel-toe raises
Using the back of a chair or counter for support, lift the heels off the floor to stand on the toes. Hold for 5 seconds before slowly lowering back down to the floor. Repeat this exercise 15 times with two sets and a 30-second rest between each set. Once the injured foot becomes stronger, try standing on the injured foot only.
Calf stretch
Stand and face a wall with the hands placed on the wall at eye level. Next, take a lunge position by placing the injured foot slightly behind with the heel flat on the ground and the other leg slightly forwards with a bent knee. Turn the back foot inwards slightly. Then, gently lean towards the wall until there is a stretch in the back calf. Hold this position for 15-30 seconds, then repeat this method 3-4 times a day.
Balance exercise
Stand beside a chair, using it for support if needed, with the injured foot furthest from the chair. Stand on the injured foot and slightly bend the knee. Bend forward from the waist and reach forward with the hand furthest from the chair. Repeat this exercise 15 times with 2 sets.
Alternative & Homeopathic Treatment
The most recommended homeopathic treatment for your tibialis tendon injury includes the PRICE principle, which stands for Protect, Rest, Ice, Compression, and Elevation:
- Protect – In more severe cases, it is necessary to protect the damaged area. This may be done through the use of a walking boot or in some cases, a cast may be necessary to restrict movement completely which allows the nerve, joint, and surrounding tissues a chance to heal.
- Rest – In this case, rest would indicate tapering down from your regular exercise activity and discontinuing running.
- Ice – Apply ice to the affected area. The rule for icing is to apply ice no more than 20 minutes per hour.
- Compression – This helps prevent and decrease swelling. Swelling can cause increased pain and slow the healing response, so limit it as much as possible. A compression stocking can help to limit the amount of swelling and promote blood flow back out of the lower leg.
- Elevation – Depending on your pain level and the amount of swelling present, this step may be more or less beneficial.