Tendonitis Ankle, also known as peroneal tendonitis, is a condition related to the tendons present in the muscles of the ankle. These tendons are strong string-like tissues that attach the muscles of the lower leg and the foot, making the movement of the ankle possible in directions similar to any hinged synovial joint. Most issues related to pain in the foot or ankle(1) are most commonly related to tendonitis. It is not unusual to confuse the term tendonitis, which refers to the swelling that occurs in and around the tendons. Such type of inflammation has the tendency to cure on its own with rest, but it can pinpoint a severe orthopedic condition if the pain persists and is left untreated.
Achilles Tendon is one of the few tendons that are located in the lower leg of the human body. This is located at the back of the leg that contains two muscles namely the gastrocnemius muscle and the soleus muscle. Both these muscles are connected with each other and at the bone with the help of the Achilles tendon.(2) The insertion point, in this case, is the heel bone or the calcaneus. This exactly is the same tendon that allows muscular and bone movement and enables “jumping”.
Tendon injuries in this tendon are very commonly seen, especially in people who play sports or are athletic. The injury point is usually the point of attachment of the bone and the muscle with this tendon. The injury at this point has a good healing rate although the blood supply is usually smaller as compared to the rest of the skeletal muscles in the body. The most common cause of this condition is found to be high-impact sports and overuse of the calf muscles affecting this tendon.
Ankle tendonitis forms one of the four possible tendinitis conditions which can be either dorsal tendonitis which is related to the foot, lateral tendonitis which is linked with the pinky toe, medial tendonitis which is related to the big toe, and lastly the posterior tendonitis which reflects the attachment of the tendon with the ankle.(3) The condition might also become chronic if retrocalcaneal bursitis remains untreated.
Posterior Tibial Tendonitis – Inner Ankle
When discussing ankle tendonitis, it is important to understand the anatomy of the lower leg and how each muscle linked with the ankle attaches to the ankle bone. There is a muscle called the tibialis posterior located in the deepest area of the leg. It terminates on the inside of the ankle bone and is the most commonly regarded area of pain in this condition. Posterior tibial tendonitis is also known as flat feet. People with flat feet can sometimes be born with too many toes on each foot, which is a prominent sign of this type of tendonitis. The term too many toes actually mean that four of the foot toes can be visible from behind the leg or ankle, making it look like the person has more than five toes.
Peroneal Tendonitis – Outer Ankle
This type of tendonitis refers to the swollen tendon that attaches to the outer side of the ankle. The outer side is the place where the little pinky toe of the foot is located. If a person has this condition, the pain and swelling are observed on the outer ankle side just above and below the ankle, making it extremely difficult to walk because of the severity of the pain. There is a small pointed bone called the styloid process attached to one of the metatarsals, which are mini bones in the ankle. The styloid process linked with the fifth metatarsal bone presents with pain when this type of tendonitis(4) occurs.
Flexor Tendonitis – Inner Back Ankle
This type of tendinitis is accompanied by pain at the back of the ankle but on a deeper level. This pain arising from the depth of the ankle usually occurs in dancers, gymnasts, and people who are involved in activities that require balancing on the toes with the help of the ankle joint. Ankle sprains are observed in these types of balancing activities, but if the ankle injury is severe, it can lead to tendon tears and even immobilization for a certain period of time.
Extensor Tendonitis – Foot Top
This tendinitis is observed in the tendons which are located above the foot and have insertion, again, at the ankle joint. Since it is on the foot top, even closed shoes can cause it. People suffering from rheumatoid arthritis often show complaints of extensor tendonitis.
Physical therapy is the most used treatment option when it comes to ankle tendonitis, but there are other treatment options available too. Patients with this condition usually end up discouraged after the physical therapy sessions, but if the condition is severe the physician might recommend other forms of therapy. For example, the use of orthotics or braces in this condition can treat the pain permanently, or at least comparatively for a longer time. The brace is called the Ankle Foot Orthotic or AFO; it holds the muscle and the bone in such a position that allows the tendon to relax and take its time to heal. The healing time is usually 6 months but if the improvement is not seen, the last option is surgery.
Causes of Tendonitis Ankle
People who are aged 40 and above are usually prone to this disease condition. Stretching before strenuous exercise is often recommended by a wrong range of motions and repetitive movements often result in tendon damage. Diseases like arthritis, gout, and diabetes can trigger inflammation of the ankle tendons. Having high arches on the foot is yet another risk factor for this condition. Some people have naturally tight tendons and have a risk of developing this condition. Smokers and people who are overweight also are at higher risk of Tendonitis.
Ankle tendonitis involves the bones like the tibia and fibula that end up on the ankle joint and also all the muscles and tendons that are associated with the attachments on the ankle top and bottom. In short, all the activities and lifestyles that promote the overuse of this tendon can cause sprain, tendon rupture, and lead to acute ankle injury.(5)
Symptoms of Tendonitis Ankle
The most common symptoms of tendonitis(6) ankle include:
- Pain in the ankle that can be sideways or on the top or bottom of the ankle (the pain is often sharp, intense, and snapping in nature)
- Swollen foot top and swollen ankle
- Redness and warm skin around the ankle area, showing inflammation
- Thickened/swollen tendons, often accompanied by a movable mass of nodules around the ankle joint
Diagnosis of Tendonitis Ankle
There are more than 60% of people worldwide, who are often misdiagnosed when the real cause of pain in the foot is the ankle tendonitis condition. The initial step of diagnosis is a physical exam, where the physician checks for the sign of inflammation i.e. swelling and redness. Visual examination is followed by questions from the patient about how the patient feels like and what type of history and lifestyle the patient has.
After the physical exam, there are a certain series of tests to confirm the diagnosis. Simple ankle sprains do not need a radiological exam. Magnetic Resonance Imaging (MRI) gives a good insight into the number and intensity of fractures and injuries in the ankle. X-ray images are usually recommended first, but it is only useful for hard tissues. If the doctor suspects damage in the soft tissues like tendons and ligaments, magnetic resonance imaging provides adequate information to confirm the diagnosis.(7)
Treatment of Tendonitis Ankle
All types of tendinopathies are usually treated with more or less similar strategies. The tiptoes also contain tendons that are indirectly linked with the ankle joint so the treatment basically focuses on treating the tendon pain. The patients are often referred to podiatrists and physical therapists to improve their range of motion and decrease the intensity of pain. Such therapies have proven to decrease the time of recovery and the patient is able to get back on foot in a shorter period.(8)
RICE method is yet another option recommended by orthopaedic surgeons if invasive interventions are unnecessary. Medications along with the RICE method are the highly adopted first-line treatment(9) for this disease. Applying heat, and cold ice packs can ameliorate the pain. Compression and elevation and very useful when the patient is recommended rest for the healing of the tendon. Medications include NSAIDs, like ibuprofen which is the least interactive drug among the effective pain killers. Anti-inflammatory medications are a better option when it comes to pain in the soft tissues. Paracetamol is not as effective as NSAIDs in this case of ankle pain, and opioids are not recommended. In case the inflammation is not managed well, steroid injections are another alternative to speed up healing effectively.
The healthcare provided to ankle tendonitis patients has advanced today and newer technologies for chronic pain management, like shockwave therapy, are also available. Braces and surgery are the last options if the other methods do not work. The orthopaedic surgeon will confirm the condition of the tendons and if the immobilization technique is rendered ineffective, the patient is immediately referred to the surgical option.
Frequently Asked Questions
How do you treat tendonitis in the ankle?
Tendonitis is not treated much differently when it occurs in the ankle. The initial treatment is pain management through the RICE method and rest. Medications like NSAIDs are recommended to the patient. If the tendonitis is severe, other options like braces and surgery are also available.
What does tendonitis feel like in the ankle?
Ankle tendonitis occurs with pain in the ankle sides, front, or back. The pain sensation is snapping, sharp and intense in nature. Other visual symptoms include redness and swelling around the ankle joint.
How long does it take for tendonitis in the ankle to heal?
Tendonitis in the ankle usually takes around six months to heal itself. If the injury is severe, the tendonitis might not heal on its own and requires many intense and invasive procedures for treatment.
Can you walk with ankle tendonitis?
Ankle tendonitis occurs because of overuse of the ankle. Balancing activities and all movements that involve the ankle should be avoided in this condition. The physician recommends rest for faster healing and to avoid aggravating the pain associated with this injury.
What is the fastest way to heal tendonitis in the ankle?
The fastest way to heal tendonitis in the ankle is to give rest a top priority. Tendonitis is caused by overuse of the ankle joint and rest is the only solution. If tendonitis occurs because of secondary reasons, like osteoarthritis, the root cause should be treated and managed side by side.
How do you know if you have tendonitis in your ankle?
If there is redness, swelling, and pain in or around your ankle, there are chances you have tendonitis. If you are regularly involved in high-impact sports or body balancing activities like dancing, you are at risk of developing Tendonitis. Your doctor will conduct physical and radiological exams which will confirm if you have ankle tendonitis or not.
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- Davda, K., Malhotra, K., & O’Donne, P. (2017). Peroneal tendon disorders. Efort Open Reviews. https://eor.bioscientifica.com/view/journals/eor/2/6/2058-5241.2.160047.xml
- Wang, X.-T., Rosenberg, Z. S., Mechlin, M. B., & Schweitzer, M. E. (2005). Normal Variants and Diseases of the Peroneal Tendons and Superior Peroneal Retinaculum: MR Imaging Features. RadioGraphics, 25(3), 587–602. https://doi.org/10.1148/rg.253045123
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- Schafer, K. A., Adams, S. B., & McCormick, J. J. (2020). Peroneal Tendonitis and Tendonopathy. The Peroneal Tendons, 183–191. https://doi.org/10.1007/978-3-030-46646-6_9
- Sinha, P., Kim, A., Umans, H., & Freeman, L. M. (2000). Scintigraphic Findings in Peroneal Tendonitis: A Case Report. Clinical Nuclear Medicine, 25(1), 17. https://journals.lww.com/nuclearmed/Abstract/2000/01000/Scintigraphic_Findings_in_Peroneal_Tendonitis__A.4.aspx
- Slater, H. K. (2007). Acute Peroneal Tendon Tears. Foot and Ankle Clinics, 12(4), 659–674. https://doi.org/10.1016/j.fcl.2007.07.008
- McLennan, J. G. (1980). Treatment of acute and chronic luxations of the peroneal tendons. The American Journal of Sports Medicine, 8(6), 432–436. https://doi.org/10.1177/036354658000800609