Tendon Terms & Anatomy
Tendon: a band of connective tissue that connects muscle to the 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 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. Tendinosis 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.
1. Achilles Tendonitis / Tendinosis
Achilles tendonitis is the most common type of tendonitis in the foot and Achilles Tendonitis is a common area of pain 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 Insertional Achilles Tendonitis area of painnodule on the back of the heel. This is Achilles tendinosis (tendinosis) 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 that involve quick sprints like basketball, soccer, or tennis can contribute to the development 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 squatting can cause tendonitis.
2. Posterior Tibial Tendonitis
The posterior tibial tendon starts at the inside of the leg and runs down the inside of the Area of pain in the posterior tibial tendonitisthe 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 micro tears, 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 flat feet. 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 instance. 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 Pronated position weight bearing 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 whilFlatfoot pictures with arch collapse and too many toes sign 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 at decreasing inflammation and taking stress off the tendon.
Stages of PTTD
peritonitis with possible tendon degeneration (deterioration). Alignment of the foot is normal with normal flexibility and mild discomfort and weakness. Treatment is conservative.
the 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 a considerable weakness of the tendon and moderate pain. Treatment starts with conservative therapies but may result in surgery (tendon transfers vs joint fusions).
the 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).
the 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 initiating 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 that can be self-treated with over-the-counter orthotics and icing, a visit to your doctor is necessary.
3. Peroneal Tendonitis
Peroneal tendonitis is another common tendonitis in the foot. The peroneal tendons are located on the outside of the ankle and inserted 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.
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.
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.
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.
Wear shoes with a heel:
The best shoes to take the stress off of the Dansko Shoe with rocker bottomAchilles 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 demonstrated 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.
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 on the right. When the 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 Plantarflexion motion image(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.
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.
Take anti-inflammatory medications:
Ibuprofen and Naproxen are two common anti-inflammatory medications that 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.