Extensor Tendonitis/Tendinopathy

Extensor tendonitis

Extensor tendonitis is inflammation of the extensor tendons which run along the top of the foot. It is an overuse injury that is common in runners, especially if your shoes do not fit properly, or are laced too tight.

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Extensor tendonitis symptoms

  • The main symptom of extensor tendonitis is pain on the top of the foot.
  • It is often described as an aching pain, which increases with exercise, in particular, running.
  • Symptoms are likely to develop gradually over time, becoming progressively worse.
  • You may have some diffuse swelling over the top of your foot.
  • Curling the toes may trigger pain because this places stress on the tendons by stretching them.

View other causes of pain on top of the foot.

Assessment tests

Resisted dorsiflexion

A professional therapist performs a resisted dorsiflexion test to help diagnose extensor tendonitis.

This involves getting you to lift your foot and toes up whilst they gently resist the movement. If this is painful then the test is positive, therefore indicating potential extensor tendon injury.

Injuries with similar symptoms:

Tibialis anterior tendonitis is a common form of extensor tendonitis. However, it often causes pain at the front of the ankle rather than across the top of the foot.

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What is Extensor tendonitis?

Extensor tendonitis - extensor muscles and tendons of the foot

Extensor tendonitis is the ‘inflammation’ of the extensor tendons. The term Extensor tendinopathy is probably a more accurate description of most injuries. This is because it also describes the degeneration of the tendon.

Pain from most long-term, chronic injuries is likely to be degeneration from wear and tear, not tendonitis. Studies have shown that long-term injuries usually do not have inflammatory cells present.

The extensor muscles

Foot extensor muscles

The extensor tendons run along the top of the foot and connect the muscles in the lower leg to the foot bones. When your muscles contract, they cause your foot and toes to move upwards. This movement is known as dorsiflexion.

When you walk the muscles work to lift your foot up, but also work eccentrically as you place your foot down.

An eccentric muscle contraction occurs when your muscle contracts at the same time as it lengthens. This places larger stress on the muscles. The muscles contract eccentrically when running downhill.

  • The extensor hallucis longus muscle connects to the big toe/great toe via the tendon (hallucis meaning big toe in latin).
  • The extensor digitorum longus connects to the other four toes (digitorum means digits, fingers, or toes in latin).
  • Other tendons in the foot which also lift the foot up are the tibialis anterior tendon and the extensor hallucis brevis.

Extensor tendonitis causes

Overuse is the direct cause. Repetitive strain causes the tendons to become inflamed and eventually degenerate. However, there are a number of factors that may increase your chances of injury. These include:

Footwear

Wearing badly fitting shoes, especially with the laces tied too tightly. This causes excess pressure on the top of your foot.

Training

A sudden change in training, particularly running uphill. Running on a treadmill means you can run for long periods on an incline.

When you run uphill you have to lift your foot higher than normal, therefore resulting in higher stresses through the extensor muscles and tendons.

Running downhill the muscles work eccentrically which again places stress on the extensor tendons as can running on ice or slippery surfaces.

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Extensor tendonitis treatment

Treatment involves reducing initial pain and inflammation along with a program of stretching and strengthening exercises.

Rest

Rest until the pain has gone. Continuing to train when the foot is painful will only make the injury worse and delay the healing.

If your injury becomes chronic or the tendon degenerates then healing will take much longer.

Cold therapy

Apply ice or cold therapy and compression wrap for 10 minutes every hour initially, reducing the frequency as your symptoms improve over the next 48 hours.

Do not apply ice directly to the skin as it may cause ice burns.

Wrap ice in a wet tea towel, or use a cold therapy and compression wrap.

Heat

Once the initial painful acute stage has passed, applying heat may be more effective. In the early stages when you most likely have acute inflammation, ice will help reduce this.

However, for more chronic injuries where acute inflammatory cells are not likely to be present, heat may be more suitable.

Footwear

Make sure you wear appropriate footwear, in particular, and do not lace your shoes too tightly. Over-tightening the laces put direct pressure on the extensor tendons in the foot. It may help to try a different lacing pattern. Or consider wearing elastic laces which allow your foot to expand.

Replace running shoes after 400 miles of running, or 12 months. After this amount of wear the midsole starts to degrade.

Medication

A doctor may prescribe anti-inflammatory medication such as ibuprofen for Extensor tendonitis. But do not take ibuprofen if you have asthma.

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Injections

If it is a long-term problem, a steroid injection may be given although repeated injections to tendons can weaken them. In very rare cases surgery is performed.

See a sports injury professional

A professional therapist will assess your foot and confirm the diagnosis, in particular, ruling out the possibility of a metatarsal stress fracture.

Often pain on passive stretching indicates tendinitis, but pain, when your toes are pulled outwards might indicate a stress fracture.

Extensor tendonitis exercises

As soon as you can walk normally without pain, you can begin rehabilitation exercises. Perform stretching exercises initially, and later, strengthening exercises to strengthen the extensor muscles.

Extensor tendonitis stretches

Tibialis anterior stretching exercise

The extensor muscles can be stretched by kneeling down with the feet pointing backwards. Aim to flatten the ankles towards the floor to stretch the extensor muscles. You should feel a gentle stretch at the front of your ankle.

A more advanced version is to lift the knees upwards increasing the stretch. Hold the stretch for 10 to 15 seconds, relax and repeat once or twice more.

Perform extensor tendonitis stretches at least once a day, but three times a day is recommended.

Strengthening

Because this is often an overuse injury, doing too much too soon may increase the chances of your injury recurring, rather than achieving the opposite result.

Toe raise exercise
  • Strengthening exercises should always be done pain-free and very gently to begin with.
  • Toe raises will work the extensor muscles and involve simply lifting the foot up and down repeatedly.
  • Avoid overdoing it, especially if you resume normal training.
  • Running alone will work the extensor muscles, so overloading them through exercises before a run is not advised.

References & further reading

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