Extensor Tendonitis/Tendinopathy

Extensor Tendonitis

Extensor tendonitis, also referred to as extensor tendinopathy is inflammation or degeneration of the extensor tendons which run along the top of the foot. Symptoms include pain on top of the foot which becomes worse during activity. Causes include overuse and even badly fitted or too tight shoes. Treatment involves rest, application of cold therapy during the acute stage, followed by a full rehabilitation program.

On this page:

  • Symptoms
  • Causes & anatomy
  • Treatment

Extensor tendonitis symptoms

Symptoms of extensor tendonitis consist of pain on the top of the foot which is made worse during running and is relieved with rest. Pain is likely to occur gradually over time through overuse with the athlete complaining of an aching pain on the top of the foot. There may also be some diffuse swelling over the top of the foot.

Symptoms may also be felt when the tendons are stretched by curling the toes. One assessment test is resisted dorsiflexion where the therapist resists the athlete attempting to pull the foot upwards. If the pain is triggered then the extensor tendons are likely to be involved.

Extensor tendonitis causes & anatomy

Extensor tendonitis - extensor muscles and tendons of the foot

The extensor tendons run along the top of the foot and when the extensor muscles contract they cause the foot and toes to move upwards. 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, or extensor tendinopathy as it is probably better known amongst the medical profession, is one of the most common causes of pain on top of the foot. Repetitive strain from overuse can cause the tendons to become inflamed or degenerate. The term tendonitis implies inflammation of the tendon (itis meaning inflammation) whereas tendinopathy is probably a more accurate term as in most cases acute inflammatory cells are not present. Tendinopathy is a general term which includes degeneration of the tendon rather than acute inflammation.

Tibialis anterior tendonitis is most common with symptoms of pain across the front of the ankle as opposed to pain across the top of the foot. Extensor tendonitis is usually caused by overuse. Badly fitting shoes or shoes that are laced too tightly causing pressure on the top of the foot can cause inflammation of the tendons. A change in training methods, particularly running uphill, particularly on a treadmill can also place more stress on the extensor tendons at the top of the foot.

Running uphill means the foot has to be lifted slightly higher on each stride. Running downhill the muscles work eccentrically which again places stress on the extensor tendons as can running on ice or slippery surfaces.

Extensor tendonitis treatment

What can the athlete do about inflamed extensor tendons?

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 it becomes chronic or the tendon degenerates then healing will take much longer. Apply a cold therapy and compression wrap.

Apply ice or cold therapy for 10 minutes every hour initially, reducing the frequency as required over the next 48 hours. Ice can be applied in a wet tea towel or ideally with a re-useable cold therapy and compression wrap. Do not apply ice directly to the skin as it may burn. Read more on PRICE principles.

Once the initial painful acute stage has passed, the application of heat may be more effective. Ensuring footwear is appropriate and in particular the shoes are not laced too tightly may also help. Over-tightening the laces put direct pressure over the extensor tendons in the foot. It may help to try a different lacing pattern. Running shoes are usually good for 400 miles of running and after this period should be replaced. Read more about choosing running shoes.

When all pain has gone, a full rehabilitation program to strengthen the extensor muscles should be done. These should always be done pain-free and with care. Because this is often an overuse injury, doing too much too soon may increase the chances of the injury recurring rather than achieving the opposite result.

Toe raise exercises which lift the foot up and curl the toes back will work the foot extensor muscles. These should be done in the seated position initially and will also work other muscles of the lower leg and shin.

What can a sports injury specialist or doctor do?

A professional will assess the injury and confirm the diagnosis, ruling out the possibility of a metatarsal stress fracture. Often pain on passive stretching indicates tendinitis, but a pain when the toes are pulled outwards might indicate a stress fracture.

A doctor may prescribe anti-inflammatory medication such as ibuprofen although this should not be taken if the patient has asthma. 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.

Extensor tendonitis exercises

Extensor muscles stretching exerciseExtensor tendonitis stretching exercises are done by kneeling down with the feet pointing backward. Aim to flatten the ankles towards the floor to stretch the extensor muscles. You should feel a gentle stretch at the front of the 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. Stretching should be done at least once a day and depending on the individual three times a day may be recommended.

Toe raise exerciseStrengthening 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 tiring them out before a run is not advised.

This article has been written with reference to the bibliography.