Extensor tendonitis is inflammation of the extensor tendons which run along the top of the foot. It is an overuse injury which is common in runners, especially if your shoes do not fit properly, or are laced too tight. Here we explain the symptoms, causes, and treatment of extensor tendonitis and tendinopathy.
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.
- A professional therapist may perform a resisted dorsiflexion test to help diagnose extensor tendonitis.
- This involves getting the patient to lift the foot and toes up against whilst they gently resist the movement.
- If this causes pain then the test is positive, therefore indicating potential extensor tendon injury.
What else could it be?
- 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.
What is Extensor tendonitis?
Extensor tendonitis is ‘inflammation’ of the extensor tendons. The term Extensor tendinopathy is probably a more accurate description of most injuries. This is because it also describes 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
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 a larger stress on the muscles. The extensor 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.
More on lower leg muscles
What causes Extensor tendinopathy/tendonitis?
Overuse is the direct cause. Repetitive strain causes the tendons to become inflamed and eventually degenerate. However, there are a number of factors which may increase your chances of injury. These include:
Wearing badly fitting shoes, especially with the laces tied too tightly. This causes excess pressure on the top of your foot.
More on Choosing running shoes
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.
Extensor tendonitis treatment
Treatment involves reducing initial pain and inflammation along with a program of stretching and strengthening exercises.
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.
Apply ice or a 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.
More on Cold therapy
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.
Replace running shoes after 400 miles of running, or 12 months. After this amount of wear the midsole starts to degrade.
Make sure you wear appropriate footwear, in particular, do not lace your shoes too tightly. Over-tightening the laces put direct pressure over the extensor tendons in the foot. It may help to try a different lacing pattern.
A doctor may prescribe anti-inflammatory medication such as ibuprofen. But do not take ibuprofen if you have 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.
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 a 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 tendon stretches
- The extensor muscles can be stretched 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 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.
- Stretching should be done at least once a day and depending on the individual three times a day may be recommended.
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.
- 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
- Extensor tendonitis research papers – Google Scholar