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 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.

Assessment tests

Resisted dorsiflexion
  • 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?

What is Extensor tendonitis?

Extensor tendonitis - extensor muscles and tendons of the foot

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

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 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.

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.
  • 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

Self-help for extensor tendinopathy

  • 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.
  • Use a wet tea towel or 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, applying heat may be more effective.
  • 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.

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

  • As soon as normal walking is pain-free begin rehabilitation.
  • Perform stretching exercises initially, and later, strengthening exercises to strengthen the extensor muscles.
  • Make sure exercises are pain-free.
  • 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.

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 your toes are pulled outwards might indicate a stress fracture.
  • 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.

Extensor tendonitis exercises

Extensor tendonitis stretching exercises are most important.

Tibialis anterior stretching exercise
  • 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.
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

This article has been written with reference to the bibliography.

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