The Most Common Tendon Problems of the Foot and Ankle: A Comprehensive Guide: Part 1

sarangndesai
3 days ago
29 min read

The most common foot and ankle tendon problems explained by a fellowship-trained orthopedic surgeon: Achilles, peroneal, posterior tibial, FHL. Diagnosis to surgery.

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THE MOST COMMON TENDON PROBLEMS OF THE FOOT AND ANKLE

A Comprehensive Guide From a Fellowship-Trained Orthopedic Foot and Ankle Surgeon

By Sarang Desai, DO — Fellowship-Trained Orthopedic Foot and Ankle Surgeon

Sports Medicine | McKinney and Flower Mound, Texas

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THE SHORT ANSWER

Five tendons cause the overwhelming majority of foot and ankle tendon pain:

1. Achilles — back of the heel and lower calf

2. Peroneal — outside of the ankle, behind the fibula

3. Posterior tibial — inside of the ankle, arch collapse

4. Tibialis anterior — front of the ankle and top of the midfoot

5. Flexor hallucis longus (FHL) — behind the inside of the ankle, big toe

The single most important concept in this entire article: most of these are not "tendonitis." Tendinopathy refers to tendon degeneration without substantial inflammation — a failed healing response, not an inflammatory one.[1][2]

That's not a technicality. It's why anti-inflammatories disappoint, why rest alone fails, and why loading the tendon with progressive strength work is the single best-evidenced treatment across virtually every tendinopathy studied.[3][4]

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I see a version of this conversation several times a day in McKinney and Flower Mound. Someone comes in having been told they have "tendonitis," having rested for three months, taken ibuprofen, and gotten nowhere — and they're frustrated because resting is supposed to work.

It didn't work because rest doesn't fix a degenerated tendon. Let me explain what's actually happening.

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PART 1: WHY TENDON PROBLEMS HAPPEN

Tendons are built for a specific job — and it's a demanding one.

Tendons have a complex biology that provides a unique combination of strength, flexibility, and elasticity — and that same design predisposes them to injury.[2]

The foot and ankle are especially vulnerable because the biomechanics are intricate. These tendons are responsible for energy absorption and transfer during propulsion, stability during stance, and proprioception. When the mechanics go wrong, the result is connective tissue changes and altered muscle function.[1]

"Tendinitis" vs. "tendinopathy" — why the word matters

The term tendinopathy is preferred to tendinitis because what's present in the pathologic tendon is a disordered, degenerative healing process — not inflammation.[2]

Tendinopathy is best understood as a failed healing response of the tendon.[5]

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Think of it less like a sprained ankle that's swollen and angry, and more like a frayed rope. Ice and ibuprofen don't repair a frayed rope. Controlled, progressive load does — that's how tendon remodels.[5]

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Why it happened to you

The cause of tendinopathy is usually multifactorial, involving both intrinsic and extrinsic risk factors.[1]

Intrinsic (things about you):

- Age — tendon quality declines

- Foot shape — a high arch and varus hindfoot loads the peroneals; a flat, pronated foot loads the posterior tibial tendon

- Body mass index, hypertension, diabetes, collagen vascular disease[6]

- Prior corticosteroid exposure[6]

- Areas of relative hypovascularity in the tendon[6]

Extrinsic (things you did):

- A change in activity — this is the classic history. Most patients report that a change in activity affected the use of the tendon.[2]

- New mileage, new sport, new shoes, new job

- Hard court surfaces — highly relevant for the pickleball surge across DFW

The most common story I hear: "I started pickleball four months ago." Not because pickleball is dangerous, but because a previously sedentary tendon was suddenly asked to do lateral push-off on concrete three times a week.

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PART 2: A MAP OF YOUR ANKLE — LOCATING THE PROBLEM BY PAIN LOCATION

Where it hurts tells you which tendon it is roughly 80% of the time.

Where it hurts	Likely tendon	What it does	Classic tip-off
Back of heel / lower calf	Achilles	Plantarflexion, push-off	Morning stiffness; pain 2–6 cm above the heel[7]
Outside of ankle, behind the fibula	Peroneal brevis/longus	Eversion, lateral stability	Often mistaken for a lingering ankle sprain[8]
Inside of ankle, into the arch	Posterior tibial	Supports the arch, inverts	Arch collapsing; "too many toes" sign[8]
Front of ankle / top of midfoot	Tibialis anterior	Lifts the foot	Positive passive stretch test[8]
Behind the inside of the ankle, into big toe	Flexor hallucis longus	Bends the big toe	Pain with big toe motion; dancers, but not only dancers[9]
Bottom of heel	Plantar fascia (not a tendon)	Arch support	First-step morning pain[7]

The anatomy, briefly:

- The peroneal tendons run immediately posterior to the lateral malleolus. Both evert the ankle and can be injured with ankle inversion — which is exactly why they get hurt in sprains.[10]

- The posterior tibial tendon runs posterior to the medial malleolus, inserting on the navicular and beyond. It is the main dynamic stabilizing tendon of the medial longitudinal arch, absorbing shock at heel strike, stabilizing at midstance, and generating force at toe-off.[10]

- The anterior tibialis tendon runs lateral to the anterior tibia, under the inferior extensor retinaculum, to insert on the medial cuneiform and first metatarsal.[10]

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PART 3: THE ACHILLES TENDON

The biggest, strongest tendon in the body — and the one I treat most.

Achilles tendinopathy

Achilles tendinopathy is one of the most common painful foot and ankle conditions overall.[11] Midportion Achilles tendinopathy presents with pain approximately 2 to 6 cm proximal to the Achilles insertion on the heel.[7]

That distance matters enormously, because insertional disease (right at the heel bone) and midportion disease (2–6 cm up) respond to different treatment. Insertional disease tolerates stretching poorly and often needs a heel lift rather than a drop stretch. Full breakdown here: Insertional vs. Midportion Achilles Tendinopathy: What's the Difference?

The treatment that actually works: loading.

Eccentric strengthening should be considered for all patients with Achilles tendinopathy. In eccentric exercise, the muscle-tendon unit lengthens under load while contracting.[12]

The protocol I prescribe, straight from the evidence: stand on a step with all weight on the ball of the affected foot in plantarflexion, slowly lower the heel below the forefoot, then use the uninjured leg to return to the start. Three sets of 15, twice daily — first with the knee straight, then repeated with the knee slightly flexed.[12]

The results justify the tedium. In a trial of 40 patients, the eccentric group improved on the VISA-A score from a mean of 60.7 at baseline to 89.4 at one year (P<.001), against a minimal clinically important difference of 7.37.[12] Adding concentric exercise provided no additional benefit at one year.[12]

Broader confirmation: loading exercise therapies by far surpass non-loading therapies or a wait-and-see policy, and 12 weeks of concentric or eccentric strength training combined with reduced sport load is the best-evidenced treatment — even when intensity is reduced from 80–90% of 1RM down to 55%.[3]

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A detail I emphasize with athletes: you do not have to stop your sport completely. Limiting activity to a self-monitored pain level between 2 and 5 out of 10 did not limit improvement during strength training treatment.[3]

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Exercise specifics: Best Exercises for Achilles Tendon Pain — and Which Ones to Avoid

What does not work as well as patients hope:

- NSAIDs. Neither naproxen at 3 months nor piroxicam at 1 month showed significant benefit over placebo when added to physical therapy, and topical 10% diclofenac showed no benefit over placebo over four weeks. Separate work found no effect of oral NSAIDs in either late or early stage Achilles and patellar tendinopathy.[13][3]

- PRP. Well-controlled studies have shown no significant effect of PRP treatment for tendinopathy. Also see: The Real Science Behind Peptides and Healing Orthopedic Injuries [3]

What has reasonable support:

- Extracorporeal shockwave therapy (ESWT). A meta-analysis of 8 randomized trials (442 patients) found ESWT associated with greater improvement in AOFAS (SMD 1.35; 95% CI 0.24–2.41; P=.01) and VISA-A scores (SMD 1.53; 95% CI 0.69–2.37; P=.0003) — though the VISA-A difference was less than the MCID, and improvement showed no decay beyond 6 months.[13]

- Night splinting or a dual-bladder compression brace produced functional improvement similar to eccentric training, useful for patients who can't perform eccentrics.[12]

- Combining eccentric training with shockwave produced higher success rates than either alone.[5]

Achilles rupture — a different animal entirely

Tendinopathy progresses to rupture in about 4% of cases, most commonly in older adults.[14]

Exam findings that distinguish a tear from a strain: a palpable gap or visible indentation at the distal tendon, an abnormal lump at the posterior ankle, limited plantarflexion with calf squeeze (Thompson test), and increased passive dorsiflexion.[14]

A gap measurement of ≥5 mm during dorsiflexion in active individuals, or ≥10 mm in sedentary individuals, should prompt surgical evaluation. Rerupture rates run[14] 0.6% to 3.5% with surgical repair, depending on technique.[14]

Deeper dives: Achilles Tendon Rupture Surgery: The Complete Guide · When Do You Need Surgery for an Achilles Tear? · Can You Walk on a Torn Achilles Tendon?

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PART 4: THE PERONEAL TENDONS

The most frequently missed tendon problem in the ankle.

Why they get missed. Peroneal tendon disorders are commonly mistaken for, or occur alongside, lateral ankle sprains. They are frequently missed and are a genuine source of lateral ankle pain.[8][15]

They should be considered in every patient with chronic lateral ankle pain.[14]

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The pattern that should raise suspicion: an "ankle sprain" that is still hurting on the outside of the ankle three months later. That is often a peroneal tendon tear, not a slow-healing ligament.[8][14]

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Two distinct problems, two different treatments:

Tendinopathy and tears. These result from trauma including ankle sprains, from preexisting tendinopathy, or from repetitive microtrauma due to instability. The brevis and longus are rarely torn simultaneously.[14] Varus hindfoot is a known risk factor.[8]

Nonoperative care: immobilization, laterally posted orthotics, and physical therapy for progressive tendon loading.[8] Peroneal tenosynovitis typically responds to conservative therapy, with surgery reserved for refractory cases.[15]

When surgery is needed, the decision hinges on how much viable tendon remains:

- Tears involving <50% of the tendon → primary repair and tubularization[15]

- Tears involving >50% → tenodesis[15]

Subluxation and dislocation. Different mechanism entirely — usually forceful peroneal contraction during sudden dorsiflexion while landing or stopping abruptly.[15]

This one is more surgical by nature. Operative treatment is frequently required, consisting of anatomic repair or reconstruction of the superior peroneal retinaculum, with or without deepening the retromalleolar groove. In athletes, surgery is often immediately indicated for recurrent symptomatic subluxation or dislocation.[15]

Results are good. In 18 patients treated with modified fibular groove deepening plus SPR repair, VAS and AOFAS-hindfoot scores improved significantly, all incisions healed without complication, and all patients recovered their pre-injury gait.[16]

Anatomic variants that predispose you. Worth knowing, because they explain why this happened to you and not your training partner: a flat or convex retromalleolar groove, hypertrophy of the peroneal tubercle, an accessory peroneus quartus muscle, a low-lying peroneus brevis muscle belly, and an os peroneum.[14]

Detail: Peroneal Tendon Tears and Surgery: A Complete Guide · Peroneal Tendon Injuries: Causes, Symptoms, Treatment and Recovery

The link people miss: repetitive microtrauma from instability drives peroneal injury.[14] If your ankle keeps rolling, fixing the tendon without addressing the instability is treating the symptom: Chronic Ankle Instability Surgery: A Surgeon's Complete Guide

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PART 5: THE POSTERIOR TIBIAL TENDON (PTTD)

The tendon whose failure changes the shape of your foot.

This is the one where delay has real structural consequences. The posterior tibial tendon is the main dynamic stabilizer of the arch.[10] When it fails, the arch goes.

Presentation: medial ankle pain, pes planovalgus deformity (flatfoot with the heel drifting outward), and a positive "too many toes" sign — when viewed from behind, you see more toes on the affected side because the foot has rotated out.[8]

Who gets it. Overuse and overload in the setting of hypovascularity, high BMI, hypertension, diabetes, collagen vascular disease, corticosteroid exposure, and excessive pronation. It is common in women with obesity between 40 and 60 years of age.[6]

The exam test I use in every case: single-limb heel raises. The patient should be able to perform 5 to 10 single-limb heel raises without difficulty. Swelling and tenderness are typically found along the tendon proximal to its navicular insertion, and pain or weakness is reproduced with resisted inversion of a plantarflexed foot.[14]

If you cannot do a single heel raise on one leg, that is a meaningful finding and worth an evaluation.

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The warning that matters most: untreated posterior tibial tendinopathy may progress to or worsen a painful flatfoot, requiring extensive surgical reconstruction.[14]

Early flexible dysfunction is a tendon problem. Late rigid deformity is a bone and joint reconstruction. Those are enormously different operations.

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Nonoperative treatment:

- Acute phase: ice, NSAIDs, activity reduction[14]

- Support the medial longitudinal arch — taping, orthotics, or a brace with an air cell to lift the arch[14]

- Walking boot immobilization for severe acute cases[14]

- Eccentric exercises are recommended over concentric[14]

The orthotic evidence is supportive but modest. A systematic review of 4 RCTs (186 subjects) found orthotic treatment may be effective in reducing pain in early-stage PTTD, with foot orthoses plus exercise programs outperforming orthoses alone, and personalized internal longitudinal arch support more effective than flat insoles or standard treatment. The authors noted 75% of trials were at high risk of bias for blinding and called for further research.[14]

When surgery: considered when three to six months of nonoperative treatment is ineffective, with the procedure based on the specific stage of disease.[8][14] Staging traditionally follows the Johnson and Strom classification, the first system to categorize PTTD.[6]

More: Posterior Tibial Tendon Dysfunction (PTTD)

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PART 6: THE TIBIALIS ANTERIOR TENDON

Less common, easy to miss, and prone to a specific silent failure.

Presentation: anterior ankle and medial midfoot pain, diagnosed with a positive tibialis anterior passive stretch test.[8]

Treatment: initial immobilization followed by physical therapy, with surgical debridement considered if nonoperative care fails.[8]

The version that gets missed: a spontaneous tibialis anterior tendon rupture, which typically occurs in patients over 45 and often presents not with pain but with a subtle foot drop, a slapping gait, or catching the toes on carpet. Because there may be little pain, patients often attribute it to weakness or aging. A visible lump at the front of the ankle with an inability to actively lift the foot deserves prompt evaluation.

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PART 7: FLEXOR HALLUCIS LONGUS (FHL) — "DANCER'S TENDINITIS"

The tendon most commonly diagnosed late, and the one whose reputation is misleading.

FHL tendonitis has historically been described mostly in dancers and other athletes. But a study of 656 patients treated in a foot and ankle division found it is more common than previous evidence suggests and frequently occurs in nonathletes.[9]

The most important line in that study, and the reason it's in this article:

Most patients had been previously seen by orthopedic providers who had not appreciated the condition, leading to a delay in diagnosis of more than a year in many cases.[9]

Diagnosis hinges on tenderness anywhere along the tendon — most frequently at the fibro-osseous tunnel behind the medial ankle. Pain with big toe motion, particularly with the ankle in plantarflexion, is characteristic.[9]

Treatment works, and it's specific. With nonoperative treatment focused on a specific FHL stretching program plus immobilization in more severe cases, 44% of patients (180 of 409) decided surgery was unnecessary.[9]

Completing the stretching program was strongly protective against needing surgery (OR 0.15; 95% CI 0.08–0.27; P<0.001). Surgery was more likely in patients with clinical hallux rigidus (OR 2.4) or posteromedial ankle pain (OR 1.78).[9]

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The lesson: a generic ankle stretching program will not fix this. A tendon-specific stretching program cut the surgery rate dramatically. Which tendon you're stretching matters.[9]

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PART 8: HOW THESE ARE DIAGNOSED

The exam does most of the work.

For peroneal disorders specifically, MRI is the standard radiographic method — but diagnosis and treatment are based primarily on history and physical examination. That principle holds across foot and ankle tendon problems.[15]

Diagnosis is typically based on history and exam findings, with radiography an acceptable initial imaging modality, and ultrasound or MRI useful when the diagnosis is unclear.[2]

What each study contributes:

Study	Best for	Limitations
X-ray	Bone spurs, calcific insertional tendinopathy, calcaneal avulsions, os peroneum, alignment, arthritis	Cannot see tendon substance[14]
Weight-bearing X-ray	Arch collapse and hindfoot alignment in PTTD	Static only
Ultrasound	Tendon structure, dynamic assessment of subluxation, hyperemia and fluid in acute tendinitis; guided injection	Operator-dependent[14]
MRI	Tear location and extent, tenosynovitis, associated cartilage or bone pathology; confirms extent of Achilles injury	Static; can over- or under-call partial tears[14], [15]

Why I value ultrasound for one specific question. Subluxation is a dynamic problem — the tendon snaps out of its groove during motion. An MRI with your ankle lying still may look normal. High-resolution ultrasound with dynamic imaging is specifically noted as adequately depicting peroneal tendons and aiding management.[14]

Where I use MRI decisively: deciding <50% vs. >50% tendon involvement in a peroneal tear, because that threshold determines repair versus tenodesis.[15] For patients wanting to understand the strengths of each modality, the same logic is laid out in detail here: How Lisfranc Injuries Are Diagnosed: X-ray vs. CT vs. MRI

Conditions I make sure to rule out, because they mimic tendon pain:

- Stress fracture — Stress Fractures of the Foot and Ankle

- Cartilage lesion of the talus — deep joint pain, catching: Ankle Cartilage Injury (Osteochondral Lesion of the Talus)

- Nerve pain — Morton neuroma causes burning pain in the ball of the foot with numbness radiating to the third and fourth toes: Morton's Neuroma [11]

- Plantar fasciitis — over 1 million US patient visits per year, presenting with plantar heel pain: Plantar Fasciitis: Causes, Symptoms, Treatment and Recovery [11]

- Ankle arthritis — Ankle Arthritis Treatment in DFW: What the 2026 AAOS Guidelines Mean for You

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PART 9: TREATMENT — WHAT WORKS, RANKED

Tier 1: The foundation (do these).

The mainstays are activity modification, relative rest, pain control, and protection, with early initiation of rehabilitative exercise emphasizing eccentric loading.[2]

A systematic review of systematic reviews reached the clearest possible verdict: exercise therapies, particularly eccentrics, appeared to be the most consistently effective treatment across all tendinopathies. Eccentric overloading in chronic Achilles tendinopathy produced a 29%–94% decrease in pain intensity, and heavy eccentrics may outperform traditional physiotherapy.[4]

One caveat worth stating honestly: one review raised the possibility that eccentric exercise is more beneficial for athletic than non-athletic populations with Achilles tendinopathy.[4]

Also foundational, and unglamorous: immobilization in a boot for severe acute cases, orthotics matched to your foot shape (arch support for posterior tibial, lateral posting for peroneal), and footwear change.

Tier 2: Reasonable adjuncts.

- ESWT — good evidence in Achilles, an alternative to eccentrics with similar pain reduction; combining it with eccentric training beats either alone[4][5][13]

- NSAIDs, short-term — despite the absence of histologic inflammation, short-term use reduces pain and increases range of motion, which can help patients complete their rehabilitation exercises[2]

- Night splints — comparable functional improvement to eccentrics in Achilles[12]

- Topical nitroglycerin — varying levels of evidence in certain tendinopathies[2]

Tier 3: Popular but weakly supported.

The use of injectables including PRP, autologous blood, polidocanol, corticosteroids, and aprotinin in and around tendons is popular, but there is minimal clinical evidence to support their use. Well-controlled studies show[5] no significant effect of PRP in tendinopathy.[3]

A Cochrane review of 18 trials (732 patients) evaluating CSI, PRP, hypertonic glucose, and autologous blood against controls was similarly unpersuasive.[13]

I don't tell patients these are worthless. I tell them the evidence is weak, and I'd rather they spend that money and those weeks on supervised loading.

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THE STEROID WARNING — READ THIS

Care must be taken when injecting corticosteroids into and near major load-bearing tendons because of the risk of rupture.[2]

This is why I do not inject steroid into or around the Achilles or the posterior tibial tendon. Prior corticosteroid exposure is itself a risk factor for posterior tibial tendinopathy.[6] A shot that helps for six weeks and precedes a rupture is a bad trade.

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Tier 4: Surgery.

The goals of operative treatment are to excise fibrotic adhesions, remove areas of failed healing, and make multiple longitudinal incisions in the tendon to detect intratendinous lesions, restore vascularity, and stimulate healing. Newer techniques — endoscopy, electrocoagulation, minimally invasive stripping — aim to disrupt abnormal neoinnervation and interfere with pain transmission.[5]

How I decide:

- Posterior tibial: 3–6 months of failed nonoperative care, procedure chosen by stage[8][14]

- Peroneal tears: repair if <50%, tenodesis if >50%[15]

- Peroneal subluxation: retinacular repair ± groove deepening, often earlier in athletes[15]

- Achilles rupture: gap ≥5 mm in active patients, ≥10 mm in sedentary patients prompts surgical evaluation[14]

- FHL: after a dedicated FHL stretching program has genuinely been tried[9]

Patients with low functional demands do well with conservative treatment, while those with high functional demands may benefit from surgery when nonsurgical treatment fails.[14] That sentence is the crux of most of my clinic conversations.

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PART 10: RECOVERY AND REALISTIC TIMELINES

The hardest thing to accept about tendons is how slow they are. Tendon remodels over months, not weeks.

Condition	Nonoperative improvement	Post-surgical recovery
Achilles tendinopathy	12 weeks of loading minimum; meaningful gains often at 3–6 months, continuing to 1 year[3], [12]	4–6 months; up to 12 with debridement/reconstruction
Achilles rupture	Cast 4 weeks in plantarflexion, then 6 weeks PT, then AFO or heel wedges[14]	6–9 months to sport
Peroneal tendinopathy	6–12 weeks	Repair 3–4 months; tenodesis or groove deepening 4–6 months
Posterior tibial (early)	3–6 months before judging failure[8]	Reconstruction 6–12 months
Tibialis anterior	6–12 weeks with immobilization then PT[8]	4–6 months
FHL	Weeks to months with specific stretching[9]	3–4 months

One genuinely encouraging finding: improvement in tendinopathy recovery appears faster the shorter the condition has been present, shown in recreational athletes — though this trend was not clear in elite athletes, where recovery was independent of whether symptoms had been present 1, 2, or 3 months.[3]

For recreational athletes across DFW, the practical translation is simple: coming in at six weeks is meaningfully better than coming in at six months.

Timeline detail: How Long Does It Take an Achilles Tendon to Heal? · Can Achilles Tendinitis Heal Without Surgery?

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PART 11: RETURN TO SPORT

These assume a diagnosis-specific rehab program has been completed and strength testing is symmetric. Nonoperative tendinopathy return is generally faster than post-surgical.

- Running — the Achilles and posterior tibial are loaded hardest. Gradual return, walk-run intervals, and no more than roughly 10% weekly mileage increase. Hills and speed work last.

- Pickleball and tennis — heavy lateral loading of the peroneals. The fastest-growing source of these injuries in North Texas. Lateral shuffle and split-step drills before match play.

- Basketball and volleyball — repetitive jumping and landing loads the Achilles; landing in sudden dorsiflexion is the peroneal subluxation mechanism. Full jump-landing progression required.[15]

- Soccer — cutting, plus direct blows over the peroneals. Progressive change-of-direction work.

- Football — position-dependent; lineman loads differ from a receiver's.

- Baseball — push-off from the mound loads the Achilles; catchers load the FHL in deep squats.

- Golf — earliest return of the group. Trail-foot Achilles and lead-foot posterior tibial loading in the follow-through.

- Dance and gymnastics — the classic FHL population, plus extreme Achilles demand in pointe and tumbling. Return requires full pain-free plantarflexion strength.

- CrossFit — double-unders, box jumps, and Olympic lifts are among the highest tendon-load activities. Substitutions, not rest, during rehab.

Sideline perspective on these decisions: A Pro Sports Team Physician's Guide to Foot and Ankle Sports Injuries

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PART 12: RETURN TO WORK

- Desk work — usually 1–2 weeks after surgery; often uninterrupted with tendinopathy

- Standing or retail work — 6–12 weeks post-surgery; supportive footw