Ankle tendons are the unsung heroes of your foot’s movement and stability. Your ankle comprises several vital tendons that connect muscles to bones, facilitating movement and stability.
The Achilles tendon, the body’s largest and strongest tendon, links your calf muscles to the heel bone, enabling activities like walking, running, and jumping. The posterior tibial tendon, located on the inner side of your ankle, supports the foot’s arch and aids in walking.
On the outer side, the peroneal tendons stabilize the ankle and prevent sprains. Injuries to these tendons are common and approximately 25% of ankle CT scans reveal tendon injuries, with subluxation or dislocation being the most frequent.
Here’s a breakdown of what they do, common injuries, how to stretch ankle tendons, symptoms and solutions. How to keep your ankle tendons healthy and avoid problems.
What is Ankle Tendons
Ankle tendons are like the strings of a finely tuned instrument, so our feet can move in harmony with the rest of our body. The Achilles tendon which connects the calf muscles to the heel bone is for push off movements like running and jumping.
The two peroneal tendons, the peroneus longus and brevis, are for stabilizing and balancing the foot and ankle during movement.
The posterior tibial tendon helps to maintain the stability of the medial longitudinal arch and the anterior tibialis tendon is for dorsiflexion and inversion of the foot.
These tendons work together to make smooth, coordinated movements so we can walk, run and jump with ease. No wonder injuries to these tendons can really impact our mobility and quality of life.
Common Causes of Ankle Tendon Injuries
Ankle tendon injuries can be as diverse as the activities that cause them. One of the most common is a high arch foot structure which makes you more prone to peroneal tendon injuries.
Those who do sports that involve a lot of ankle movement like basketball, soccer or tennis are more likely to develop peroneal tendonitis.
Acute ankle injuries are usually due to trauma or sudden changes in physical activity. For example a severe twisting motion can cause peroneal tendon dislocation. Chronic ankle instability and overuse can also cause tendon injuries.
Here are some common causes of ankle tendon injuries:
- High arches
- Sports that involve a lot of ankle movement
- Acute trauma or sudden activity change
- Severe twisting
- Chronic instability and repetitive strain
Starting a new activity or increasing its intensity too quickly can cause tendon injuries. Avoid overtraining and gradually increase the intensity of the activity.
High impact sports like basketball, soccer or racket sports can cause more severe injuries like Achilles tendon tears.
Symptoms of Ankle Tendon Injuries
Common symptoms are pain on the lateral side for peroneal tendon injuries and medial ankle pain for posterior tibial tendinopathy. Acute pain immediately after an injury especially in cases of tendon rupture is also a symptom.
Those with tibialis anterior tendinopathy often present with anterior ankle and medial midfoot pain, tenderness and swelling. Swelling is a common symptom with peroneal tendon tears and can mean inflammation.
Common symptoms of ankle tendon injuries are:
- Lateral ankle pain which is often related to activities that strain the ankle
- Medial ankle pain for posterior tibial tendinopathy
- Acute pain after an injury
- Anterior ankle and medial midfoot pain for tibialis anterior tendinopathy
- Swelling and inflammation
In addition to pain and swelling many patients will report a feeling of instability in the ankle especially during lateral movements.
Untreated peroneal tendonitis can worsen symptoms and can cause a tendon tear. Some patients will experience peroneal tendon pain which is a snapping feeling in the affected foot which means a possible tendon dislocation.
Ankle Tendons Types
Your ankle is supported by several key tendons that connect muscles to bones, enabling movement and stability. Here are the main types of ankle tendons:
1. Achilles Tendon
The largest and strongest tendon in your body, it connects your calf muscles (gastrocnemius and soleus) to your heel bone (calcaneus). It helps you push off the ground when walking, running, or jumping.
2. Posterior Tibial Tendon
Runs along the inside of your ankle and attaches to the bones of your midfoot. It supports the arch of your foot and stabilizes your ankle during movement.
3. Peroneal Tendons
These include the peroneus longus and peroneus brevis tendons, which run along the outside of your ankle. They help stabilize your ankle and foot, especially during side-to-side movements.
4. Anterior Tibial Tendon
Located at the front of your ankle, it connects the shin muscle (tibialis anterior) to the bones in your midfoot. It helps lift your foot upward (dorsiflexion) and supports walking and running.
5. Flexor Tendons
These include the flexor hallucis longus (big toe), flexor digitorum longus (other toes), and tibialis posterior tendons. They run along the inside of your ankle and help control toe movement and foot stability.
6. Extensor Tendons
It includes the extensor hallucis longus (big toe) and extensor digitorum longus (other toes) tendons. They run along the front of your ankle and help lift your toes and foot upward.
How to Stretch Ankle Tendons
Stretching your ankle tendons can help improve flexibility, reduce stiffness, and prevent injuries like tendonitis. Here are some effective stretches:
1. Calf Stretch (Gastrocnemius)
- Stand facing a wall with one foot forward and the other back.
- Keep your back leg straight and press your heel into the ground.
- Lean forward, keeping your back heel down, until you feel a stretch in your calf.
- Hold for 20-30 seconds, then switch legs. Repeat 2-3 times.
2. Achilles Stretch (Soleus)
- Similar to the calf stretch, but bend your back knee slightly.
- Keep your heel on the ground and lean forward to feel a deeper stretch in your lower calf and Achilles tendon.
- Hold for 20-30 seconds, then switch sides. Repeat 2-3 times.
3. Towel Stretch
- Sit on the floor with your legs straight out in front of you.
- Loop a towel around the ball of one foot and gently pull the towel toward you, keeping your knee straight.
- Hold for 20-30 seconds, then switch feet. Repeat 2-3 times.
4. Ankle Alphabet
- Sit in a chair and lift one foot off the ground.
- Use your big toe to “write” the alphabet in the air, moving your ankle in all directions.
- Repeat with the other foot. This helps improve mobility and flexibility.
5. Plantar Fascia Stretch
- Sit with one leg crossed over the other.
- Grab your toes and gently pull them back toward your shin until you feel a stretch along the bottom of your foot and ankle.
- Hold for 20-30 seconds, then switch feet. Repeat 2-3 times.
6. Resistance Band Stretch
- Sit with your legs straight and loop a resistance band around the ball of your foot.
- Gently pull the band toward you while pointing your toes forward, then flex your foot back toward you.
- Perform 10-15 reps on each foot to strengthen and stretch the ankle tendons.
Ankle Tendons and Ligaments Relationship
Your ankle’s tendons and ligaments work together to provide stability, support, and movement, but they serve different roles. Tendons connect muscles to bones, enabling movement by transmitting the force generated by muscles to the bones.
Ligaments, on the other hand, connect bones to other bones, providing stability to the joints and preventing excessive movement that could lead to injury.
Achilles Tendon and Lateral Ligaments
The Achilles tendon, which connects your calf muscles to your heel bone, works in tandem with the lateral ligaments (anterior talofibular, posterior talofibular, and calcaneofibular ligaments) to stabilize your ankle during activities like walking, running, or jumping.
While the Achilles tendon helps you push off the ground, the lateral ligaments prevent excessive rolling or inversion of the ankle, which could cause sprains.
Posterior Tibial Tendon and Deltoid Ligament
The posterior tibial tendon supports the arch of your foot and stabilizes the inner ankle. It works closely with the deltoid ligament, a strong ligament on the inner side of your ankle, to prevent over-eversion (outward rolling) of the ankle.
Together, they maintain medial stability and proper alignment of the ankle joint.
Peroneal Tendons and Lateral Ligaments
The peroneal tendons (peroneus longus and brevis) run along the outer ankle and help stabilize the foot during side-to-side movements.
They work alongside the lateral ligaments to counteract excessive inversion (inward rolling) of the ankle, which is a common cause of ankle sprains.
Image by brgfx on Freepik
Anterior Tibial Tendon and Anterior Talofibular Ligament (ATFL)
The anterior tibial tendon helps lift your foot upward (dorsiflexion) and works in coordination with the ATFL, one of the most commonly injured ligaments during ankle sprains.
The ATFL stabilizes the front of the ankle, while the anterior tibial tendon ensures smooth movement during walking or running.
Flexor and Extensor Tendons and Ankle Joint Capsule
The flexor tendons (flexor hallucis longus, flexor digitorum longus) and extensor tendons (extensor hallucis longus, extensor digitorum longus) control toe movement and foot stability.
They interact with the ankle joint capsule and surrounding ligaments to maintain proper alignment and prevent hyperextension or hyperflexion of the ankle.
Diagnosing Injuries
A thorough patient interview is important in diagnosing ankle tendon injuries to get the exact mechanism of injury.
Conditions to rule out:
- Ankle sprains
- Rheumatoid arthritis
- Calcaneus fractures
- Fractured os peroneum
Physical Examination
During physical examination the assessment includes inspection for swelling, muscle strength testing, palpation during range of motion and ankle stability tests. Special tests such as single limb heel raises are used to assess the severity of posterior tibial tendinopathy.
Peroneal tendinopathy weakness can be assessed through resisted eversion and plantar flexion. Changes in gait pattern after an injury is also an important indicator during physical examination. These are important to get information about the patient’s condition.
Imaging
Imaging is necessary to confirm diagnosis and assess the extent of tendon injury. X-rays, ultrasound and MRI are commonly used for this purpose. Imaging is necessary if symptoms persist for more than 6 weeks or if nonoperative treatment fails as MRI may be needed for surgical considerations.
These imaging will give you detailed information about the severity of the injury and will guide your treatment. For example an MRI can show partial tears or significant damage that can’t be seen through physical examination alone.
Treatment Options for Ankle Tendon Injuries
Treatment for ankle tendon injuries can be conservative or surgical. The choice of treatment depends on the severity of the injury and the patient’s overall health and activity level, usually decided by foot and ankle surgeons.
Conservative Treatments
Initial treatment for ankle tendon injuries usually involves ice, NSAIDs and activity reduction.
Nonoperative treatment also involves activity modification, physical therapy, corticosteroid injection and ankle brace to alleviate symptoms. Short term immobilization can help manage pain during ambulation and promote healing.
Conservative treatment is important to manage pain and recovery. Physical therapy is especially important to regain strength and mobility to have a smoother healing process.
Surgical Treatments
For severe peroneal tendonitis, surgical options include synovectomy to clean out the damaged tissue, usually minimally invasive.
Surgical procedures for Stage III posterior tibial tendinopathy may be arthrodesis while Stage I may be debridement with or without tenosynovectomy. The peroneal tendon sheath may also require specific treatment for peroneal tendon disorders.
Surgical repair may involve grafting tissue from another part of the body and tendon transfer when the tendon is severely damaged. Intervention is necessary when conservative treatment fails to give relief.
Rehabilitation and Recovery
Rehabilitation after tendon surgery usually requires a cast or boot to protect the area. Therapeutic exercise is focused on range of motion and muscle strength to aid recovery. Recovery from ankle sprain may take 6 weeks to 3 months for significant mechanical stability.
Hydrotherapy helps in range of motion and additional benefit from water resistance. Balance and neuromuscular control exercises are part of rehabilitation to prevent chronic ankle instability after acute injury.
Gradual return to activity should include sport specific exercises tailored to the individual. Full return to sports is usually achieved when almost full range of motion and at least 80% of pre-injury strength is restored.
Preventing Ankle Tendon Injuries
Sports that involves repetitive ankle movement increases the risk of tendon injury. Overuse injuries like degenerative tears usually develops over time due to repetitive strain.
Here are some tips to prevent ankle tendon injuries:
- Warm-Up: Always warm up before physical activity.
- Strengthening: Focus on exercises that strengthen the ankle and surrounding muscles.
- Flexibility and Stretching: Stretch regularly.
- Proper Footwear: Wear footwear that provides support.
- Gradual Progression: Gradually increase physical activity.
- Cross-Training: Mix up exercises to avoid repetitive strain.
- Healthy Weight: Keep yourself at a healthy weight.
Good technique, enough rest and recovery and not overtraining reduces the risk of injury.
Prognosis and Long-term Outlook
Recovery time for posterior tibial tendon reconstruction is 4-6 months. Patients undergoing surgical treatment for peroneal tendon injuries aim to return to sports 3 months post-op. 87% of patients return to sports after operative treatment for peroneal tendon tears.
Recovery time for Achilles tendon reconstructive surgery is 3-6 months. Patients who return to full activities after peroneal tendon tear repair do so after 13 months on average.
But 30% of individuals may still experience mechanical laxity or subjective instability up to 1 year after ankle tendon injury. Successful healing of ankle ligaments means improved mechanical stability over time.
Bottom Line: Summary
- Knowing the anatomy and function of ankle tendons is key as injuries can really impact mobility.
- Common causes of ankle tendon injuries are high arches, sports that involve a lot of ankle movement and acute trauma.
- Solutions range from physical therapy to surgery depending on the severity of the injury.
