Tendon injuries (tendinosis and ruptures)

In summary: when a tendon in the foot or ankle is overloaded, it can become irritated, lose quality and degenerate (tendinosis), or suffer a partial rupture. The pain can persist and limit walking, sports or daily activities. It is not always an inevitable progression of tendonitis: overload, gait pattern, a previous injury or changes in the foot structure are often involved.

In the foot and ankle, the most frequently affected tendons are the posterior tibial, located on the inner side, and the peroneal tendons, on the outer side. Other tendons can also be injured, such as the Achilles or the extensor and flexor tendons of the toes. Treatment depends on the affected tendon, the extent of the injury and the needs of each individual. In Martorell, Barcelona (Teknon) and Igualada, we assess each case on an individual basis.

Symptoms can appear gradually or after a specific movement. The most common is a localised pain that worsens when walking, climbing stairs, running or standing for long periods. There may also be tenderness when pressing on the area, swelling, morning stiffness or a feeling of weakness. In a partial rupture, some people notice a sudden change, but there is not always a clear popping sound or trauma.

In the case of the posterior tibial tendon, the pain is usually located behind the ankle and on the inner side of the foot. Over time, it can make it difficult to support the medial arch or stand on tiptoes. Injuries to the peroneal tendons usually cause discomfort on the outer side of the ankle, especially on uneven terrain or during activities that require stability. These signs alone do not confirm the diagnosis.

How we diagnose and treat them

The key is to see the tendon, not to guess. High-resolution ultrasound shows it to us in motion during the same consultation: it allows us to assess its thickness, structure, response during certain movements and the possible existence of tendinosis, associated inflammation or a partial rupture (split). It also helps to compare the affected area with the opposite side when necessary.

The visit begins with a conversation about the onset of the pain, the activities that trigger it, previous injuries and any illnesses or factors that may influence recovery. We then perform a physical examination: we observe the gait pattern, the mobility of the foot and ankle, the strength and the exact location of the pain. Depending on the case, we also assess balance and the ability to perform certain movements.

X-rays can be useful to analyse the bone, foot alignment, the joint or possible deformities that may be overloading the tendon. It does not directly show the quality of the tendon, but it provides important information about the foot as a whole. In specific situations, the assessment can be completed with other imaging tests if the examination or progression makes it advisable.

We can also carry out a gait analysis when we suspect that the distribution of loads, the way of walking or the support of the foot are contributing to the injury. This assessment does not replace the examination of the tendon, but it can help to understand why the overload persists and to better plan the treatment.

The first step is usually to temporarily reduce the activities that trigger the pain, without always immobilising or stopping moving completely. Physiotherapy and a progressive exercise programme can help to regain strength, control and load tolerance. The exercises must be adapted to the state of the tendon and advanced gradually, especially if there is a partial rupture.

When the gait pattern or foot alignment favours overloading, we may indicate custom-made orthotics. The aim is to redistribute pressures and facilitate the tendon working in better conditions. Orthotics are not necessary in all cases and should be part of a broader plan, which may include appropriate footwear and exercise.

If the pain persists despite these measures, or if the injury justifies it, ultrasound-guided regenerative procedures can be considered, such as PRP or growth factors. These are performed under ultrasound guidance to direct the treatment to the appropriate area. The indication depends on the diagnosis, the state of the tendon and the circumstances of each patient; they are not a universal solution nor do they guarantee the same result in everyone.

Surgery is reserved for significant injuries, ruptures with loss of function, associated structural alterations or cases that do not progress satisfactorily with a well-planned treatment. Depending on the injury, it may involve repairing or reinforcing the tendon and correcting factors of the foot that maintain its overload. Before operating, we explain the aim, the alternatives and the aspects of the recovery process.

When to seek advice

It is advisable to request an assessment if the pain lasts longer than you expected, returns every time you resume activity or interferes with walking. Also if persistent swelling, weakness, a feeling of instability or difficulty standing on tiptoes appear. An early consultation can help to identify the cause and prevent you from continuing to bear weight on an injured tendon.

If the pain starts after trauma and you cannot put weight on your foot, you notice a sudden loss of strength or observe a deformity, a medical assessment is required without delay. An accurate diagnosis is what allows us to choose between observation, rehabilitation, mechanical support, ultrasound-guided treatment or surgery when it is truly necessary.