Tendon pain in the foot and ankle can start as something that seems minor—a little soreness after running, pain behind the ankle after a workout, or discomfort along the inside of the foot that gradually becomes harder to ignore. We see these problems in athletes, active adults, and patients whose tendon has been under stress for a long time.
The term “tendonitis” is commonly used, although tendinopathy is often more accurate because tendon problems can involve both irritation and structural degeneration. The important part of treatment is identifying which tendon is involved and, just as importantly, understanding why that tendon is being overloaded.
Anatomy
The foot and ankle contain several major tendon groups that work together to control movement and stabilize the foot. We generally think about them according to where they travel around the ankle: posterior, medial, lateral, and anterior.
The Achilles tendon powers push-off and connects the calf muscles to the heel. The posterior tibial tendon supports the arch and helps control the position of the foot. The peroneal tendons stabilize the outside of the ankle and turn the foot outward. The tibialis anterior lifts the foot and helps control the foot as it contacts the ground.
Other tendons, including the flexor hallucis longus and flexor digitorum longus, help control the toes while contributing to foot stability.
Because these tendons perform different jobs, pain in one location can mean something very different from pain in another.
What Tendonitis Actually Means
A tendon becomes painful when the demands placed on it exceed its ability to tolerate and recover from those loads.
Repetitive running, jumping, changes in training, prolonged walking, an abnormal foot position, previous injury, or certain systemic conditions can all contribute. In some patients, there is a clear increase in activity. In others, the tendon has gradually become less tolerant of normal activity over time.
We do not assume that the tendon itself is the only problem. Foot alignment, ankle stability, footwear, muscle strength, flexibility, and activity patterns can all influence how much force reaches a tendon.
Achilles Tendon Problems
The Achilles tendon is the strongest tendon around the ankle and is essential for walking, running, and jumping.
Pain can occur in the middle portion of the tendon, several centimeters above the heel, or directly where the tendon attaches to the calcaneus. Some patients develop thickening or a palpable tender area. Others notice stiffness when they first start moving or pain during running and jumping.
A completely different situation is an Achilles rupture. A patient with a rupture may describe a sudden “pop” or feeling of being kicked in the back of the ankle and may have difficulty pushing off or standing on the toes.
We distinguish these problems because an irritated tendon and a ruptured tendon require very different treatment.
Posterior Tibial Tendon Problems
The posterior tibial tendon travels behind the inside of the ankle and plays an important role in supporting the arch.
Patients may initially notice pain or swelling along the inner ankle. As the tendon becomes less capable of supporting the foot, the arch can gradually collapse and the heel can drift outward. We may see the toes more prominently from behind, sometimes called the “too many toes” sign.
One of the most useful parts of the examination is watching the patient perform a heel raise. Difficulty performing a single-leg heel rise can indicate significant posterior tibial tendon dysfunction.
Treatment depends on whether the foot remains flexible or has progressed to a rigid deformity. Orthotics, immobilization, and targeted physical therapy can be useful earlier in the process. More advanced deformity may eventually require reconstruction or fusion procedures.
Peroneal Tendon Problems
The peroneal tendons run behind the outside ankle bone and help turn the foot outward while providing dynamic ankle stability.
Patients typically point to pain behind or just below the lateral malleolus. There may be tenderness, swelling, or a sensation that the tendons are moving or snapping around the ankle.
Peroneal tendon problems can develop from repetitive activity, but previous ankle sprains and foot alignment can also contribute. A high-arched or varus foot may place additional demands on the tendons as they work to stabilize the outside of the ankle.
We evaluate the tendons themselves as well as ankle stability and overall foot alignment. If there is a tendon tear or recurrent tendon displacement, treatment may need to address both problems.
Tibialis Anterior Tendon Problems
The tibialis anterior tendon travels down the front of the ankle and attaches near the medial midfoot. It helps lift the foot and control its position during walking.
Pain may occur along the front of the ankle or near the inside of the midfoot. Weakness with dorsiflexion can be an important finding.
Tibialis anterior tendon problems are more common with degenerative changes but can also occur after injury or repetitive stress. Depending on the severity, treatment may include activity modification, temporary immobilization, an ankle-foot orthosis, and physical therapy. Significant tendon disruption may require surgical reconstruction.
Flexor Tendon Problems
The flexor hallucis longus helps bend the great toe and travels behind the ankle before continuing into the foot. The flexor digitorum longus performs a similar function for the lesser toes.
These tendons are particularly important in activities that repeatedly load the toes and ankle, including dancing and certain sports. Pain with toe movement, tenderness along the tendon, or crepitus can help localize the problem.
Because the tendons travel through narrow spaces around the ankle and foot, irritation can sometimes produce symptoms beyond simple soreness.
What We Look for at the First Visit
We start with the patient’s story: where the pain began, whether there was an injury, what activities make it worse, and whether the activity level recently changed.
Then we watch the patient walk and examine the foot and ankle. We look for swelling, tendon thickening, changes in alignment, weakness, instability, and loss of motion.
We test the tendon both by stretching it and by asking it to contract against resistance. Reproducing the patient’s familiar pain during a specific maneuver can be more useful than simply finding generalized tenderness.
X-rays help us evaluate bone alignment, arthritis, previous injuries, and other structural abnormalities. Ultrasound can show tendon movement dynamically and can help identify thickening or tears. MRI is useful when the diagnosis remains uncertain or when we need to understand the extent of tendon damage before surgery.
Nonsurgical Treatment
Treatment depends on which tendon is involved and why it is being overloaded.
We may temporarily reduce running, jumping, or another aggravating activity while maintaining appropriate low-impact movement. A brace or boot can sometimes be useful when ordinary walking continues to aggravate the tendon.
Physical therapy is often central to recovery. Rather than simply stopping activity, rehabilitation progressively rebuilds tendon capacity through appropriate strengthening, flexibility work, balance training, and correction of movement patterns.
Orthotics may be appropriate when foot alignment is contributing to excessive tendon loading. Footwear changes can also make a meaningful difference.
Medication can help control symptoms in selected patients, but reducing pain is not the same as correcting the mechanical problem.
When Surgery Becomes Reasonable
Most tendon problems do not require surgery. We consider surgery when there is significant structural damage, a tendon tear, persistent symptoms despite appropriate nonsurgical treatment, or an underlying mechanical problem that cannot be adequately corrected without an operation.
Depending on the tendon involved, surgery may include removal of damaged tissue, direct tendon repair, tendon reconstruction, stabilization of a displaced tendon, or correction of the underlying foot deformity.
The procedure should match the problem. We do not want to perform an operation simply because an MRI shows an abnormal tendon if the imaging finding does not match the patient’s symptoms and examination.
Recovery
Tendons need time to adapt. Pain may improve before the tendon has regained its full capacity.
After nonsurgical treatment, we gradually progress from symptom control to strengthening and then to the activities that originally caused the problem. Returning to running or jumping too quickly can recreate the same overload that started the condition.
After surgery, recovery depends on the specific tendon and procedure. Early protection is followed by progressive motion, strengthening, balance work, and eventually a return to normal activity.
What a Good Outcome Means
A successful treatment is not simply an ankle that feels better while sitting in the office.
We want patients to walk comfortably, perform the activities they need or enjoy, and have a tendon that can tolerate those demands. For an athlete, that may mean returning to running or sports without recurrent pain. For another patient, it may mean comfortably walking, working, or standing throughout the day.
Our approach is to identify which tendon is involved, why it is being overloaded, and what needs to change so the tendon can tolerate normal activity again. When surgery is necessary, the goal is to repair or reconstruct the tendon while addressing the mechanical problem that contributed to its failure.
The content on this page has been authored, edited, or approved by the doctors below, and was last reviewed for accuracy on September 15, 2026.
