What are the extensor tendons?
The extensor muscles sit at the front of the shin. Their tendons pass under the extensor retinaculum at the front of the ankle and fan out over the top of the foot to the toes. They lift the foot and toes when you walk, controlling the foot as the heel strikes and as it lowers. Because the top of the foot has little padding, these tendons are easily compressed by shoes and laces, and they work hard during uphill walking and running. Tendonitis here is part of the broader group of tendon overuse problems.
Symptoms
- Aching or burning pain along the top of the foot, sometimes extending to the front of the ankle.
- Pain that increases with walking, running or uphill activity and eases with rest.
- Pain when pulling the toes or foot upward against resistance.
- Tenderness along the tendon rather than on one spot of bone.
- Mild swelling over the top of the foot.
- A creaking sensation (crepitus) in some cases.
- Pain in the big toe or along its tendon when extensor hallucis longus is involved.
Causes and risk factors
- Tight laces or shoes that press on the top of the foot.
- Sudden increases in running distance, speed or hill work.
- Tight calf muscles, which make the extensors work harder.
- Flat feet or high arches that change how load is shared.
- Running on uneven or sloping surfaces.
- New or worn-out footwear.
- Standing or walking for long periods in unsupportive shoes.
How it is diagnosed
A clinician examines the foot, presses along the tendons and bones, and tests the strength of the muscles that lift the foot and toes. Pain on resisted toe or ankle lifting supports extensor tendonitis. Point tenderness on a metatarsal bone suggests a stress fracture, which may need an X-ray or MRI. Ultrasound can show tendon thickening or fluid around the tendon. Gout, arthritis and nerve compression are other causes of pain on the top of the foot, and peroneal tendonitis affects the outside of the ankle.
Home treatment
- Reduce activities that cause pain, such as hills, long runs and long walks, for one to three weeks.
- Loosen your laces or skip the eyelets over the sore area; try different lacing patterns.
- Add padding under the tongue of the shoe if pressure is an issue.
- Ice for 15 minutes after activity.
- Choose footwear with enough room on top and good cushioning.
- Keep fit with cycling or swimming if they are pain-free.
- Short-term paracetamol or anti-inflammatories may help if suitable for you.
Stretches and strengthening
- Calf stretches: straight and bent knee against a wall, 30 seconds, 3 times each.
- Gentle top-of-foot stretch: while seated, point the foot and curl the toes under, only to mild tension.
- Toe lifts: lift the toes while keeping the heel down, 3 sets of 15.
- Resisted ankle dorsiflexion with a light band, slowly, 3 sets of 12, progressing as pain allows.
- Heel raises on both feet, then one, to improve calf strength.
- Single-leg balance for 30 seconds to improve control.
- Exercises should cause no more than mild discomfort that settles within 24 hours.
Recovery and return to running
Most cases improve within two to six weeks. Return to running when walking is pain-free and you can do 20 single-leg heel raises and resisted toe lifts without pain. Start with short runs on flat ground, every other day, and increase distance gradually. Hills and speed work come last. Persistent pain beyond six weeks, or pain that keeps returning, should be assessed by a physical therapist, who may look at footwear, running technique and strength. Our guide to shin pain after running covers training load in more detail.
Three common situations
- New trail shoes and pain after the first long run: pressure from a stiff tongue or tight lacing is a likely cause; changing the lacing and easing back usually solves it.
- Hill training for a race: extensors work hard uphill; reduce hill volume for a while and strengthen the calves.
- Pain on top of the foot with one very tender bone: treat as a possible stress fracture and get it checked before running again.
Key points to remember
- Extensor tendonitis causes pain along the top of the foot that worsens with activity.
- Tight laces, shoe pressure, hills and training increases are common triggers.
- Loosening laces, relative rest, calf stretches and gradual loading help most people.
- A pinpoint tender bone needs assessment for a stress fracture.
Questions about extensor tendonitis
These answers are general information and do not replace an examination or individual medical advice.
How long does extensor tendonitis last?
Usually two to six weeks with relative rest and simple changes. Long-standing cases can take a few months.
Can I walk with extensor tendonitis?
Yes, as long as walking does not significantly increase pain. Reduce long walks and hills while it settles.
What does extensor tendonitis feel like?
An ache or burning along the top of the foot that worsens with activity and when lifting the toes, often with mild swelling.
Should I stretch the top of my foot?
Gentle stretching is fine if it feels comfortable, but calf stretching and gradual strengthening are more important. Avoid forceful stretches of a painful tendon.
Is extensor tendonitis the same as a stress fracture?
No. Tendonitis causes pain along a tendon, while a stress fracture causes very localised bone pain. They can feel similar, so persistent pain should be examined.
Sources
This guide is for general information and does not replace medical advice. How a problem is diagnosed and treated depends on your examination and medical history. If you think you have an emergency, contact your local emergency services.