A Guide to the Diagnosis and Treatment of Anterior Tibial Tendonitis

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Condition Description

The muscle that runs in front of the leg between the knee and ankle is the anterior tibial muscle, and it connects to the foot via the anterior tibial tendon. This tendon is a hard cord-like structure that can be felt in front of the ankle bone, and when inflamed, the condition is called anterior tibial tendonitis (ATT).

The anterior tibial muscle enables the foot to flex upward toward the head when walking up or downhill. The tendon can be injured when repetitively used in frequent walking and running, especially on hard or uneven surfaces. The use of tight shoe straps or strings over the tendon can also injure it. The result is inflammation and degeneration of the tendon or ATT.

Factors that may contribute to the development of this common athletic injury are poor flexibility and muscle weakness, poorly fitting shoes, inappropriate training and poor foot biomechanics.

Symptoms of Anterior Tibial Tendonitis

ATT causes pain on the foot and ankle:

  • Upon waking in the morning
  • When walking up or downhill
  • When bending the foot and toes upward
  • When kicking a ball with pointed toes (as in football)
  • When kneeling
  • When walking/running on uneven or hard surfaces
  • When wearing tight shoelaces or straps over the ankle

The pain may start gradually and progressively worsens over weeks or months with constant activity. The tendon may also be swollen, reddened and painful to touch.

Diagnosis is made from history and physical examination.

Treatment of Anterior Tibial Tendonitis

  1. The key to effective therapy for athletic injuries that result from overuse of muscles and tendons is to take a complete rest from any activity that causes the inflammation and pain. Therefore, for ATT the best initial step would be to refrain from constant walking and running, especially on hard or uneven surfaces and up/downhill. This will start the healing process and decrease pain and inflammation.
  2. Avoiding tight shoes with straps/laces will also relieve the tendon from constant friction and stress.
  3. Apply ice on the first couple of days for 20 minutes every two hours to decrease inflammation.
  4. After 2 days, heat therapy may be applied using warm packs, taking care not to burn the skin. This will reduce heat, increase blood flow and promote healing.
  5. Nonsteroidal anti-inflammatory drugs may be taken to decrease pain and inflammation.
  6. Physiotherapy for ATT is important for optimum healing and gradual return to normal activity. This may involve:
  • Exercises for strength, flexibility and balance
  • Joint mobilization
  • Stretching
  • Advice for modification of activities, pain, inflammation, sportswear, etc
  • Patient education
  • Rehabilitation program to prevent further injury

Most cases of ATT improve within a few weeks. If the injury has been chronic healing may take longer, usually within months of physiotherapy. In a few cases, further evaluation may be needed, and this may involve more laboratory tests, steroid treatment and pharmaceutical intervention. A plaster cast may be indicated for severe injuries to immobilize the ankle and tendon. Specialists who can help include the orthopedic surgeon, a podiatrist, a radiologist, a sport injury therapist and a physiotherapist.


Sports Injury Clinic, “Tibialis anterior tendon sheath inflammation” accessed 1/14/11


Physioadvisor, “Tibialis Anterior Tendonitis” accessed 1/14/11