Flexor Tendinopathy

You have two primary flexor tendons in your feet: the flexor hallucis longus tendon, which runs down the lower leg, behind the inner ankle and inserts into your big toe, and your flexor digitorum longus tendon, which follows the same path down the inner leg and behind the ankle, branching out to collect the four lesser toes. Together, these tendons (known collectively as the “flexors”) are responsible for moving the toes and the foot downwards (plantarflexion), as well as curling the toes. The flexor tendons also play crucial roles in stabilising the foot and ankle, working closely with surrounding muscles to keep us stable and balanced as we walk, run and move throughout our day.

When the flexor tendons become overused and damaged, this is known as flexor tendinopathy. Flexor tendinopathy feels like pain and tenderness along the course of one or both of the tendons, which can occur anywhere from the inside of the ankle to the underside of the foot. Oftentimes there is swelling accompanying the pain, and the pain will likely worsen when you engage your flexor tendons, like when pushing your foot down into the ground. In severe cases, you may also notice a visible bump or lump in the painful area.

We often see injury to the flexor tendons in those participating in dancing sports such as ballet due to the repetitive pointework involved, which requires repetitively pointing the toes and pushing down off the ground.

When the flexor tendons are overloaded or strained past the point that they can safely handle, damage can occur in the form of small microtears, inflammation and degeneration of the tendons. The most common causes of overloading and stress we see are related to increasing the intensity of sports training sessions, such as in running, jumping and dancing, as well as in sports like climbing where you’re constantly pushing off the forefoot with little rest between.

Other factors that may contribute to overloading and the development of flexor tendinopathy include:

• Poor foot posture or mechanics, such as having flat feet, high arches or other foot deformities
• Wearing shoes that are too tight, narrow or do not offer sufficient support for the foot and arch
• Muscle tightness, or weakness that may be related to historical injuries or natural age-related changes and degeneration
• Poor running or training techniques
• Medical conditions such as diabetes and rheumatoid arthritis can also weaken the flexor tendons and increase your risk of tendinopathy

If you’re experiencing pain on the inside of your ankle or the bottom of your foot, start by limiting intense sporting activities that require you to repetitively and forcefully push down with your feet and toes, if you’re regularly engaging in any. We want to try to limit the activities that cause you pain to allow the healing and repair process to have a good start. Additionally:

• Switch to supportive footwear that is not tight-fitting or narrow, and instead feels comfortable and the right size for your feet.
• Periodically ice your foot (through a towel or cloth to protect the skin) for no more than 15 minutes at a time, up to four times a day. This can help reduce your pain and inflammation.
• Periodically elevate your foot to help reduce swelling and pain
• Try using a compression bandage or sleeve over the foot to help reduce swelling and support the foot
• Using non-steroidal anti-inflammatories to help you temporarily manage your pain and swelling

Here at Matt Raden Podiatry, our trusted and experienced podiatrists listen to the concerns, goals and needs of our patients with flexor tendinopathy, and utilise a range of evidence-based treatment methods to help you get the best outcome. Our goal is not only to make you comfortable now, but to understand the root of the problem so you can exercise and stay active without being held back by foot pain.

Every appointment starts with a comprehensive assessment to uncover the causes of your foot pain, which includes analysing your gait, testing for muscle imbalances, assessing joint stiffness or tightness, analysing your foot posture and alignment, and more. We’ll then create a tailored treatment plan based on the results. This may include:

• Orthotics (insoles): as issues with foot posture and alignment (like flat feet) can result in added stress on the flexor tendons, where indicated, our podiatrists can prescribe custom foot orthotics that will work to add the right support to the foot to help relieve strain from the flexor tendons and best support your recovery. 
• Strengthening and stretching program: as muscle weakness and tightness in the lower limbs (not just the foot and ankle) can both play a role in the development of flexor tendinopathy, as well as in delays in healing and its recurrence, a stretching and strengthening program is an important part of both your current recovery and in preventing the problem from recurring in the future.
• Footwear recommendations: in some cases, your existing footwear may be leaving your feet in an unsupported position that will be working against your tendons as they recover. If that’s the case, we can recommend other footwear, both casual and sports-specific, that will support your recovery as well as your general comfort and foot health
• Activity modifications: in order to optimise your recovery, we need to ensure the activities you’re doing are supporting your healing, and not placing excess pressure on your flexor tendons and hence making your injury worse. We may suggest some modifications to your existing training routines and techniques to achieve this.
• Gait retraining: we may work with you to help retrain your gait and work on your technique to address biomechanical issues that may be contributing to your pain and injury.
• Immobilisation: in severe cases of tendinopathy, a boot or walker may be required to help immobilise the foot and allow the tendons to begin healing and repairing effectively.