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Am Fam Physician. 2022;105(5):479-486

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Tendinopathies of the foot and ankle, including posterior tibial, peroneal, and tibialis anterior, are commonly overlooked by primary care physicians. The posterior tibial tendon is the main dynamic stabilizing muscle of the medial longitudinal arch. Patients who have posterior tibial tendinopathy present with medial ankle pain, pes planovalgus deformity, and a positive too many toes sign. Nonoperative treatment options include support for the medial longitudinal arch and physical therapy focusing on eccentric exercises. Surgical treatment is considered for patients who do not respond to nonoperative treatments after three to six months and is based on the specific stage of tendinopathy. Peroneal tendon disorders are commonly mistaken for or occur concomitantly with lateral ankle sprains. Varus hindfoot is a known risk factor for peroneal tendinopathy. Treatments include immobilization, laterally posted orthotics, and physical therapy for progressive tendon loading. Tibialis anterior tendinopathy presents as anterior ankle and medial midfoot pain and can be diagnosed with a positive tibialis anterior passive stretch test. Initial treatment includes immobilization followed by physical therapy. Surgical debridement can be considered if nonoperative treatment is ineffective.

Lower extremity musculoskeletal conditions, such as ankle sprains,1 Achilles tendinopathy,2,3 and plantar fasciitis,3 are commonly diagnosed by primary care physicians, whereas other tendon injuries involving the medial (i.e., posterior tibial), lateral (i.e., peroneal), and anterior (i.e., tibialis anterior) ankle can be missed. The biomechanics of the foot and ankle are intricate. They are responsible for energy absorption and transfer during propulsion, stability during stance, and proprioception. Abnormal mechanics can result in connective tissue changes and alterations in muscle function. Tendinopathy refers to tendon degeneration without substantial inflammation and a generally chronic presentation. The cause of tendinopathy is often multifactorial, involving intrinsic and extrinsic risk factors (Table 1).47 The anatomy (Figure 18) and pathophysiology of ankle tendinopathy have been described in detail.2 This article reviews the diagnosis and treatment of posterior tibial, peroneal, and tibialis anterior tendinopathies (Table 2).

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