Tibialis anterior tendinopathy: the tendon whose treatment nobody has measured

Pain at the front of the ankle and over the instep, which wakes up on walking downhill and on running, in a runner, a hiker, or just after a change of footwear. The picture is easy to recognise. What is less easy is that the literature devoted to this tendon fits into a few dozen papers, without a single randomised controlled trial, and that most of the recommendations you read about it are borrowed from the Achilles tendon without saying so.

Clinical summary

What to have in mind before opening the clinic door. The rest of the article sets out each of these points and gives the source of every figure.

What are the fundamentals to know about the tibialis anterior tendon?

A muscle that works twice per step, a tendon that crosses two fibrous tunnels, and a literature that fits in a folder. Those three facts explain almost everything that follows.

The most powerful muscle of a compartment that gets forgotten

Tibialis anterior occupies the anterior compartment of the leg, with extensor digitorum longus, extensor hallucis longus and fibularis tertius. It arises from the lateral surface of the tibia and the interosseous membrane, descends in front of the ankle, then inserts on the medial aspect of the medial cuneiform and on the base of the first metatarsal. That insertion on the inner border of the foot gives it its dual action: it lifts the foot, and it carries it into supination.

It is the bulkiest of the foot dorsiflexors, described as the powerful dorsiflexor of the ankle, and no other really replaces it when it fails. Its function comes into play at two moments of the step, and it is the first that counts here:

• At heel strike, eccentrically : it brakes the fall of the forefoot towards the ground. It is holding work, under load, repeated at every step.
• In swing phase, concentrically : it lifts the foot to clear the ground. Short work, lightly loaded.

The clinical consequence is direct: this tendon suffers from brakingwork, not from propulsion. Anything that increases the demand for braking increases its load, and going downhill is the situation par excellence.

Two fibrous tunnels, and what they imply

Before reaching the foot, the tendon passes under two thickenings of the fascia: the superior extensor retinaculum, then the inferior retinaculum, in front of the talocrural joint. These structures hold the tendon pressed against the skeleton during dorsiflexion, which stops it bowstringing.

That arrangement has a price. In dorsiflexion, the tendon becomes prominent and finds itself caught between the bone behind and the retinaculum in front. Add external compression, tight lacing, a rigid upper, the edge of a skate, and you get a zone of mechanical conflict reproducible at every step. That is the logic of the picture the English-language literature calls lace bite, described in ice hockey players by Levitsky and co-authors in 2020.

A subject the literature has hardly covered, and that has to be said

This is the point that governs the reading of all the rest of this article. A PubMed search run on 15 August 2026 returns 53 references linking tibialis anterior to a tendinopathy, a tendinosis or a tendinitis. The same search applied to the Achilles tendon returns 2 480. Restricting to randomised controlled trials, tibialis anterior returns two, and checking them one by one shows that neither of the two covers this tendon : one studies the patellar tendon, the other the Achilles.

There is, to this day, no randomised controlled trial on the treatment of tibialis anterior tendinopathy. Every protocol proposed for this tendon is a transposition from another.

That scarcity is not a methodological detail, it is a clinical fact. It means that the practitioner treating this tendon works by analogy, and that it is better to know it than to believe you are applying a validated protocol. It also explains why so many pages devoted to the subject copy out, word for word, the Alfredson protocols designed for the Achilles.

One name, two patients: who really consults about this tendon?

Most pages devoted to this subject describe a runner. The only published clinical series describes an overweight woman of 62 who hurts at night. Both exist, but confusing their management is the most costly error on this tendon.

What the only dedicated series says

In 2009, Beischer and co-authors published in Foot & Ankle International the first clinical description of distal tibialis anterior tendinosis without rupture. Twenty-nine patients, thirty-two feet. The characteristics of that group do not resemble those of a sporting population:

The commonest symptom is described there as a burning pain of the inner border of the midfoot, often worst at night. Swelling over the tendon was frequently observed. On MRI, the tendon was thickened in all the patients, and degenerative involvement of the first tarsometatarsal or the medial naviculocuneiform joint coexisted in eleven feet.

In other words: the best-described form of this tendinopathy is a distal degenerative tendinosis of the older person, readily associated with midfoot osteoarthritis, and not an overload condition of the runner. It is a fact of the literature, and it deserves to be known before modelling sports management on a patient for whom it is not appropriate.

The sportsperson's picture, and why it is different

The other picture, the one the presenting complaint most often suggests in a sports physiotherapy clinic, sits higher: in front of the ankle, under the retinacula. It rarely comes from tendon degeneration and far more often from an external compression constraint, or from an abrupt increase in the demand for braking.

Levitsky, Vosseller and Popkin published a review of it in 2020 centred on the ice hockey player, where the mechanism is particularly clear: a rigid skate upper, tight lacing, and the tendon finds itself compressed against the bone at every dorsiflexion. They describe pain, swelling and tenderness over the tendon, worsened by dorsiflexion, and a treatment that goes first through modifying the footwear, padding the area and adapting the activity.

The same mechanism is found, without a skate, in:

• the hiker in tight high-cut boots, especially on prolonged descent;
• the runner after a change of model, lacing pulled up higher to “hold the foot”, or a return to running with downhill gradient;
• the skier, the skater and anyone wearing a rigid-upper boot;
• the soldier or the walker in combat boots, where the constraint combines tightness and carried load.

A word of honesty about this comparative table: the left-hand column rests on a series of twenty-nine patients with imaging and operative confirmation for some of them; the right-hand one on a narrative review with no sample size. That is not the same solidity. The distinction remains clinical and useful, but it has not been validated by a study that would have compared the two populations.

How do you establish tibialis anterior tendinopathy?

The diagnosis is clinical. It rests on a precise location, a tensioning manoeuvre, and a manoeuvre too rarely done: repeating the examination with the shoe on.

Locate, palpate, tension

The approach comes in three stages, and the first already does most of the work.

1. Situate the pain along the course. The tendon is easily palpated, especially if you ask the patient to lift the foot against resistance: it becomes prominent from the lower quarter of the leg to the inner border of the foot. Follow the course with a finger and note the most painful point. Pain in front of the ankle points to the retinacular zone; pain at the inner border of the midfoot, to the insertion.

2. Put the tendon under passive tension. This is the test described in the American Family Physician review of 2022: the practitioner passively takes the foot into plantarflexion and eversion, which stretches tibialis anterior. Reproduction of the usual pain along the course of the tendon supports the diagnosis. That same review is a reminder that tendinopathies of the foot and ankle are “commonly overlooked” in primary care, tibialis anterior foremost.

3. Test under load and against resistance. Resisted dorsiflexion, then heel walking, then walking down a slope or a few steps. The aim is not to grade strength but to find the situation that hurts, in gradation.

The examination almost nobody does: reproducing the constraint

If the suspected mechanism is compression by footwear, the barefoot examination may be unrevealing while the patient hurts on every outing. Three manoeuvres make up for that, and they take two minutes:

• Have the patient come with their usual shoes, those of the activity that triggers it, not their town shoes.
• Look at the mark of the lacing on the instep after taking the shoe off: redness, an imprint of the eyelets, selective tenderness under the run of the laces.
• Repeat the test shod and laced as usual, in repeated dorsiflexion, then relace skipping the painful eyelet and start again. An immediate change is diagnostic and therapeutic information in the same movement.

This last point has not been the subject of a validity study. It is a manoeuvre of mechanical common sense, consistent with the mechanism described by Levitsky and co-authors, and we present it as such: an aid to reasoning, not a validated test.

What place for imaging?

Imaging does not make the diagnosis of tendinopathy, which remains clinical. It serves three precise purposes:

• Confirm a rupture when the examination leaves a doubt. Gallo and co-authors described the MRI appearances of tibialis anterior tendon rupture as early as 2004, and it is the reference investigation when the question is asked.
• Look for an associated midfoot lesion. In Beischer's series, the tendon was thickened in all the patients, longitudinal splits were visible in nineteen feet out of thirty-two, and degenerative involvement of the first tarsometatarsal or the medial naviculocuneiform joint coexisted in eleven feet.
• Rule out another diagnosis, in particular a stress fracture, when the pain is bony and not tendinous.

Ultrasound has the advantage of being dynamic and available: it shows thickening, hypoechogenicity and hypervascularity of the tendon and its sheath, and allows comparison with the healthy side at the same time. One reservation concerns it, however, for this particular tendon: the variation in the cross-sectional area of the ankle tendons depends on age and on the level measured along the tendon, and there is no published cut-off value that would define a “pathologically thickened” tibialis anterior. Mansur and co-authors, measuring these cross-sections by MRI in sixty healthy adults, in fact showed that age-related differences were clear for the Achilles but not for tibialis anterior, and that there was no difference between the sexes.

Faced with anterior ankle pain, how do you decide?

Five diagnoses compete for this territory. Each has a sign that belongs to it, and it is on that sign that you should ask, not on the location alone.

The front of the ankle and the lower third of the leg receive pains of very different origins. Sorting is done better on the rhythm of the pain and on what reproduces it than on its site, because the territories overlap widely.

Anterior compartment syndrome, the closest neighbour

This is the trickiest differential, because it shares the exact territory of tibialis anterior: the anterior compartment. The distinction lies in the rhythm. Tendinopathy hurts at the start of the effort, sometimes warms up, and wakes up on cooling down. Compartment syndrome, for its part, appears at a reproducible threshold, often to within a few hundred metres, forces the person to slow down, and eases within a few minutes of rest to return at exactly the same point when they start again.

Measurement of intracompartmental pressures, long presented as the reference test, does not decide the matter as well as is believed. The systematic review by Aweid and co-authors, covering thirty-two studies, concludes that the pressure criteria in common use rest on weakevidence, and that the emphasis should stay on the history. Those authors note that at one minute after exertion, and at that moment only, the values of patients and controls did not overlap: from 34 to 55.4 mmHg in patients against 9 to 19 mmHg in controls, which leads them to consider that a value exceeding 27.5 mmHg at that interval, together with a suggestive history, is strongly suggestive.

This diagnosis is dealt with in detail in its own article: chronic exertional compartment syndrome. We do not develop it further here.

Why does rupture of the tibialis anterior tendon go unnoticed?

Because it hurts little, because it happens without frank trauma, and because the patient is still walking. It is the only chapter of this article where a diagnostic error really changes the prognosis.

Rare, but not exceptional

Rupture of the tibialis anterior tendon is described as the third commonest tendon rupture of the lower limb, after that of the Achilles tendon and that of the patellar tendon. It remains rare in absolute terms: the literature documenting it is made of isolated cases and small series, which makes it impossible to give a reliable incidence.

The background is fairly constant from one publication to another: a person over 45 to 50, with rupture occurring after minimal trauma, or even with no identifiable trauma. In the series of seven patients by Gwynne-Jones and co-authors, published in 2009, ages ranged from 43 to 82, and above all four of the seven patients were on systemic corticosteroid therapy, a fifth having received a local injection. The authors conclude explicitly to an association with corticosteroid therapy, systemic as well as local.

Other backgrounds have been reported in documented cases: diabetes (Siang et al. 2019, in a 73-year-old patient whose rupture had been developing for six months with a tendon gap of 4.2 cm), and gout, with an intratendinous tophaceous deposit (Jerome et al. 2008). In the sportsperson, the lesion takes another form: Santos-Faria and co-authors reported in 2022 the rupture of the muscle belly of tibialis anterior, and not of the tendon, in a 47-year-old ultramarathon runner.

The signs not to be missed

The trap lies in the fact that the rupture is not very painful. The patient does not describe the abrupt episode of the Achilles tendon; they sometimes come weeks later, for difficulty walking. The signs to look for are mechanical:

• The foot that slaps the ground at heel strike, for want of eccentric braking. It is often the symptom reported by those around the patient before the patient themselves.
• The steppage gait : the patient lifts the knee excessively so as not to catch the ground. It may be subtle and appear only with fatigue.
• Loss of the tendon's prominence on resisted dorsiflexion. The healthy tendon stands out clearly under the skin; its disappearance is a direct sign, to be compared systematically with the opposite side.
• A pseudotumour of the instep: the retracted tendon stump forms a mass readily mistaken for a cyst or a ganglion.
• Hyperextension of the big toe on dorsiflexion, described by Siang and co-authors: extensor hallucis longus compensates for the loss of tibialis anterior, and the hallux lifts abnormally markedly.

A patient over 50 whose foot slaps the ground and in whom the prominence of the tendon has disappeared on resisted dorsiflexion has a tibialis anterior rupture until proven otherwise, even if they have never had pain.

What the management changes

The Gwynne-Jones series is the only one comparing the two options on functional scores, and its sample is small: seven patients, five operated on and two treated without surgery. At follow-up, ranging from one to twelve years, the mean FAOS score was 85 in the operated group against 52 in the non-operated group, and one of the two non-operated patients had to be taken back to surgery four years after the rupture. The authors conclude in favour of surgical repair, including in the older person, and stress that an early diagnosis allows direct repair.

This result has to be read for what it is: a series of seven patients, not randomised, in which the operated and non-operated patients were not comparable at the outset. It does not demonstrate the superiority of surgery; it indicates a trend, in the same direction as the published cases as a whole.

For the physiotherapist, the practical consequence is simple and does not depend on that debate: faced with a suspected rupture, the question is not what rehabilitation to undertake, but who to refer to. The delay counts, because a tendon retracted for months can no longer be repaired directly and requires a graft or a tendon transfer, as in the cases reported by Siang and by Zmerly and their co-authors.

What risk factors, and what course without treatment?

On this tendon, almost no risk factor has been measured. This chapter therefore distinguishes what is documented from what is reasoned, because the two are too often read in the same tone.

What has been observed, and in what numbers

There is no prospective cohort study that has looked for risk factors for tibialis anterior tendinopathy. What we have is limited to the characteristics of the patients in the published series, which describes a population of attenders, not a risk:

• Older age : a mean of 62 in Beischer's series, of 59 in Grundy's.
• Female sex : 27 patients out of 29 in Beischer, 10 women to 1 man among Grundy's operated patients.
• Overweight : 21 of the 29 patients in Beischer's series.
• Associated midfoot osteoarthritis : 11 feet out of 32 in Beischer, 6 cases out of 12 in Grundy.
• Corticosteroid therapy, for rupture: 4 patients out of 7 in Gwynne-Jones.

These figures describe surgical series of a few dozen patients. They do not allow a relative risk to be calculated, and no odds ratio has been published for this tendon. That is why this article contains no chart of risk factors as odds ratios: there is nothing to put in it that would not be invented.

What is reasoned, and must be announced as such

The rest is a matter of mechanism, not of measurement. It is useful clinically, provided it is not presented to the patient as established fact. Three families of constraint increase the load on tibialis anterior:

• External compression : tight lacing, rigid upper, high eyelet, skate, ski boot, combat boots. It is the mechanism best described clinically, in the ice hockey player.
• The demand for braking : running and walking downhill, prolonged downhill gradient, going down stairs, uneven ground. The muscle works there eccentrically under load at every step.
• Recent change : a new shoe model, a move to a lower drop, a return after a break, an abrupt increase in volume or in elevation. The tendon undergoes a constraint for which it is not prepared.

The third point deserves a clarification. The idea that too rapid a progression of load favours injury is solidly established for other structures, in particular bone: the 2024 scoping review on return to running after tibial stress fracture stresses that too rapid a progression amplifies the risk of recurrence. Nothing of the kind has been demonstrated for the tibialis anterior tendon. We apply the principle because it is physiologically coherent, knowing that it is borrowed.

What becomes of an untreated tibialis anterior tendinopathy?

The honest answer is that nobody has measured it. No study has followed a cohort of untreated patients. What can be said comes down to three observations, each with its limit:

• In the form of compression related to footwear, the authors of the review on the ice hockey player describe episodes that are often brief, easing within one to two weeks once the mechanical cause is corrected. That is a clinical observation, not a cohort follow-up.
• In the distal degenerative form, the course seems markedly more drawn out: the patients operated on by Grundy and co-authors had on average a year of symptoms before the operation, all after failure of conservative treatment, and their mean preoperative AOFAS score was 52 out of 100.
• The rupture represents the feared outcome. The series show that it readily occurs on an already degenerative tendon, but no study has quantified the risk that a distal tendinosis progresses to rupture. Stating a percentage would be an invention.

What rehabilitation, and on exactly what evidence?

No randomised trial has tested a protocol on this tendon. This chapter therefore proposes a reasoned approach, indicating for each modality where the evidence comes from and what it is worth once transposed.

The basic principle, and its acknowledged borrowing

Rehabilitation of a tendinopathy rests today on progressive loading : exposing the tendon to an increasing, tolerated, regular constraint, rather than resting it. That principle is solidly supported, but it is supported elsewhere.

The trial by Breda and co-authors, published in the British Journal of Sports Medicine in 2021, compared in 76 patients with patellar tendinopathy a progressive loading programme with a classical eccentric programme: the gain on the VISA-P score at 24 weeks was 28 points against 18, that is an adjusted difference of 9 points (95 % confidence interval 1 to 16, p = 0.023). On the Achillestendon, Beyer and co-authors had shown in 2015 that heavy slow resistance and eccentric work gave equivalent results at twelve weeks.

These results are good. They do not concern tibialis anterior. The large-scale synthesis commissioned by the British Health Technology Assessmentprogramme, published in 2023 by Cooper and co-authors, in fact confirms that exercise is the first-line treatment of tendinopathies, while stressing the heterogeneity of the protocols and the uncertainty that persists about the optimal modality.

Transposing an Achilles protocol to tibialis anterior is defensible: both tendons undergo cyclical eccentric loading in walking. Presenting it to the patient as a treatment validated for their tendon is not.

A progression in four stages

Here is a usable framework, built on load-based reasoning applied to the other tendons and on the mechanical particularities of tibialis anterior. It is offered as a reasoned approach, not as a proven protocol.

Stage 1: remove the constraint that injures, without immobilising

Before any exercise, look for and remove the mechanical cause: lacing, shoe, gradient, recent volume. In the compression form, that step is sometimes enough. The American Family Physician review mentions an initial immobilisation followed by physiotherapy for this tendon; that is a described practice, not compared with an early return to loading, and it must stay brief so as not to decondition a muscle whose work is precisely to brake.

Isometrics have their place here, for their analgesic effect: Rio and co-authors showed, in patellar tendinopathy, that isometric work produced immediate analgesia. On tibialis anterior: isometric dorsiflexion against manual or elastic resistance, ankle in neutral, sets of 30 to 45 seconds, repeated several times a day, at an intensity that does not wake the pain.

Stage 2: load the tendon through a controlled range

The basic exercise is resisted dorsiflexion, with elastic or pulley, performed slowly. The logic of heavy slow resistance consists of favouring slowness and load over the number of repetitions: three to four sets of six to fifteen repetitions, three seconds up and three down, every other day.

The tolerance marker, borrowed from the Achilles and patellar tendinopathy protocols, is as follows: pain that is acceptable during the exercise, that comes down within twenty-four hours and does not worsen from one session to the next.

Stage 3: reproduce the function, that is, braking

This is the step specific to this tendon, and the one most often forgotten when strengthening it as a dorsiflexor. Tibialis anterior works above all to hold back the forefoot. The work must therefore become eccentric and move closer to the step:

• Standing, with the weight on the heels, let the forefoot descend slowly towards the ground against its own weight, then lift back up with the help of the other foot.
• Controlled descent of a slope, then of steps, insisting on a soft landing of the foot.
• Progressive downhill walking, at first short and on a gentle slope, the sensation of the “foot slapping” serving as a fatigue marker.

Stage 4: reintroduce running or long walking

Progression is by intervals of walking and running, volume before intensity, reintroducing downhill gradient last, because it is the constraint most specific to this tendon. These principles come from the recommendations for return after tibial bone stress injury: the scoping review published in 2024 in Sports Medicine formulates them from fifty studies, but concludes that the resulting recommendations rest on level IVevidence. Caution is therefore doubly in order here, since the principle is both of low evidential level and borrowed from another structure.

The passive modalities, and what they are worth

No passive modality has been evaluated on this tendon. Two remarks, however, are important in practice:

• Corticosteroid injection deserves particular caution here. That is not an opinion: in the Gwynne-Jones rupture series, four patients out of seven were on systemic corticosteroid therapy and one had received a local injection, which led the authors to retain that association. The tendon is superficial, poorly vascularised in its distal portion, and the feared consequence is a rupture.
• Shockwave therapy has been evaluated in plantar fasciitis, the Achilles tendon and the patellar tendon, with effects reported in a 2023 meta-analysis. Nothing exists for tibialis anterior, and the anatomy is not comparable.

Footwear, lacing, running: what should you change in practice?

This is the most useful chapter of this article, and paradoxically the one that rests on the most trivial cause: a lace too tight in the wrong place.

Lacing, a frequent cause with an immediate correction

The mechanism described in the ice hockey player holds for any closed shoe: in dorsiflexion, the tendon becomes prominent and finds itself caught between the bone and what covers it. Lacing tightened over the instep turns every step into compression. The correction is mechanical, free, and its effect is judged in a single outing:

• Skip the painful eyelet. Identify the tender point, then relace by passing the lace directly from a lower eyelet to the upper eyelet on the same side, with no crossover above the area. It is the most effective and the simplest modification.
• Loosen the middle third and hold from the top. Holding the foot is not achieved over the instep but around the ankle: a “lock lacing” loop at the top allows the middle to be released without the foot sliding.
• Interpose padding under the run of the laces, thin foam or a padded tongue. That is what Levitsky and co-authors describe, along with progressively breaking in a new shoe.
• Check the tongue : a thin tongue, badly centred or folding up like a concertina, concentrates the pressure on a ridge.

The shoe itself

Three elements deserve examination, and it is better to look at them than to assume them:

• The rigidity and height of the upper. The higher and more rigid the upper, the more it presses on the retinacular zone in dorsiflexion. That is the common feature of the skate, the ski boot, the combat boot and the high-cut hiking boot.
• The recent change of model. A new, unworn-in shoe, a modified drop, a stiffer sole: the demand for braking changes, and the tendon has not been prepared.
• Wear. A very worn shoe alters the landing of the step and may shift the constraint, but no data documents this for this tendon in particular.

A word on foot orthoses: the 2022 synthesis review mentions lateral wedge orthoses in the management of fibularis tendinopathies, not of tibialis anterior. Nothing allows one to state that a foot orthosis modifies the constraint on this tendon, and we do not claim so.

Running: what can be modified, and what is unknown

Two levers are consistent with the function of the muscle, and both belong to mechanical reasoning more than to evidence:

• Downhill gradient. It is the constraint most specific to tibialis anterior, since it multiplies the braking work. Removing it in the painful phase, then reintroducing it last, is the most logical modification.
• The landing of the step. A frank heel strike requires the tendon to hold back a greater travel of the forefoot. Reducing the extent of that fall, often by a slight increase in cadence, mechanically lessens the braking work. That relationship has not been measured for this tendon, and modifying the stride has its own unwanted effects: it shifts the load towards the calf and the Achilles, and must be introduced gradually.

What do the published clinical cases teach us?

Four real cases, all indexed, chosen because each corrects a false idea about this tendon. None is a vignette reconstructed for the demonstration.

How do you apply all this in practice?

A first session that comes down to four manoeuvres, and three sentences to say to the patient that avoid selling them a certainty the literature does not have.

The first session

1. Situate, then tension. Follow the course of the tendon with a finger, from the lower quarter of the leg to the inner border of the midfoot, and note the painful point. Then passive plantarflexion and eversion. Pain reproduced along the course points; pain over the bone or in the compartment points elsewhere.

2. Rule out the flag before everything else. Look at the prominence of the tendon on resisted dorsiflexion, compared with the healthy side. Watch the gait, especially the landing of the foot at heel strike. A foot that slaps, a steppage gait, an absent prominence: you refer, you do not rehabilitate.

3. Ask about the footwear, and test it. Ask for the shoe of the activity that triggers it. Look for the mark of the lacing on the instep. Relace skipping the painful eyelet, repeat the test. It is diagnostic and therapeutic in the same movement.

4. Set the starting load. Isometric dorsiflexion if the pain is sharp, slow resisted dorsiflexion otherwise, with the tolerance marker: pain acceptable during, come down the next day, not increasing from one session to the next.

What you say to the patient

Three formulations, which respect the real state of knowledge without discouraging:

• « This tendon works mainly to brake your foot as it comes down towards the ground. That is why it hurts going downhill and not going up.” A mechanical explanation that is accurate and immediately understandable.
• « We are going to start by looking at your shoes, because that is often where it happens, and because it can be corrected straight away. ” That gives a concrete action from the first session.
• « This tendon has been studied far less than the Achilles tendon. So we apply what works on the other tendons, watching your reactions closely. ” It is honest, and it justifies regular reassessment rather than following a fixed protocol.

When to refer on

• Without delay : suspected rupture, signs of infection, focal bony pain suggesting a stress fracture, neurological deficit.
• Within a few weeks : absence of any improvement after correction of the footwear and well-conducted progressive loading, which should prompt the diagnosis to be reconsidered before blaming adherence.
• After several months : surgery is discussed only after failure of well-conducted conservative treatment. In Grundy's series, the operated patients had on average a year of symptoms, and the 2022 review places the surgical discussion after three to six months of failure.

Frequently asked questions

Bibliography

Every reference has been verified by its PubMed identifier or its DOI, including its author list. The sources marked “another tendon” are those this article uses by transposition, and which do not concern tibialis anterior.

On tibialis anterior

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Differential diagnosis

16. Aweid O, Del Buono A, Malliaras P, Iqbal H, Morrissey D, Maffulli N, Padhiar N. Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg. Clin J Sport Med 2012;22(4):356-70. PMID 22627653
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18. Newman P, Witchalls J, Waddington G, Adams R. Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. Open Access J Sports Med 2013;4:229-41. PMID 24379729
19. Lavery KP, McHale KJ, Rossy WH, Theodore G. Ankle impingement. J Orthop Surg Res 2016;11(1):97. PMID 27608626

Load, exercise and return, on other tendons or other structures

20. Breda SJ, Oei EHG, Zwerver J, Visser E, Waarsing E, Krestin GP, de Vos RJ. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. Br J Sports Med 2021;55(9):501-509. another tendon PMID 33219115
21. Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. Am J Sports Med 2015;43(7):1704-11. another tendon PMID 26018970
22. Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med 2015;49(19):1277-83. another tendon PMID 25979840
23. Cooper K, Alexander L, Brandie D, Brown VT, Greig L, Harrison I, MacLean C, Mitchell L, Morrissey D, Moss RA, Parkinson E, Pavlova AV, Shim J, Swinton PA. Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness. Health Technol Assess 2023;27(24):1-389. all tendinopathies PMID 37929629
24. Charles R, Fang L, Zhu R, Wang J. The effectiveness of shockwave therapy on patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis: a systematic review and meta-analysis. Front Immunol 2023;14:1193835. another tendon PMID 37662911
25. George ERM, Sheerin KR, Reid D. Criteria and Guidelines for Returning to Running Following a Tibial Bone Stress Injury: A Scoping Review. Sports Med 2024;54(9):2247-2265. bone, not tendon PMID 39141251

The two trials the search returns, and which do not concern this tendon

26. Holden S, Lyng K, Graven-Nielsen T, Riel H, Olesen JL, Larsen LH, Rathleff MS. Isometric exercise and pain in patellar tendinopathy: A randomized crossover trial. J Sci Med Sport 2020;23(3):208-214. PMID 31735531
27. Sobhani S, Zwerver J, van den Heuvel E, Postema K, Dekker R, Hijmans JM. Rocker shoes reduce Achilles tendon load in running and walking in patients with chronic Achilles tendinopathy. J Sci Med Sport 2015;18(2):133-8. PMID 24636129

PubMed counts cited in the article: searches run on 15 August 2026 on the title and abstract fields. These are measurements carried out for this article, and not published data.