Tenosynovitis runners



by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit




Many types of tenosynovitis problems may develop in runners.

Popliteus tenosynovitis or tendonitis is a tear in the popliteus tendon. The popliteus tendon originates from the posterior of the femur and travels behind the knee to the anterior shin. The popliteus tendon prevents the lower leg from turning out when running.

Popliteus tendonitis is often caused when the feet roll in (pronate). Running downhill can also injure the popliteus tendon by stressing the tendon.


With popliteus tendonitis, inflammation (pain, swelling, and tenderness) is felt on the outside of the knee. Over time, scar tissue may form. It may take weeks to fully recover from tendonitis.

• The most important part of treating this condition is rest.

• Ice lessens inflammation. Putting crushed ice in a plastic bag and covering it with a towel and then putting this under the knee for 15 to 20 minutes a few times a day may help.

• Elevation and wrapping also help to lessen swelling.

• A patient may use anti-inflammatory medicines for the pain.

• A patient may be referred to physical therapy which will help the tendinitis heal faster.

• A physical therapist may use ultrasound and massage to increase blood flow to the injured area.

• Shoe inserts with a reinforced heel counter are also useful. This will give better heel control to keep the heel from pronating.

• A patient should not return to running until they are pain-free and are given medical clearance.

• A patient should always stretch first. This will loosen the muscles, especially the hamstring muscles. Stretching also helps lessen stress on the popliteus tendon.

• A patient should not run downhill for at least 3 weeks after they have started running again.


Another type of tendonitis in runners is patellar tendonitis. This presents with anterior knee pain. Patellar tendonitis is common in those who participate in jumping sports (eg, basketball, volleyball, high jumping) and running. Pain worsens when changing position from sitting to standing or when walking or running uphill.

Iliotibial band syndrome is a form of tendonitis that causes lateral knee pain. This syndrome is seen in cyclists, dancers, long-distance runners, football players, and military recruits.

Another form of tendonitis in runners is shin splints. This causes pain located at the anteromedial aspect of the shin. Runners running on hard surfaces without proper footwear are predisposed to this condition.

The Achilles tendon is the largest tendon in the human body and can withstand forces of 1,000 pounds or more. But it is also the most frequently ruptured tendon, and both professional and weekend athletes can suffer from Achilles tendonopathy, a common overuse injury and inflammation of the tendon.


Any number of events may trigger an attack of Achilles tendonitis, including:

• increasing running mileage or speed

• hill running or stair climbing

• starting up too quickly after a layoff

• sudden contraction of the calf muscles




Symptoms of Achilles tendonitis fall into a common pattern.

• Pain after exercise or running that gradually worsens

• Morning tenderness about an inch and a half above the point where the Achilles tendon is attached to the heel bone

• Stiffness in the tendon that diminishes as the tendon warms up • Swelling


Because several conditions such as a partial tendon tear and heel bursitis have similar symptoms, the patient should see their rheumatologist or orthopedist for a proper diagnosis.


Treatment depends on the degree of injury to the tendon, but usually involves:

• Rest

• Non-steroidal anti-inflammatory medication

• Orthotics

• Stretching, massage, ultrasound and appropriate exercises to strengthen the weak muscle group in front of the leg and the upward foot flexors

• Ultrasound-guided needle tenotomy with platelet-rich plasma, a procedure that helps build new tendon tissue.



• A patient will not be able to prevent Achilles tendonitis, but here are six steps to reduce the risk of it:

o Good quality running shoes. They should provide sufficient cushion for the heel strike. Using an orthotic may also help.

o Walk and stretch to warm up gradually before running.

o Stretch and strengthen the muscles in the calf.

o Increase running distance and speed gradually.

o Avoid quick sprints and hill running.

o Cool down properly after exercise.

In middle-aged weekend warriors, the tibialis posterior is the foot tendon most at risk for tenosynovitis and possible rupture. The diagnosis is frequently missed because progressive pronation is insidious. Athletes with this condition may present with flat foot deformity and often play sports with sudden stop-start or push-off activity, such as soccer, football, and basketball.

Patients typically complain of pain inferior to the medial malleolus (inner ankle bone) and decreased range of motion. Posterior tibial tendonitis is caused by repetitive trauma during the pronation phase of cutting, jumping, or running. Pes planus (flat foot) is a risk factor.

If the tendon subsequently ruptures, a progressive flatfoot deformity will result.

Early treatment includes avoiding activities that cause the symptoms and using anti-inflammatory medicines and a medial shoe wedge. Initially rest, ice, compression, and elevation may help. NSAIDs, and analgesics are used as needed. Cast immobilization may also be helpful during the early stages of the disease.

If necessary, no more than one glucocorticoid injection using ultrasound guidance into the tendon sheath may help. Formal physical therapy may be needed to strengthen the foot and ankle once the inflammation has resolved. Ultrasound-guided needle tenotomy with platelet-rich plasma (PRP) may be needed to heal the tendon.

If the tendon does rupture, the patient may need a reconstructive procedure. If the deformity is more severe, a fusion procedure may be necessary.

Patients with peroneal tendonitis present with pain and swelling on the lateral aspect of the ankle, usually posterior to the lateral malleolus. Long-distance running and any activity that requires repetitive cutting and pushing off can aggravate this condition.

Peroneal tendonitis may be related to acute inversion injury or chronic overuse secondary to hindfoot varus (back part of the ankle turns out).



For acute tenosynovitis, rest or immobilization and NSAIDs are initial measures. Wearing a cast for 2-3 weeks and then rehabilitation is appropriate for severe symptoms.

Ultrasound-guided needle tenotomy with platelet-rich plasma (PRP) may be needed to heal the tendon.

Patients with flexor hallucis longus tenosynovitis usually present with pain in the posteromedial aspect of the ankle. The pain improves with rest and increases in activities requiring push-off and extended running. FHL tenosynovitis typically is associated with repeated push-off maneuvers, such as those executed by ballet dancers or sprinters.

Treatment consists of immobilization, activity restrictions, and NSAIDs.

Variable lacing in running shoes can prevent extensor tenosynovitis . This is a condition where the tendons on the top of the foot become inflamed. Tight lacing is the usual culprit.

For more information about tendonitis, visit our sister site:
Tendonitis TendonitisandPRP.com provides reliable, accurate, and useful information on tendonitis treatment written by a board-certified rheumatologist. Learn more about how to get tendonitis relief using the most up-to-date methods.



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