What You Should Know About Night Pain And Distal Tibialis Anterior Tendinopathy

Doug Richie Jr. DPM FACFAS

How many foot and ankle conditions do you treat that are aggravated by malpositioning of the foot during sleep?

Yes, we commonly attribute the classic morning pain of plantar fasciitis to the equinus postioning of the foot during sleep, which presumably tightens the plantar aponeurosis. We also hear significant complaints from patients with Achilles tendinosis when they step out of bed.

What about pain during the night? Over the years, I have seen one classic condition in which pain is worse during sleep. This condition is distal tibialis anterior tendinopathy.

This observation was recently verified in a recent article published by Beischer and co-workers in Foot and Ankle International.1 With this retrospective case series of 29 patients, these authors provide valuable information about a seemingly unreported condition, which we all see frequently in our offices.

Like all tendinosis conditions, distal tibialis anterior pathology is associated with obesity. This study also verified a strong predilection for women to develop tendinosis in the tibialis anterior. The researchers speculated that prolonged equinus positioning in high-heeled footwear for many years may put damaging strain on the tibialis anterior.

Prolonged equinus positioning of the foot occurs during sleep. This recent article specifically notes that patients who sleep prone are more likely to develop pain associated with tibialis anterior tendinosis. I actually see as much complaint from these patients when they sleep supine if the bed covers are too heavy.

The solution, as proposed by Beischer and colleagues, is to have patients with tibialis anterior tendinopthy sleep with a fixed ankle or leaf spring AFO device. Remember that this device should actually be dispensed for primary use during ambulation in order to be reimbursable. The use of ambulatory AFO devices purely for sleeping will not be reimbursed and the use of night splints for tendinopathy will also not qualify for reimbursement by most payors.


1. Beischer AD et al. Distal tendinosis of the tibialis anterior tendon. Foot Ankle Int 30 (11):1053-1059, 2009.

Add new comment