Extensor Digitorum Longus Pain: US Runners

For US runners, experiencing pain along the anterior lower leg can often be attributed to issues involving the extensor digitorum longus tendon, an ailment frequently diagnosed by sports medicine professionals. Overuse injuries, a common concern, often correlate with repetitive activities such as those studied at the American Academy of Podiatric Sports Medicine conferences. Diagnostic ultrasound, a non-invasive imaging technique, plays a crucial role in visualizing the extent of the damage to the extensor digitorum longus tendon, differentiating it from other potential causes of anterior leg pain. Furthermore, customized orthotics prescribed by podiatrists can provide support and alleviate stress on the extensor digitorum longus tendon, helping to mitigate the pain experienced by runners.

Understanding Extensor Digitorum Longus (EDL) Tendonitis in Runners

Extensor Digitorum Longus (EDL) Tendonitis represents a significant impediment to the training and performance of many runners. This condition, characterized by inflammation and pain in the EDL tendon, can sideline even the most dedicated athletes. This section aims to provide a foundational understanding of EDL Tendonitis, specifically tailored to the needs of US-based runners.

Understanding this condition is paramount for effective prevention strategies, early recognition of symptoms, and ultimately, informed treatment decisions.

Defining EDL Tendonitis

Extensor Digitorum Longus (EDL) Tendonitis is an overuse injury affecting the tendon responsible for lifting the toes (digits 2-5) and assisting in ankle dorsiflexion. It's characterized by inflammation of the EDL tendon, often at the point where it crosses the ankle or inserts into the toes.

This inflammation can arise from repetitive strain, leading to microscopic tears and subsequent pain. The condition can manifest acutely following a sudden increase in training or develop gradually over time with chronic overuse.

Prevalence Among Runners

While precise epidemiological data on EDL Tendonitis is limited, it is a recognized and frequently encountered condition within the running community. The repetitive nature of running, coupled with the specific biomechanical demands placed on the lower leg, predisposes runners to this injury.

Factors such as improper footwear, inadequate stretching, and sudden increases in training intensity contribute significantly to its occurrence. Therefore, runners, particularly those in the US who often engage in high-mileage training regimens, are at a heightened risk.

The Critical Role of Early Diagnosis and Treatment

Early diagnosis and treatment are crucial in managing EDL Tendonitis and preventing long-term complications. Delaying treatment can lead to chronic pain, reduced performance, and potentially, the development of compensatory movement patterns that can increase the risk of other injuries.

Recognizing the symptoms early allows for prompt intervention through conservative measures, such as rest, ice, and targeted exercises. This proactive approach can significantly reduce recovery time and enable runners to return to their training schedules more quickly and safely. Furthermore, early intervention can prevent the condition from progressing to a stage where more aggressive treatments, such as corticosteroid injections or, in rare cases, surgery, may be considered.

Anatomy and Function of the Extensor Digitorum Longus

To fully appreciate the mechanisms behind EDL Tendonitis, a solid understanding of the Extensor Digitorum Longus (EDL) muscle and tendon is essential. This knowledge base forms the foundation for recognizing why runners are particularly susceptible to this condition. By examining the anatomy, function, and physiological actions of the EDL, we gain critical insights into injury etiology and inform targeted preventative measures.

The EDL Muscle: Origin, Insertion, and Function

The EDL muscle is located in the anterior compartment of the lower leg, a region responsible for dorsiflexion of the ankle and extension of the toes.

Its origin lies on the upper portion of the anterior fibula and the lateral tibial condyle. From this proximal attachment, the muscle extends distally.

The EDL inserts via long tendons into the dorsal aspects of the second to fifth toes. This insertion point is crucial for its role in toe extension.

Its primary function is to dorsiflex the foot at the ankle joint and extend the four lesser toes. This combined action is vital during the swing phase of running, allowing the foot to clear the ground.

The EDL Tendon: Course and Attachment

The EDL tendon is a continuation of the muscle belly. It courses along the anterior aspect of the ankle, passing beneath the extensor retinaculum, a fibrous band that helps hold the tendons in place.

As the tendon reaches the forefoot, it divides into four slips. Each slip inserts onto the dorsal aspect of the distal phalanx of toes two through five.

Specifically, the attachment occurs at the metatarsophalangeal (MTP) joints. This insertion allows for the extension of each of the lesser toes during activity.

Physiological Actions and Biomechanical Considerations

The EDL plays a critical role in several key movements, which are frequently challenged during running.

Dorsiflexion and Toe Extension

The EDL facilitates dorsiflexion of the foot, lifting the foot towards the shin. This action is essential for clearing the ground during the swing phase of gait.

Simultaneously, it extends the toes at the MTP joints, further contributing to foot clearance and proper foot placement.

Impact of Foot Inversion

Foot inversion (rolling the sole of the foot inward) can place additional stress on the EDL tendon.

This occurs because inversion increases the distance the tendon must travel to reach its insertion points. Over time, this increased stress can lead to inflammation and tendonitis.

Ankle Joint Movements and EDL Stress

Excessive or repetitive ankle joint movements, particularly those involving dorsiflexion combined with inversion, can exacerbate stress on the EDL tendon.

Runners with poor biomechanics or those who frequently run on uneven terrain are more susceptible to this type of stress.

The Role of the Synovial Sheath

The EDL tendon is surrounded by a synovial sheath. This sheath reduces friction as the tendon moves within the ankle.

Inflammation of this sheath (tenosynovitis) can occur alongside or independently of EDL Tendonitis, further contributing to pain and dysfunction. Understanding this protective mechanism helps clarify the potential sources of pain.

Causes and Risk Factors for EDL Tendonitis in Runners

Understanding the root causes and contributing risk factors is paramount in preventing and managing Extensor Digitorum Longus (EDL) Tendonitis among runners. EDL Tendonitis, characterized by inflammation and pain in the EDL tendon, typically arises from a complex interplay of overuse, biomechanical imbalances, and external stressors. This section delves into the specific factors that contribute to the development of this common running injury.

Common Causes: Overuse and Training Errors

Overuse is a primary culprit behind EDL Tendonitis. Running, by its nature, is a repetitive activity, and the EDL muscle is continuously engaged in dorsiflexion and toe extension with each stride. This repetitive motion can lead to microscopic tears and inflammation within the tendon.

Sudden increases in training intensity or mileage are particularly problematic. When runners abruptly increase their weekly mileage, speed work, or hill training, the EDL tendon is subjected to a workload it isn't adequately prepared for. This rapid escalation overwhelms the tendon's capacity to adapt, resulting in inflammation and pain.

Intrinsic Risk Factors: Biomechanical Predispositions

Intrinsic risk factors are inherent characteristics of the runner's body that increase their susceptibility to EDL Tendonitis. These factors often involve biomechanical abnormalities.

Overpronation, the excessive inward rolling of the foot upon impact, is a significant intrinsic risk factor. Overpronation causes the lower leg to rotate internally, placing increased stress on the EDL tendon as it works to maintain foot and ankle stability.

Biomechanical abnormalities such as flat feet (pes planus) or high arches (pes cavus) can also contribute. Flat feet often lead to overpronation, while high arches may result in decreased shock absorption, both of which increase stress on the EDL tendon. Furthermore, leg length discrepancies and tibial torsion can also alter biomechanics and increase risk.

Poor flexibility in the ankle and foot further exacerbates the problem. Tight calf muscles, in particular, limit ankle dorsiflexion, forcing the EDL tendon to work harder to achieve adequate foot clearance during the swing phase of running. Limited range of motion in the foot also decreases shock absorption.

Extrinsic Risk Factors: Environmental and Equipment-Related Factors

Extrinsic risk factors are external elements related to a runner's training environment, equipment, and habits.

Improper footwear, including worn-out or ill-fitting running shoes, significantly elevates the risk of EDL Tendonitis. Worn-out shoes lose their cushioning and support, increasing impact forces on the foot and ankle. Ill-fitting shoes can alter gait patterns and contribute to abnormal stress on the EDL tendon. Selecting shoes appropriate for your foot type and gait is crucial.

Running on hard or uneven surfaces places additional stress on the musculoskeletal system, including the EDL tendon. Concrete and asphalt offer little give, increasing impact forces with each stride. Uneven surfaces, such as trails with rocks and roots, require increased muscle activation for stabilization, adding to the load on the EDL.

Tight calf muscles, though seemingly unrelated, are a common extrinsic risk factor. Tightness in the gastrocnemius and soleus muscles restricts ankle dorsiflexion, forcing the EDL to compensate. This compensation increases the workload on the EDL tendon, making it more prone to inflammation and injury. Regular stretching of the calf muscles is essential for maintaining proper ankle mechanics.

Recognizing the Symptoms: Clinical Presentation and Diagnosis

Identifying Extensor Digitorum Longus (EDL) Tendonitis early is crucial for effective management and preventing chronic pain. A combination of symptom awareness, thorough physical examination, and, when necessary, diagnostic imaging leads to an accurate diagnosis. This section details how EDL Tendonitis typically presents and the diagnostic procedures employed.

Common Symptoms of EDL Tendonitis

Runners experiencing EDL Tendonitis often report a constellation of symptoms that, when considered together, point towards the condition. It's important to note that symptom severity can vary significantly between individuals.

Pain is the most common presenting symptom. The pain is typically localized along the top of the foot and/or the anterior ankle.

This pain may radiate distally towards the toes or proximally up the lower leg.

Another key indicator is pain exacerbation with dorsiflexion and toe extension.

Activities that require these movements, such as uphill running or prolonged walking, often intensify the discomfort.

Swelling may or may not be present. When it does occur, it is usually mild and located around the affected tendon.

Redness and tenderness to the touch are less frequent but can be observed in more acute cases of inflammation.

The Physical Examination Process

A comprehensive physical examination is essential for confirming the diagnosis of EDL Tendonitis. It involves a systematic evaluation of the foot and ankle.

Palpation of the tendon is a critical step. The examiner will gently press along the course of the EDL tendon to identify specific points of tenderness.

Pain elicited during palpation is a strong indicator of tendonitis.

Assessment of ankle and toe range of motion helps determine the extent of the injury. The examiner will assess the range of motion for dorsiflexion, plantarflexion, toe extension, and toe flexion.

Limited or painful range of motion can signify EDL Tendonitis.

Strength testing of dorsiflexion and toe extension assesses the function of the EDL muscle.

Weakness or pain during these movements supports the diagnosis.

Biomechanical evaluation of foot and ankle alignment is crucial. The examiner will assess for factors like overpronation, flat feet, high arches, and leg length discrepancies, all of which can contribute to EDL Tendonitis.

The Role of Imaging Techniques

While a clinical diagnosis is often sufficient, imaging techniques may be necessary to confirm the diagnosis or rule out other conditions.

Ultrasound is a valuable tool for assessing tendon inflammation and detecting tears. It's non-invasive and relatively inexpensive. Ultrasound provides real-time imaging.

MRI (Magnetic Resonance Imaging) offers a more detailed view of the soft tissues and is useful for visualizing soft tissue damage and ruling out other conditions, such as stress fractures or nerve entrapments. MRI provides a higher resolution image than ultrasound.

MRI is generally reserved for cases where the diagnosis is unclear or when more serious pathology is suspected.

Ruling Out Other Conditions: Differential Diagnosis

Extensor Digitorum Longus (EDL) Tendonitis, while frequently encountered in runners, shares symptomatic overlap with several other conditions affecting the foot and lower leg. A precise diagnosis hinges on carefully differentiating EDL Tendonitis from these mimics to ensure appropriate and effective treatment strategies are implemented. Failure to do so can lead to prolonged discomfort and delayed recovery.

Common Conditions Mimicking EDL Tendonitis

Several conditions present with symptoms similar to EDL Tendonitis. These require careful consideration during the diagnostic process.

Stress Fractures

Stress fractures, particularly those affecting the metatarsals or the tibia, can cause pain along the top of the foot or the anterior lower leg. The pain is often activity-related and increases with weight-bearing.

Unlike EDL Tendonitis, stress fractures usually present with pinpoint tenderness directly over the bone, which can be identified through palpation. Diagnostic imaging, such as X-rays or bone scans, is often necessary to confirm the presence of a stress fracture.

Muscle Strains in the Anterior Compartment

Strains affecting muscles within the anterior compartment of the lower leg, such as the Tibialis Anterior, can produce pain and discomfort that may be mistaken for EDL Tendonitis. These strains typically occur due to overuse or sudden forceful contractions.

Differentiating muscle strains involves assessing the specific location of the pain and tenderness. Resisted dorsiflexion and inversion will often reproduce the pain associated with Tibialis Anterior strains, while similar movements may or may not aggravate EDL Tendonitis.

Tenosynovitis

Tenosynovitis, or inflammation of the tendon sheath, can affect any tendon in the foot and ankle, including the EDL tendon. The primary difference lies in the nature of the inflammation. Tenosynovitis involves the sheath surrounding the tendon, whereas tendonitis specifically affects the tendon itself.

Clinically, tenosynovitis may present with more diffuse swelling and crepitus (a crackling sensation) upon movement of the tendon. Ultrasound imaging can be particularly helpful in visualizing the inflamed tendon sheath and distinguishing it from isolated tendon inflammation.

Anterior Compartment Syndrome

Anterior compartment syndrome involves increased pressure within the anterior compartment of the lower leg. This elevated pressure compromises blood flow and nerve function.

The hallmark symptoms include severe pain, tightness, and paresthesia (numbness or tingling) in the foot and lower leg. In acute cases, compartment syndrome requires immediate medical intervention, including fasciotomy, to relieve the pressure. Chronic exertional compartment syndrome (CECS) may present with activity-related pain that resolves with rest, but it lacks the tenderness specific to EDL Tendonitis.

Nerve Entrapment

Entrapment of nerves in the foot and ankle, such as the superficial peroneal nerve, can cause pain and sensory disturbances that mimic EDL Tendonitis. Nerve entrapment often results in pain, numbness, or tingling along the distribution of the affected nerve.

A careful neurological examination, including assessing sensation and nerve conduction studies, can help differentiate nerve entrapment from EDL Tendonitis. Tinel's sign (tapping over the nerve to elicit symptoms) may also be positive in cases of nerve entrapment.

The Importance of Accurate Differentiation

Accurate differentiation of these conditions from EDL Tendonitis is paramount. Misdiagnosis can lead to ineffective treatment, prolonged symptoms, and potentially chronic complications. A thorough clinical evaluation, coupled with appropriate diagnostic imaging when necessary, is essential to ensure that runners receive the correct diagnosis and the most effective treatment plan.

Treatment Strategies for EDL Tendonitis

Effective management of Extensor Digitorum Longus (EDL) Tendonitis demands a multi-faceted approach. This strategy aims to alleviate pain, reduce inflammation, restore function, and prevent recurrence. Treatment protocols typically involve acute phase interventions, structured rehabilitation programs, and, in some cases, advanced medical procedures.

Acute Phase Management: RICE and NSAIDs

The initial phase of treatment centers on minimizing inflammation and pain. The cornerstone of this acute management is the RICE protocol: Rest, Ice, Compression, and Elevation.

• Rest: Cessation of aggravating activities, such as running, is paramount to allow the tendon to heal. Cross-training activities that do not stress the EDL tendon, such as swimming or cycling at low intensity, may be considered to maintain cardiovascular fitness.

• Ice: Applying ice packs to the affected area for 15-20 minutes, several times a day, helps reduce inflammation and pain. Always use a barrier (e.g., a towel) between the ice pack and the skin to prevent frostbite.

• Compression: Using a compression bandage can help minimize swelling. Ensure the bandage is not too tight, which could impede circulation.

• Elevation: Elevating the foot above heart level assists in reducing swelling by promoting fluid drainage.

Over-the-counter Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen or naproxen, can provide pain relief and reduce inflammation. However, it's crucial to adhere to recommended dosages and be aware of potential side effects, such as gastrointestinal upset. Long-term use of NSAIDs should be discussed with a healthcare professional.

Rehabilitation and Physical Therapy Interventions

Following the acute phase, a structured rehabilitation program is essential to restore strength, flexibility, and proper biomechanics. Physical therapy plays a crucial role in guiding this process.

Stretching Exercises

Stretching exercises are vital for restoring flexibility to the EDL and surrounding muscles.

• EDL Stretch: Gently flex the toes downwards and hold the stretch for 20-30 seconds, repeating several times a day.

• Calf Stretches: Tight calf muscles can contribute to altered biomechanics and increased stress on the EDL tendon. Regular calf stretches, such as the gastrocnemius and soleus stretches, are essential.

• Tibialis Anterior Stretch: Stretching the tibialis anterior muscle helps balance the forces around the ankle. Perform this stretch by pointing the toes downwards and inwards.

Strengthening Exercises

Strengthening the lower leg muscles helps provide support and stability to the ankle and foot.

• Toe Raises: Perform toe raises by lifting only the toes off the ground while keeping the heel planted.

• Heel Raises: Heel raises strengthen the calf muscles, which indirectly supports the EDL.

• Ankle Inversion/Eversion Exercises: Using resistance bands, perform controlled ankle inversion and eversion exercises to strengthen the muscles that control ankle stability.

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• Toe Curls and Marbles Pick-up: These exercises help strengthen the intrinsic foot muscles, which are crucial for proper foot mechanics.

Taping Techniques

Kinesio taping can be used to provide support to the EDL tendon, reduce pain, and improve proprioception. Taping techniques can help to offload the tendon and promote proper alignment of the foot and ankle. A physical therapist can guide runners on the appropriate taping methods.

Orthotics

Orthotics, such as arch supports, may be recommended to correct biomechanical issues, such as overpronation. Orthotics help to redistribute pressure and reduce stress on the EDL tendon. Custom-molded orthotics provide more individualized support compared to over-the-counter options.

Advanced Treatment Options

In cases where conservative treatments fail to provide adequate relief, advanced treatment options may be considered.

• Corticosteroid Injections: Corticosteroid injections can reduce inflammation and pain in severe cases. However, these injections should be used with caution due to potential side effects, such as tendon weakening or rupture. They provide temporary relief and should be combined with rehabilitation to address the underlying cause of the tendinopathy.

It's important to note that corticosteroid injections are not a long-term solution and should be administered by a qualified healthcare professional.

The Role of Physical Therapists

Physical Therapists (PTs) are integral to the management of EDL Tendonitis. They provide comprehensive assessments, develop individualized treatment plans, and guide patients through the rehabilitation process. PTs use a variety of techniques, including manual therapy, exercise prescription, and education, to help runners return to their pre-injury activity level safely and effectively.

PTs also play a vital role in identifying and addressing biomechanical factors that may contribute to EDL Tendonitis. Their expertise ensures a comprehensive and tailored approach to managing this condition.

Preventing EDL Tendonitis: Practical Strategies for Runners

Prevention is paramount when it comes to Extensor Digitorum Longus (EDL) Tendonitis. By implementing proactive measures, runners can significantly reduce their risk of developing this debilitating condition and maintain their training regimen. Prevention hinges on addressing training habits, footwear choices, and muscular imbalances.

Smart Training Techniques

Overtraining and sudden increases in training load are significant contributors to EDL Tendonitis. Implementing sensible training strategies is crucial for injury prevention.

Gradual Progression

The principle of progressive overload is key to safe and effective training. Avoid increasing mileage or intensity by more than 10% per week. This allows the tendons and muscles to adapt to the increased stress without being overloaded. This gradual approach ensures that the EDL tendon isn't subjected to sudden, excessive strain.

Rest and Recovery

Rest days are just as important as training days. Allowing the body adequate time to recover is essential for preventing overuse injuries. Incorporate at least one or two rest days per week into your training schedule. These days should involve complete rest or very low-intensity activities.

Warm-up and Cool-down

Proper warm-up and cool-down routines prepare the muscles and tendons for activity and aid in recovery. A dynamic warm-up before running increases blood flow and flexibility. A cool-down, including static stretching, helps reduce muscle soreness and improve flexibility.

Footwear and Orthotics: The Foundation of Prevention

The shoes you choose and whether you use orthotics can have a profound impact on the health of your EDL tendon. The right footwear can mitigate stress, while orthotics can correct underlying biomechanical issues.

Shoe Selection

Choosing the right running shoe is paramount. Consider your foot type (neutral, pronated, or supinated) and running style when selecting shoes. Visit a specialty running store for a professional fitting. Replace your running shoes every 300-500 miles to ensure adequate cushioning and support. Worn-out shoes lose their shock-absorbing capabilities, increasing stress on the lower leg.

Orthotic Intervention

Orthotics can be instrumental in correcting biomechanical imbalances, such as overpronation. Overpronation places excessive stress on the EDL tendon, increasing the risk of tendinitis. Custom-molded or over-the-counter orthotics can provide support and correct alignment. Consult with a podiatrist or physical therapist to determine if orthotics are appropriate for you.

Flexibility and Strength: Building a Resilient Lower Leg

Muscular imbalances and inflexibility can significantly contribute to EDL Tendonitis. A comprehensive flexibility and strength program is vital for maintaining healthy tendons and muscles.

Stretching Regimen

Regularly stretching the calf muscles, ankle, and foot is crucial. Tight calf muscles can limit ankle dorsiflexion. Limited dorsiflexion increases stress on the EDL tendon. Focus on stretches like the gastrocnemius and soleus stretches, holding each stretch for 20-30 seconds. Also, incorporate stretches specifically targeting the tibialis anterior.

Strengthening Exercises

Strengthening the lower leg and foot muscles improves stability and reduces stress on the EDL tendon. Include exercises such as calf raises, toe raises, and ankle inversion/eversion exercises with resistance bands. Incorporating intrinsic foot muscle exercises, like toe curls and marble pick-ups, can further enhance foot stability and mechanics.

Knowing When to Seek Professional Help

Recognizing when self-management strategies are insufficient and professional medical intervention is necessary is a critical aspect of managing Extensor Digitorum Longus (EDL) Tendonitis. Failing to seek timely care can lead to chronic pain, prolonged recovery, and potentially more severe complications. Understanding the specific signs and symptoms that warrant a consultation with a healthcare professional empowers runners to make informed decisions about their health and well-being.

Indications for Consulting with Professionals

Several key indicators should prompt a runner to seek advice from a sports medicine physician, podiatrist, or physical therapist. These professionals possess the expertise to accurately diagnose and effectively treat EDL Tendonitis, ensuring a safe and efficient return to running.

Persistent Pain

Persistent pain despite diligent home treatment is a primary indication for seeking professional help. If rest, ice, compression, elevation (RICE protocol), and over-the-counter pain relievers fail to provide significant relief after a week or two, further evaluation is warranted. This persistent discomfort may signal a more complex underlying issue that requires targeted intervention.

Functional Limitations

Difficulty with ambulation, specifically difficulty walking or running due to pain, is a serious sign. The inability to perform daily activities without significant discomfort suggests that the EDL Tendonitis is impacting functional mobility and requires professional assessment. Continuing to push through the pain can exacerbate the condition and delay healing.

Visible Signs of Inflammation

Significant swelling or redness around the ankle or top of the foot is indicative of acute inflammation and potential tissue damage. While mild swelling can be managed with home remedies, pronounced inflammation necessitates professional evaluation to rule out infection or other complications.

Suspicion of a Stress Fracture

The possibility of a stress fracture should always be considered, especially in runners who have recently increased their training intensity or volume. Stress fractures can mimic the symptoms of EDL Tendonitis, and a missed diagnosis can lead to further bone damage. If the pain is deep, localized, and worsens with weight-bearing, imaging studies may be necessary to rule out a fracture.

When an Orthopedic Surgeon is Necessary

While sports medicine physicians, podiatrists, and physical therapists can effectively manage most cases of EDL Tendonitis, certain situations necessitate referral to an orthopedic surgeon. These typically involve more severe or complex cases that may require surgical intervention.

Failure of Conservative Treatment

Failure of conservative treatment, despite adherence to a comprehensive rehabilitation program, is a key indication for surgical consultation. If symptoms persist or worsen after several months of physical therapy, bracing, and activity modification, surgery may be considered as a last resort.

Suspected Tendon Tear

A suspected tendon tear or other structural damage to the EDL tendon is another critical reason for referral. A complete or partial tear can significantly impair function and may require surgical repair to restore stability and range of motion. MRI imaging is often necessary to confirm the presence and extent of a tendon tear.

Structural Abnormalities

Underlying structural abnormalities may warrant a surgical consult. Issues within the foot itself, or lower leg may exacerbate the condition, delaying recovery. Orthopedic surgery may be necessary to correct structural problems and provide long-term relief.

By recognizing these critical indicators and seeking timely professional help, runners can effectively manage EDL Tendonitis, minimize the risk of complications, and return to their sport safely and efficiently.

So, if you're a US runner feeling pain on the top of your foot, especially after upping your mileage, don't ignore it. Give your body some rest, maybe try some new lacing techniques, and definitely consider seeing a physical therapist. Addressing that extensor digitorum longus tendon early can get you back on the road feeling strong and pain-free in no time!