Tibialis Anterior Tendon Rupture: Diagnosis and Surgical Repair of the Top of Foot Tendon

What Is the Tibialis Anterior Tendon?

The tibialis anterior is the primary dorsiflexor of the foot — the muscle-tendon unit responsible for lifting the foot during the swing phase of walking and controlling the foot during the landing phase. The tendon runs down the front of the leg, crosses the ankle, and inserts into the medial cuneiform and the base of the first metatarsal on the top-inner aspect of the foot. When this tendon ruptures, the foot cannot be lifted adequately, causing a slapping gait or foot drop — an inability to clear the foot from the ground without compensatory hip flexion (steppage gait).

Who Gets Tibialis Anterior Tendon Ruptures?

Unlike most tendon ruptures which occur in athletes during high-load activities, tibialis anterior tendon rupture has a bimodal presentation. Young athletic individuals can rupture the tendon acutely during sudden eccentric loading — such as stopping suddenly or landing from a jump. More commonly, however, the rupture occurs in patients over 60 years old through chronic attritional degeneration — the tendon slowly weakens from cumulative microtrauma and degenerative change until it fails without dramatic incident. Many older patients do not recall a specific injury and present late with painless foot drop and progressive gait dysfunction.

Symptoms and Diagnosis

Acute rupture presents with sudden pain at the front of the ankle, swelling, and immediate inability to lift the foot. A palpable defect or gap in the tendon may be felt along its course on the anterior ankle. Chronic ruptures may present with only mild weakness and the gradual onset of tripping or scuffing the toe during walking.

Clinical examination assesses active dorsiflexion strength — the patient is asked to lift the foot against resistance. Significant weakness or absence of dorsiflexion confirms tendon discontinuity. Ultrasound provides rapid dynamic assessment of the tendon. MRI defines the exact rupture location, gap length, and tendon end quality — critical information for surgical planning.

Treatment Options

Non-Operative Management

Elderly, low-demand patients or those with significant comorbidities may be managed non-operatively with an ankle-foot orthosis (AFO) that passively dorsiflexes the foot during the swing phase, restoring clearance without surgery. While functional outcomes are acceptable in this population, a permanent orthosis is required as the tendon will not heal spontaneously.

Surgical Repair: Primary End-to-End Repair

Acute ruptures with good tendon end quality and minimal gap are repaired primarily — the two tendon ends are debrided and sutured together with high-strength core sutures and a circumferential running suture to restore continuity. The ankle is held in slight dorsiflexion during repair to set appropriate tension. Primary repair is most successful when performed within six weeks of rupture before tendon ends retract and atrophy.

Surgical Reconstruction with Graft or Tendon Transfer

Chronic ruptures with significant gap, tendon attrition, and retracted stumps that cannot be directly opposed require reconstruction. Options include allograft tendon interposition to bridge the defect, or tendon transfer using the extensor hallucis longus tendon. The EHL transfer is the most commonly used reconstruction — the EHL, which primarily extends the big toe, can be re-routed to restore dorsiflexion power with acceptable donor site morbidity (the big toe loses active extension but can be managed with a simple toe fusion or tenodesis).

Recovery After Tibialis Anterior Repair

The repaired or reconstructed tendon is protected in a short leg cast with the ankle in dorsiflexion for four to six weeks. Non-weight-bearing is maintained during this period. Gradual transition to a boot and then regular footwear follows at six to eight weeks with concurrent physical therapy focusing on progressive dorsiflexion strengthening. Return to normal ambulation without an orthosis typically occurs at four to six months after primary repair and six to nine months after reconstruction.

Outcomes

Surgical outcomes for tibialis anterior tendon repair and reconstruction are favorable, with most patients achieving functional restoration of dorsiflexion strength and return to normal gait. Early diagnosis and prompt referral to a foot and ankle surgeon — before significant tendon retraction and atrophy occur — provides the best opportunity for primary repair and the most predictable recovery. If you have noticed weakness lifting your foot or a change in your gait pattern, contact Balance Foot & Ankle for evaluation.

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Dr. Tom Biernacki, DPM

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Dr. Carl Jay, DPM

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Dr. Tom Biernacki, DPM

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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.