Thursday, May 23, 2019

Tibialis Posterior tendinopathy by Mike Blackwell & Will Dao

What is the condition?

Tibialis Posterior tendinopathy (PTTD) presents as pain on the inside of ankle bone sometimes extending into sole of foot. The Tibialis Posterior (Tib. Post.) attaches from on the inside of the shin bone, wrapping around the inside ankle bone of the foot and attaching to the tuberosity of the navicular, the medial cuneiform and the cuboid (small bones of the foot) as well as into the bases of the 2nd- 4th metatarsals (long bones of foot) . It is the main arch supporting tendon of the foot arch and is responsible for inverting the ankle (bringing the foot in towards the opposite foot).


How do I get the condition?

There are several causes of (PTTD) and they are:
i. Overloading pattern– “too much too soon” such as somebody training for their first marathon having never ran before and not adhering to 10% rule of load increases (see blog on ….. for more information on 10% rule)
ii. A sudden change in training surface/ terrain– such as going from running on grass to running on the athletics track or from road running to trail running. Equally, if a runner suddenly introduces hill running when they have always traditionally ran on flat surfaces then this can be enough to irritate the Tib. Post. tendon.
iii. Muscle imbalances of the lower limb, hips or trunk– if muscles in the rest of the legs are weak or tight then this can increase the load placed on the Tib. Post tendon. This can eventually result in injury of Tib. Post.
iv. Unsupportive footwear or change in footwear– If your footwear doesn’t have sufficient arch support such as you find in shoes like Vans or Converse then you can get irritation of Tib. Post. Furthermore, if runners change from a shoe with a high pitch (higher heel and lower toe box) to a minimalist shoe all of a sudden, this sudden change can be too much too son for the Tib Post. tendon to cope with and can be irritated.



The main message to glean from the above is that tendons don’t like sudden change in loading habbits but prefer gradual and progressive changes in load.


How long will it take to Fix?

This is too hard to answer as a generalised rule as it all depends on how long you have had the injury (the longer you’ve had the injury, the longer it usually takes to recover), how severe your injury is and what your preexisting base line fitness is (strength, mobility and cardiovascular fitness). Early signs of symptom improvement should start to happen after 5-7 days of commencing physio treatment but fully strengthening any muscle takes at least 8 weeks. As such, TPT should be improved significantly by 2-3 months of consistent work with your physio.


What do I do to Fix it?

There are several stages to the recovery of this injury which is as follows:
i. Non Steroidal Anti Inflammatories (NSAIDS)– one of the best things to do when you first notice these symptoms is to speak to your GP or Pharmacist about commencing anti inflammatories such as ibuprofen or nurofen. A common concern that we often hear from patients is that they don’t want to take medication as this is “masking the pain” but in actual fact there is inflammation associated with TPT and the anti inflammatories actually treat that issue. Also, we recommend that you take them for 4-5 days continuously for recommended dose to receive the biggest benefit from these medication.

ii. Wear supportive shoes, tape foot or orthotics– To allow the Tib Post to rest, we recommend either wearing supportive footwear (good running shoes tend to work well) or having your foot strapped with a low dye technique. If your physio feels your foot requires additional support and the foot tape was helpful then they may refer you to see a podiatrist for orthotics (customised insoles) for your shoes.

iii. Massage & joint mobilisation– although we don’t recommend massage of the affected tendon, it can be helpful to massage the surrounding areas such as the lateral shin muscles, the gastrocnemius (calf) muscle, achilles tendon and soles of the foot to offload the Tib. Post. Furthermore, stiffness in some the joints of the foot, ankle or rest of the lower limb could be contributing to your injury so mobilisation of the appropriate stiff joints can help the initial receovery.

iv. Strengthen Tib. Post.- PTTD occurs because the capacity that the Tib. Post. tendon has to cope with the load being placed on it is not enough. As such specific exercises to strengthen the Tib Post are necessary

A. Tibialis Posterior strengthening exercises- Make sure that you point your foot down before you start this exercise so that the tendon at the front of the ankle is relaxed. Then quickly lift foot up towards ceiling (1 second) and then slowly relax foot back towards the floor (4 seconds). 8 repetitions, 3 sets, alternate days.

B. Calf raise exercises- 2 leg then 1 leg- the main focus should be on maintaining the arch in your foot throughout this exercise, specifically not letting your arch collapse during this exercise

v. Work on strength & mobility higher up the kinetic chain– As well as looking at the overall strength and mobility of the foot itself for PTTD injuries, it is important to look further up the kinetic chain as far as the pelvis and lower back. Muscle imbalances or joint stiffness higher up the chain can lead to the foot and ankle having to take extra load which can exceed this structures capacity. This is when PTTD injuries can occur.

vi. Return to sport– like with any injury, return to sport after PTTD should be a gradual and progressive process guided by your physio to avoid reinjury.

If you have any further questions on Tibialis Posterior Tendinopathy or any of our other blogs then please email us at , call us on http://Tel:0292310420 or come and see us at Fix Physio Sydney in Sydney CBD