I work in a physical therapy clinic that sees a large number of complicated foot and ankle injuries. One of the more common injuries is posterior tibialis tendinopathy. It can occur on it’s own or along with other conditions such as plantar fasciitis. It is a relatively easy condition to treat if caught early on. It can develop complications if left untreated. Read on to learn more about this condition. Let’s start with anatomy!
What is the tibialis posterior?
The tibialis posterior is a muscle that is located in the back of the lower leg. It is located underneath the calf muscle. It attaches to the back of the lower leg bones (fibula and tibia). It then travels down the leg and transitions to tendon above the ankle. The tibialis posterior tendon moves behind the medial maleolus (the big bump on the inside of your ankle) to the arch of the foot where it attaches to several bones on the inside bottom area of the foot. This muscle performs inversion (rolling the ankle and arch inward) and plantarflexion (pointing the foot down). The tibialis posterior also plays a vital role in supporting the main arch of the foot and improving the activation of the calf muscle.
What is the difference between tendinopathy, tendonitis and tendinosis?
Before delving into the tibialis posterior specifically, let’s first review the basics of tendons. A tendon is the connective tissue that attaches the muscle to the bone. Tendinopathy is a term used to encompass any issue with the tendon. This is includes tendonitis and tendinosis. There is a difference between tendonitis and tendinosis. Many of the conditions that were previously thought to be tendonitis are actually tendinosis. However because we do not necessarily know if the tendon has tendonitis or tendinosis, we refer to the condition as tendinopathy.
Tendons can get inflamed with a force that is too strong or quick. This tensile force on the tendon can cause micro-tears in the tendons. This is tendonitis. It is postulated that untreated tendonitis can become tendinosis. Tendonitis is an inflammatory condition and will respond to anti-inflammatory medication. It typically has a recovery period of 1-6 weeks .
Tendinosos is a degeneration of the tendon’s collagen proteins. This is hypothesized to occur after a period of untreated tendonitis. Collagen provides the tendon with durability and strength. Tendinosis is caused by chronic overuse with no time for the tendon to rest and heal. It does not have signs of acute inflammation and is not improved with anti-inflammatory medication such as ibuprofen. Early stage tendinosis can heal within 6 to 10 weeks but chronic stage can take 3 to 6 months. Tendinosis is probably more common than tendonitis but the term tendonitis is often used to encompass both.
What is posterior tibialis tendinopathy?
Posterior tibialis tendinopathy is an irritation of the tendon of the tibialis posterior. It could either be a tendinitis or, more likely, a tendinosis. This condition tends to be an overuse injury that occurs slowly over several weeks rather than after a specific injury. However, it can occur suddenly with an overloading of the tendon, such as in dance.
The tibialis posterior muscle transitions to tendon before passing behind the ankle. There is a limited blood supply at the area of the tendon that passes behind the ankle at the medial malleolus. This is the area that is most likely to become problematic.
What are the symptoms of posterior tibial tendinopathy?
There are several symptoms associated with posterior tibialis tendinopathy. These include:
- Pain on the inside of the ankle behind the medial malleolus (large bony bump on the inside of the ankle)
- Pain can travel to the arch of the foot and up the calf
- Pain tends to increase gradually over time
- Swelling might be present behind the ankle to the arch of the foot
- Pain with walking and running
- Difficulty or inability to stand on tip toes
- Arch and ankle tend to roll outward when standing
What are the risk factors for posterior tibialis tendinopathy?
There are several risk factors associated with posterior tibialis tendinopathy. These include:
- Flat feet – This is the biggest risk factor. A flat foot puts the tibialis posterior muscle and tendon on constant stretch which puts increased stress on the muscle and tendon.
- Overuse – This could be from increasing training intensity or duration too quickly.
- Shoe wear – Poor shoe wear that does not properly support the arch during high impact activities, such as running, can lead to posterior tibialis tendinopathy.
- Age – Tendon injuries are more common over the age of 40.
Special considerations
Posterior tibialis tendinopathy can become a serious condition if not treated. The tendon can partially tear or completely rupture which causes a flat foot deformity. This is known as posterior tibial tendon dysfunction and is the main cause of adult-acquired flat foot deformity. This can be a debilitating condition that causes difficulty with mobility and could require surgery.
Who should I see?
- Physical therapy – This would be my first stop. Physical therapy can help decrease the pain and swelling with techniques including manual therapy and dry needling. PT can evaluate and address abnormal joint mobility, muscle weakness, and flexibility. Your PT will also assess your gait, shoe wear, training schedule, and technique to prevent the problem from happening again.
- Orthopedic physician – An orthopedist might be necessary if a tear is suspected or the injury is not responding to physical therapy. Your orthopedist can order imagining to determine the extent of the tendon injury.
What can I do at home?
- Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to treat posterior tibialis tendinopathy. Basically stay away from the activities that are causing pain. This gives the tendons time to rest and heal. If you keep doing what is causing the injury, it is not going to get better. Swimming and biking would be good alternative activities that do not put much stress through the ankle and foot.
- Ice – Ice can help decrease the pain and swelling at the tendon. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or preventing you from participating in an activity. Ice immediately after activity.
- Stretching – Stretching the calf muscles can help improve the motion at the ankle. This includes stretching the gastrocnemius and the soleus. See the video below.
- Strengthening – It is important to strengthen the tibial posterior, calf muscles, and the muscles of the knee, and hip. All of these muscles work together to stabilize the ankle and foot while running, cutting, and jumping. Using loop resistance bands , resistance bands and ankle weights can increase strength and difficulty of the exercises. See the videos below.
- Balance – Working on balance is important in strengthening the foot and ankle but also improving proprioception. Improving proprioception will help improve the overall stability of the ankle. See the video below.
- Shoe wear and orthotics – Having flat feet is a huge risk factor for posterior tibialis tendinopathy because it puts an increase pull on the tendon. Changing shoe wear or using orthotics to place the foot in a neutral position will help decrease the stress on the tendon. An overpronation shoe might help or you might need orthotics. Most running stores will evaluate your foot type and suggest appropriate shoe wear and/or orthotics. Your PT can also evaluate your foot and help determine appropriate shoe wear.
- Bracing – Using a stability brace or ankle sleeve can be helpful to decrease pain and improve stabilization at the ankle. This is especially useful for those that have chronic ankle instability or who have suffered from previous ankle injuries.
- Compression socks – Compression socks can help decrease swelling and pain by improving circulation while running and walking.
In review
- The tibialis posterior is a muscle that is located in the back of the lower leg.
- This muscle performs inversion (rolling the ankle and arch inward) and plantarflexion (pointing the foot down).
- The tibialis posterior also plays a vital role in supporting the main arch of the foot and improving the activation of the calf muscle.
- Posterior tibialis tendinopathy is an irritation of the tendon of the tibialis posterior.
- It could either be a tendinitis or, more likely, a tendinosis.
- This condition tends to be an overuse injury that occurs slowly over several weeks rather than after a specific injury.
- Symptoms include pain on the inside ankle and foot when walking and running.
- Risk factors include flat feet.
- Physical therapy can treat this condition and help prevent reoccurrence.
- An orthopedist might be needed if a tear is suspected.
- There are several things you can do at home.
- Relative rest
- Ice
- Stretching
- Strengthening
- Balance
- Shoe wear
- Bracing
- Compression socks
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.verywellhealth.com/posterior-tibial-tendonitis-2548561
https://www.sportsmedtoday.com/posterior-tibial-tendinopathy-va-137.htm