Posterior Tibial Tendonitis

author : AMSSM

comments : 2

The diagnosis, treatment and prevention of posterior tibial tendonitis.

Member Question

So I had this pain that I believe was a result of an injury during a time I subbed in a soccer game last year.  The pain gradually got worse and so I went to the ortho ankle foot specialist and yadda yadda yadda, MRI, etc...and I have posterior tibial tendonitis.   So I just chilled for two months from running but I kept biking and swimming.  I ran a mile three days ago on the treadmill and it felt GREAT and the day after it was great too!  Then yesterday I ran 1.5 miles and now I'm feeling it afterwards.

So what are my options?  If someone says, "Hey there, justified, I had this and I sucked it up and didn't run for six months and then everything was fine" then that's what I'll do.  I just want to get better.   Also should I cut biking altogether or do something else?  Should I wear a brace?  A stability type shoe?  Don't say I have to stop swimming cause then I'll just cut my foot off.

Answer from Jane T. Servi, MD      
Member AMSSM 

I am sorry for your diagnosis of posterior tibial tendonitis. Tendonitis can be a tenacious injury, but in general, with time and treatment it will resolve. The posterior tibialis muscle is a stabilizing muscle of the lower leg. It begins from its attachment on the shin bone close to the knee and connects via the tendon to the bones on the inside and bottom of the foot, traveling behind the inside bump (medial malleolus) of the ankle. The tendon is one of the major supporting structures of the foot helping to maintain the arch and providing support as a person steps off of the toes while walking.

Overuse of the posterior tibial tendon is one of the major causes of tendonitis (inflammation of the tendon). It often occurs after activities that involve the tendon such as walking, running, hiking and stairs. Overuse can be a result of a new activity, increasing an old activity or a new stress placed on the stability of the foot such as uneven ground, an old shoe that has lost its support, or a change in shoe wear that results in the foot or ankle doing more work to steady itself. Other causes of tendonitis include degeneration of the tendon with long term wear and tear and trauma such as a blow to the ankle or twisting injuries that occur with sports such as soccer.

Treatment options vary on the severity of the injury. The primary treatment is to discontinue activity that causes irritation.  Non-painful activities can be continued. Thus, if you could swim without causing pain and if pain did not develop within 48 hours of swimming than you can continue that activity with minimal concern of persistent aggravation on the tendon.  High impact activity will place more strain on the tendon than low impact activities and prolonged activities more so than those of shorter duration.

An orthotic or ankle brace to stabilize the foot or ankle is frequently prescribed and for a non-resolving injury, a boot/cast to fully immobilize the ankle may rarely be used. Anti-inflammatory medicine is commonly used and needs to be taken consistently to obtain the anti-inflammatory effect. Regular icing can help to additionally reduce the swelling. There are also several techniques in physical therapy including ultrasound (deep heat), iontophoresis (cortisone cream driven in by deep heat), ASTYM (soft tissue mobilization), dry point needle therapy (inserting an acupuncture like needle into a muscle knot) and rarely a corticosteroid (potent anti-inflammatory) injection to bathe the surrounding tendon sheathe (may predispose tendon to rupture and should be used judiciously with restriction of activity for 48 hours after injection). Another option in treatment includes the use of PRP (platelet rich plasma) therapy. From a small volume of a patient’s blood, platelets are separated and injected back in to the area of injury, utilizing the growth and restorative properties of platelets to promote healing. Very rarely, surgery may be an option to remove the degenerative tissue within the tendon. After the healing phase, it is equally important to treat the underlying issues that may have contributed to the injury which are also addressed in prevention of this injury.

Of course, prevention is the best recipe for avoiding nagging injuries all together. Prevention for posterior tibialis tendonitis is multifactorial. First, address the alignment of the foot with proper shoe wear for your foot (pronation versus supination). This can be addressed in a professional running shoe store or with a sports medicine podiatrist. Also wear the proper shoe for each sport. Frequently orthotics may be needed to control stability. Furthermore, it is important to keep shoe wear up to date (300-500 miles) as worn-out shoes lose cushioning, shock absorption and stability. Frequently overlooked is symmetry between strength and flexibility in the ankle and leg as well as between the right and left legs. Additionally, balance (proprioception) work on a balance board or Bosu ball can help prevent stress to the tendon. And finally it is always important to remember that when starting a new activity or increasing an old activity; proceed in a slow and progressive manner.

Good Luck!

Jane T. Servi, MD

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date: November 12, 2012