Posterior Tibial Tendonitis

Posterior Tibial Tendonitis is a common source of medial ankle pain. It is more commonly known in the UK as Posterior Tibial Tendinopathy. We will explore all topics around this condition including symptoms, treatment, exercises, and surgery.

There are other sources of inner ankle pain such as Tarsal Tunnel syndrome, Flexor Hallucis Longus Tendinopathy, Medial Malleolus stress fractures, or Navicular stress fractures. So, is Posterior Tibial Tendonitis permanent, or can it be cured?

What is the Posterior Tibial Tendon?

The Posterior Tibial Tendon is a long thin tendon that runs along the inner ankle. A tendon attaches a muscle to a bone and the Posterior Tibial Tendon attaches the Posterior tibialis muscle to the side of the foot, mainly the navicular bone.

Its main action is to turn the foot inwards (inversion) and downwards (plantarflexion). When walking, standing, and running it acts as a key stabilizer of the medial arch of the foot. When the Posterior Tibial Tendon becomes overloaded,  it becomes inflamed, irritated and painful resulting in tendonitis.

What Causes Posterior Tibial Tendonitis?

In most cases, Posterior Tibial Tendonitis is caused by a change in activity levels. For one person, this may be walking 500-1000 more steps in one day, for another, it could be increasing their weekly running distance from 30 miles to 60 miles. Sudden changes in running speed, volume, or intensity can play a role.

Ankle Injuries: Ankle sprains can lead to compensatory movements that overload the medial arch of the foot and cause Posterior Tibial Tendonitis. This can also the case in scenarios where someone is recovering from an ankle fracture. The ankle joint can become stiff as a result, leading to more rotation of the midfoot through the gait cycle and overloading the Posterior Tibial Tendon.

Foot Type: A flat foot, especially an adult acquired flat foot secondary to Posterior Tibial Tendon Dysfunction can lead to tendonitis as excess stress and stretch is placed on the Posterior Tibial Tendon. Posterior Tibial Tendonitis is less common in those with a high arch although it is possible in those with a stiff big toe as they struggle to push off.

Running: This is one of the most common causes of Posterior Tibial Tendonitis. The high impact involved and repetitive nature of the action can easily overload the medial foot, especially if there is a sudden change in running volume or speed. We commonly see this in Marathon Training plans with the combination of continued extra running volume alongside interval and hill training can be a significant risk factor for Posterior Tibial Tendonitis.

Barefoot running is not necessarily bad for feet but evidence suggest that novice runners should have more cushioned shoes and over time they can reduce levels of support. Birkenstocks do have the potential to overload the Posterior Tibial Tendon. They are one of the more supportive forms of sandals but they are not as supportive as trainers.

Finally, being overweight is a risk factor as the extra weight can place more pressure on the medial arch of the foot where the Posterior Tibial Tendon attaches.

Posterior Tibial Tendonitis Symptoms

Posterior Tibial Tendonitis symptoms are located on the inner ankle as the tendon wraps around the back of the fibula and pain can extend down onto the insertion of the tendon onto the medial longitudinal arch of the foot. In acute episodes, there may be some visible swelling along the line of the tendon but it is unusual to see bruising as this is more indicative of a tendon tear.

The pattern of pain for Posterior Tibial Tendonitis is for the tendon to be painful first thing in the morning when stepping out of bed but this should ease within an hour. Pain is mechanical meaning that the pain is worse during or immediately after use and should decrease with rest. If the tendon is aggravated during the day it may be sore at night when going to bed but it is uncommon for Posterior Tibial Tendonitis to wake you from your sleep.

In acute episodes, it may be too painful to walk and there may be a crunching or clicking noise. The pain is often sharp and becomes more of a dull ache in more chronic cases. In long term cases, it is not unusual for symptoms to develop in both feet as the previous unaffected side becomes overloaded.

Posterior Tibial Tendonitis Diagnosis

If someone suspects that they have the symptoms of Posterior Tibial Tendonitis, they should see a Physical Therapist for a clinical diagnosis. This is achieved following a clinical interview and clinical tests involve palpating the tendon for pain and resisting the movement of plantarflexion and inversion. If there is pain in resistance to this movement, it is a positive test.

In relation to imaging, diagnostic ultrasound is the recommended choice as it has high accuracy and is low in cost. An MRI is another form of scan that can diagnose Posterior Tibial Tendonitis but it is expensive. An x-ray is useful to rule out conditions that provide similar symptoms to Posterior Tibial Tendonitis but it’s not possible to diagnose Posterior Tibial Tendonitis using an x-ray.

Home Treatment for Posterior Tibial Tendonitis

It is possible to manage an acute episode of Posterior Tibial Tendonitis at home. If you suspect you have the early symptoms of tendonitis you could try the following:

• Immediately offload the foot
• Apply ice to reduce pain levels
• Wear supportive trainers
• Wear an ankle brace for additional support
• Avoid impact exercises
• Avoid long periods of time on your feet.
• Self-massage using a foam roller or massage gun

Physical Therapy for Posterior Tibial Tendonitis

Physical Therapy is the best and most evidence-based form of treatment for Posterior Tibial Tendonitis. It covers an array of forms of treatment and we will cover the most effective. Following a clinical assessment to confirm a diagnosis of Posterior Tibial Tendonitis treatment can include massage to reduce pain levels, mobalisations of the ankle joint to reduce stiffness or assisted stretching exercises.

Posterior Tibial Tendonitis Taping is an effective way to offload the Posterior Tibial Tendon, helping to reduce pain levels. This usually involves a rigid figure-6 ankle taping. Some Therapists may consider KT Tape but there is little evidence to support its use while a Posterior Tibial Tendonitis brace is effective at supporting the ankle and providing pain relief. This is a short to the medium-term solution.

Activity modification involves managing the amount of time on your feet to facilitate recovery. Usually, with runners, we try to keep them running, at a reduced volume. This is important to keep some load going through the tendon. This helps to facilitate strengthening exercises for Posterior Tibial Tendonitis which is the most effective form of treatment for Posterior Tibial Tendonitis. These normally begin as band strengthening, progressing into weight bearing and then hopping exercises.

A Gait Analysis may be required if your therapist feels a biomechanical issue is causing your pain, they might assess your gait using a slow-motion video to identify the reason. Insoles or Orthotics may be prescribed as these are a very effective long-term solution for pain relief

Steroid Injections such as a corticosteroid is an effective in providing pain relief for cases that are struggling to adapt to strengthening exercises but something to be avoided where possible as they cause long-term deconditioning to the tendon. A period of 1-2 weeks in a walking boot is generally recommended post injection. Surgery is a last resort for Posterior Tibial Tendonitis. This may involve debridement of the tendon and is usually followed by 12 weeks of Physical Therapy.

Other forms of treatment may include acupuncture for pain relief. Night splints have minimal benefit and compliance is poor as they are uncomfortable to wear while shoe inserts can provide temporary relief but they are not a long-term solution.

Related Article: Best Exercises for Posterior Tibial Tendonitis

Conclusion:

In most cases, physical therapy consisting of nonsurgical treatment methods such as activity modification, taping, and strengthening exercises cure Posterior Tibial Tendonitis. In very irritable cases a boot or custom orthotic may be required while surgery is only necessary in severe cases.

Online Physiotherapy with James McCormack

This is not medical advice and we recommend a consultation with a medical professional such as James McCormack to achieve a diagnosis. He offers Online Physiotherapy Appointments for £45.