Tibialis Posterior Tendinopathy
Tibialis Posterior Tendinopathy
What is a Tibialis Posterior Tendinopathy?
Tibialis posterior tendinopathy is an injury to your tibialis posterior tendon. The tibialis posterior muscle has a tendon that runs down the inside of your lower leg. It raps behind your ankle bone (medial malleolus) and joins on to your midfoot. Its job is to help support our foot arch and to support our ankle. The tendon can become painful at times, causing you to be unable to run, jump or even walk without pain. During its acute inflamed phase, you may see it described as tibialis posterior tendonitis.
What are Tendons?
Tendons are the tough fibres that connect muscle to bone. Most tendon injuries occur near joints, such as the shoulder, elbow, knee, and ankle. A tendon injury may seem to happen suddenly, but usually, it results from many tiny tears to the tendon that have occurred over time. Health professionals may use different terms to describe a tendon injury. You may hear:
Tendinitis (or Tendonitis): This means “inflammation of the tendon,” but inflammation is rarely the cause of tendon pain.
Tendinosis: This refers to tiny tears in the tissue in and around the tendon caused by overuse.
Tendinopathy: This is an umbrella term that can refer to either tendinitis or tendinosis. As it is common to find tendinosis and tendinitis in the same tendon, the term tendinopathy is often used.
Tibialis Posterior injuries can include:
- Tibialis Posterior tendinitis (an inflamed tendon).
- Tibialis Posterior tendinosis (a non-inflamed degenerative tendon).
- Tibialis Posterior tenosynovitis (an inflamed tendon sheath).
- A ruptured Tibialis Posterior tendon (secondary to degeneration or tear).
What Causes Tibialis Posterior Tendinopathy?
Tibialis Posterior Tendinitis or Tendinosis is nearly always caused by an overloading of the tendon, especially where it curves around your ankle bone. The tendon’s overloading can be due to excessive weight, as in loaded calf raises, overtraining such as a significant increase in running time or intensity, or a combination of the two such as an increase in jumping exercise or activities.
There are also certain biomechanical reasons why a Tibialis Posterior may not cope with an increase in load. These include poor foot posture, ankle joint stiffness, and even poor knee and hip control from weak or inhibited muscles. If the tendon has a degree of tendinosis, this weakens the tendon structure, leading to tendinitis if overloaded.
Common Causes of Tibialis Posterior Tendinopathy include:
- Over-training or unaccustomed use – “too much too soon.”
- A period of under-training, then moving back to previous training loads
- A sudden change in training surface – e.g. grass to bitumen
- Flat (over-pronated) feet
- Tight hamstring (back of thigh) and calf muscles
- Toe walking (or constantly wearing high heels)
- Poorly supportive footwear or a change in footwear (even to new shoes!)
- Hill running
- Poor eccentric strength
How is Tibialis Posterior Tendinopathy Diagnosed?
Your physiotherapist or sports doctor can usually confirm the diagnosis of Tibialis Posterior tendinopathy in the clinic. They will base their diagnosis on your history, symptom behaviour and clinical tests.
Further investigations include a US scan or MRI. X-rays are of little use in the diagnosis.
Please seek the advice of a tendinopathy physiotherapist regarding your tibialis posterior tendinopathy diagnosis and management.
Tibialis Posterior Tendinopathy Treatment
Tibialis posterior tendinopathy is a relatively common problem that we see at PhysioWorks. It is, unfortunately, an injury that often recurs if you return to sport too quickly – especially if a thorough rehabilitation program is incomplete.
Researchers have concluded that there are mostly seven stages that need to be covered to rehabilitate these injuries and prevent a recurrence effectively.
What is the Treatment for Tibialis Posterior Tendinopathy?
Phase 1 – Early Injury Protection: Pain Reduction & Anti-inflammatory Phase
As with most soft tissue injuries, the initial treatment is RICE – Rest, Ice, Compression and Elevation.
In the early phase, you’ll be unable to walk without a limp, so your Tibialis Posterior tendon needs some active rest from weight-bearing loads. You may need to be non or partial-weight-bearing, utilise crutches, a wedged Achilles walking boot or heel wedges to temporarily relieve some of the pressure on the Tibialis Posterior tendon. Your physiotherapist will advise you on what they feel is best for you.
Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot. Anti-inflammatory medication (if tolerated) and natural substances, e.g. arnica, may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the first 48 to 72 hours to encourage additional bleeding. Most people can tolerate paracetamol as pain-reducing medication.
As you improve, a rigid tape or kinesio-style supportive taping will support the injured soft tissue.
Phase 2: Regain Full Range of Motion
If you protect your injured Tibialis Posterior tendon appropriately, the torn tendon fibres will successfully reattach. Mature scar formation takes at least six weeks. During this period, you should be aiming to optimally remould your scar tissue to prevent a poorly formed scar that will re-tear in the future.
It is important to lengthen and orientate your healing scar tissue via massage, muscle stretches, neurodynamic mobilisations, and eccentric exercises. Signs that you have full soft tissue extensibility include walking without a limp and performing Tibialis Posterior tendon stretches with a similar end of range stretch feeling.
Phase 3: Restore Eccentric Muscle Strength
Muscles work in two directions. They can shorten (called a concentric action) and lengthen in a controlled manner (called an eccentric movement). Most Tibialis Posterior injuries occur during the controlled lengthening (eccentric) phase. Your physiotherapist will guide you on an eccentric tibialis posterior strengthening program when your injury healing allows.
Phase 4: Restore Concentric Muscle Strength
Calf strength and power should gradually progress from non-weight bear to partial, and then full weight bear and resistance loaded exercises. You may also require strengthening your other leg, gluteal and lower core muscles, depending on your assessment findings. Your physiotherapist will guide you.
Phase 5: Normalise Foot Biomechanics
Tibialis Posterior tendon injuries can occur from poor foot biomechanics, e.g. flat foot.
Your foot will require an assessment to prevent chronic tendinopathy. In some instances, you may need a foot orthotic (shoe insert), or you may be a candidate for the Active Foot Posture Stabilisation program.
Your physiotherapist will happily discuss the pros and cons of both options with you.
Phase 6: Restore High Speed, Power, Proprioception & Agility
Most Tibialis Posterior tendon injuries occur during high-speed activities, which place enormous forces on your body (contractile and non-contractile). To prevent a recurrence as you return to sport, your physiotherapist will guide you with exercises to address these essential rehabilitation components to prevent a recurrence and improve your sporting performance.
Depending on what your sport or lifestyle entails, a customised speed, agility, proprioception and power program prepares you for light sport-specific training.
Phase 7: Return to Sport
Depending on your chosen sport’s demands, you will require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport.
Your PhysioWorks physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete return to sport. The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a thorough rehabilitation program has minimised your chance of future injury.
What Results Should You Expect?
There is no specific time frame for when to progress from each stage to the next. Many factors will determine your Tibialis Posterior tendinopathy rehabilitation status during your physiotherapist’s clinical assessment.
You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves.
It is also vital to carefully monitored each progression as attempting to progress too soon to the next level can lead to re-injury and frustration.
The severity of your tendon injury, your compliance with treatment, and the workload you need to return will ultimately determine how long your injury takes to rehabilitate successfully.
Common Ankle Injuries
The most common ankle injury is a sprained ankle, but ankle pain can have numerous sources.
An ankle fracture occurs when there is a break in one or more of the bones. The most common ankle fractures are avulsion fractures of your distal fibula, which can be a side effect of an ankle sprain. All suspected fractures require medical investigation and professional management by your health professional to avoid long-term foot and ankle issues. If your healthcare professional suspects an ankle fracture, you will be referred for at least an X-ray and potentially an Orthopaedic Surgeon.
- Ankle Fracture (Broken Ankle)
- Stress Fracture
- Stress Fracture Feet
- Severs Disease
- Heel Spur
- Shin Splints
While muscle strains are more common in your legs, there are essential muscles that converge into tendons that wrap around your ankle to stabilise your ankle and foot to protect them from sprains and allow you to walk and run. These muscles and their tendon vitally provide you with a normal foot arch and avoid flat feet. Your muscles or tendons can become injured or inflamed as a result of overuse or trauma. The inflammation is called tendonitis. They can also tear, completely rupture, or sublux out of place. Medically tendon injuries are known as tendinopathies, and at the ankle may include:
- Achilles Tendinopathy
- Achilles Tendon Rupture
- Peroneal Tendinopathy
- Tibialis Posterior Tendinopathy
- FHL Tendinopathy
- Plantar Fasciitis
Your ankle pain and dysfunction can lead to degenerative conditions such as ankle osteoarthritis. While arthritis usually is a chronic deterioration of your ankle joint, it is crucial to slow ankle arthritis progression. Please seek the professional advice of your ankle and foot health practitioner, e.g. physiotherapist or podiatrist.
Biomechanical disorders may result in foot deformation, painful weight-bearing and potentially nerve compression. In simple terms, this is where your foot and ankle do not have normal bone alignment and motion contr. Here are a few possible conditions related to poor ankle biomechanics.
- Anterior Ankle Impingement (Front of Ankle Pain)
- Posterior Ankle Impingement (Back of Ankle Pain)
- Pes Planus (Flat Feet)
- Tarsal Tunnel Syndrome
Nerve-Related Ankle Pain
Children & Youth Conditions
Systemic Conditions that may cause Ankle Pain
Soft Tissue Inflammation
Other Useful Information
Article by John Miller
Common Youth Leg Injuries
Why are Children's Injuries Different to Adults?
Adolescent injuries differ from adult injuries, mainly because the bones are still growing. The growth plates (physis) are cartilaginous (strong connective tissue) areas of the bones from which the bones elongate or enlarge. Repetitive stress or sudden large forces can cause injury to these areas.
Common Adolescent Leg Injuries
In the adolescent leg, common injuries include:
Pain at the bump just below the knee cap (tibia tubercle). Overuse injuries commonly occur here. The tibia tubercle is the anchor point of your mighty quadriceps (thigh) muscles. Because of excessive participation in running and jumping sports, the tendon pulls bone off and forms a painful lump that will remain forever. This type of injury responds to reduced activity and physiotherapy.
More info: Osgood Schlatter's Disease
Pain at the lower pole of the knee cap (patella). Overstraining causes Sinding-Larsen-Johansson disease. Because of excessive participation in running and jumping sports, the tendon pulls bone off the knee cap. This type of injury responds to reduced activity and physiotherapy.
More info: Sinding Larsen Johansson Syndrome
Anterior Knee Pain
Anterior knee pain or patellofemoral syndrome frequently gets passed off as growing pains. Cause of this pain includes overuse, muscle imbalance, poor flexibility, poor alignment, or more commonly, a combination of these. Anterior knee pain is one of the most challenging adolescent knee injuries to sort out and treat. Accurate diagnosis and treatment with the assistance of a physiotherapist with a particular interest in this problem usually resolves the condition quickly.
More info: Patellofemoral Pain Syndrome
The cartilage between the leg bones have a better blood supply and are more elastic in adolescents than in adults. As adolescents near the end of bone growth, their injuries become more adult-like. Hence more meniscal and ACL (anterior cruciate ligament) injuries are likely. MCL (medial collateral ligament) injuries result from a lateral blow to the knee. Pain felt on the inner side (medially) of the knee. MCL injuries respond well to protective bracing and conservative treatment.
More info: Knee Ligament Injuries
ACL (anterior cruciate ligament) injuries
This traumatic knee injury is significant. Non-contact injuries of the ACL are becoming more common than contact injuries of the ACL. Adolescent females are at high risk. Combination injuries with MCL or menisci are common. Surgical reconstruction is needed if the adolescent wishes to continue participating in "stop-and-start" sports.
More info: ACL Injury
Your meniscus is crescent-shaped cartilage between the thigh bone (femur) and lower leg bone (tibia). Meniscal injuries usually result from twisting. Swelling, catching, and locking of the knee are common. If physiotherapy treatment does not resolve these damages within six weeks, they may require arthroscopic surgery.
Heel pain is commonplace in young adolescents due to the stresses of their Achilles tendon pulling upon its bony insertion point on the heel (calcaneum). It is a common overuse injury due to excessive volume of training and competition, particularly when loads are increased dramatically in a short period. Diminished flexibility and muscle-tendon strength mismatching may predispose you. Physiotherapy, reduced activity, taping and orthotics are the best ways to manage this debilitating condition for the active young athlete.
More info: Sever's Disease
An ankle sprain is probably the most common injury seen in sports. Ankles sprains involve stretching of the ligaments and usually occur when the foot twists inward. Treatment includes active rest, ice, compression and physiotherapy rehabilitation. An ankle sprain usually improves in 2-6 weeks with the correct treatment. Your ankle physiotherapist should check even simple ankle sprains. A residually stiff ankle post-sprain can predispose you to several other lower limb issues.
More info: Sprained Ankle
Patellar (kneecap) instability can range from partial dislocation (subluxation) to dislocation with a fracture. Partial dislocation treatment is conservative. Dislocation with or without fracture is a much more severe injury and usually will require surgery.
More info: Patella Dislocation
The separation of a piece of bone from its bed in the knee joint is Osteochondritis Dissecans (OCD). This injury is usually due to one major macro event with repetitive macro trauma that prevents complete healing. This injury is potentially severe. Treatment varies from rest to surgery. An Orthopaedic Surgeon's opinion is vital.
Growth Plate Fractures
A fracture through the growth plate can be a severe injury that can stop the bone from growing correctly. These fractures should be treated by an Orthopaedic Surgeon, as some will require surgery.
Image source: https://radiologyassistant.nl/pediatrics/hip/hip-pathology-in-children
An avulsion fracture occurs when a small segment of bone attached to a tendon or ligament gets pulled away from the main bone. The hip, elbow and ankle are the most common locations for lower limb avulsion fractures in the young sportsperson.
Treatment of an avulsion fracture typically includes active rest, ice and protecting the affected area. This active rest period is followed by controlled exercises that help restore range of motion, improve muscle strength and promote bone healing. Your physiotherapist should supervise your post-avulsion exercises. Most avulsion fractures heal very well. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. An avulsion fracture to your foot or ankle may require a cast or walking boot.
An excessive gap between the avulsed bone fragment and main bone may not rejoin naturally in rare cases. Surgery may be necessary to reunite them. In children, avulsion fractures that involve the growth plates also might require surgery. All avulsion fractures should be reviewed and managed by your trusted physiotherapist or an Orthopaedic Surgeon.
For more information regarding your youth sports injury, please consult your physiotherapist or doctor.
Common Youth Leg Injuries
Pelvis & Hip
- Osgood Schlatter's Disease
- Sinding Larsen Johannson Disease
- Patellofemoral Pain Syndrome
- Patella Dislocation
- Meniscus Tear
- Discoid Meniscus
- Juvenile Osteochondritis Dissecans