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, 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 specific biomechanical reasons why a Tibialis Posterior may not cope with an increase in load. These include poor foot posture, ankle joint stiffness, and deficient knee and hip control from weak or inhibited muscles. If the tendon has a degree of tendinosis, this weakens the tendon structure, leading to overloading tendinitis.
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 seven stages 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. Depending on your assessment findings, you may also require strengthening your other leg, gluteal and lower core muscles. 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. Would you 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