Tibialis Posterior Tendonitis (Tendinopathy)

Tibialis posterior tendinopathy

Tibialis posterior tendonitis (tendinopathy) is an overuse injury causing pain on the inside of the ankle. Pain is felt on the inside of the ankle which may radiate under the arch of the foot. Here we explain the symptoms, causes and treatment of Tibialis posterior tendonitis.

Tibialis posterior tendinopathy symptoms

  • Symptoms include pain on the inside of the ankle, specifically behind the medial malleolus. This is the bony protrusion on the inside of the ankle.
  • Pain comes on gradually over time. It may be a niggle that the athlete continues to train with for some time.
  • Symptoms may also radiate along the length of the tendon as it passes under the foot.
  • A creaking sensation called crepitus can sometimes be felt when the tendon moves.
  • There is unlikely to be swelling in the early stages, but later there may be some around the back of the malleolus.If you have a lot of swelling, then an acute partial tear of the tendon should be suspected.

Diagnosis & assessment

A professional therapist will do a number of tests to assess your ankle.

  • Stretching the tibialis posterior – pain may be made worse by passive eversion, or resisted inversion. Passive eversion is when a therapist turns the foot outwards to stretch the tibialis posterior.
  • Resisted inversion – this is when the patient turns the soles of the feet inwards as the therapist resists the movement. If pain is produced then the test is positive.
  • Heel raise – another test a professional therapist might do is to view the athlete from behind performing a heel raise on a step. If they have posterior tibialis tendinopathy then they may have difficulty keeping the ankle straight. It will remain rolled in and flattened. In severe cases the patient will have difficulty doing a heel raise altogether.
  • Avulsion strains – if there is significant pain under the foot then this may indicate a partial avulsion where the tendon pulls away from the bone at the attachment to the navicular bone.
  • MRI – an MRI or magnetic resonence imaging can confirm the diagnosis 1.

What is Tibialis posterior tendonitis?

Tibialis posterior tendinopathy

Tibialis posterior tendonitis is an overuse injury causing inflammation of the Tibialis posterior tendon. Tendinopathy is probably a more accurate term to use as it refers to wear and tear or degeneration of the tendon rather than acute inflammation.

The tibialis posterior muscle passes down the back of the leg and under the medial malleolus, or bony bit on the inside of the ankle. It inserts on the lower inner surfaces of the navicular and cuneiform bones in the midfoot and the base of the 2nd, 3rd, 4th and fifth long metatarsal bones under the foot.

It is used to plantarflex the foot (going up on your toes) and to invert the foot (turning the soles of the feet inwards).


Causes

Athletes who overpronate, where the foot rolls in or flattens too much are at increased risk as this places more strain on the tibialis posterior muscle causing it to repeatedly overstretch and overwork more that if would with normal foot biomechanics.

It is most likely to affect older female athletes who do lots of walking or running. Sports and activities that increase the risk of tibialis posterior tendinopathy are those which require prolonged stretching of the tibialis posterior muscle. These include:

  • Ballet dancing
  • Ice skating
  • Sprinters who run a lot on tight bends

Long-term injuries to the tibialis posterior can result in insufficiency of the muscle and a condition called tibialis posterior dysfunction (PTTD) which results in fallen arches, or flat feet.

There is sometimes confusion between PTTD and tibialis posterior tendinopathy and the terms are often used interchangeably. However, these conditions are slightly different as PTTD is a dysfunction of the muscle and tendinopathy is a degeneration of the tendon.


Treatment for Posterior tibial tendonitis

The aims of rehabilitation of Tibialis Posterior tendinopathy can be broken down into stages:

  • Decrease initial pain and inflammation.
  • Improve mobility and flexibility.
  • Improve strength
  • Re-establish neural control and coordination.
  • Return to full fitness.

What can the athlete do?

  • Apply the PRICE principles of protection, rest, ice, compression, and elevation. Ice or cold therapy to reduce pain and inflammation. Ice should not be applied directly to the skin but in a wet tea towel. Commercially available hot and cold packs are often more convenient.
  • Cold therapy can be applied for 10 minutes every hour for the first 24 to 48 hours if the tendon is painful or inflamed. Later on, after the acute stage, heat may be more beneficial.
  • Compression – use a tube grip bandage or taping. Even better are products that specifically apply compression at the same time as cooling.
  • When pain allows, stretching exercises for the tibialis posterior and calf muscles should be done. Specific exercises for the tibialis posterior will strengthen the muscle which should help prevent future injury.

Corticosteroid injections should NOT be used to treat tibialis posterior tendinopathy. It increases the risk of a complete tendon rupture.

What can a sports injury professional or doctor do?

  • Applying electrotherapy such as ultrasound can help with pain and inflammation.
  • A doctor may prescribe anti-inflammatory medication such as Ibuprofen in the short-term to reduce inflammation, although long-term they are thought to be of little benefit.
  • Always check with a doctor before taking medication and do not take ibuprofen if you have asthma.
  • Cross friction sports massage techniques may be applied to the tendon and deep tissue massage to the tibialis posterior and calf muscles may help increase flexibility and condition of the muscles.
  • A sports injury professional can demonstrate, advise and monitor a tibialis posterior tendonitis rehabilitation program to strengthen your ankle. In particular, the tibialis posterior muscle.
  • Orthotic inserts can be prescribed and fitted if required to correct poor foot biomechanics. If the tendon is ruptured then it must be repaired surgically.

Tibialis posterior tendinopathy exercises

Tibialis posterior strengthening exercise

Exercises can begin as soon as they can be performed without pain. Strengthening exercises for Tibialis posterior tendinopathy focus on developing strength and in particular eccentric strength. This means strengthening the muscle at the same time as it lengthens.

Read more on Tibialis posterior strengthening exercises.


References

  1. Chhabra A, Soldatos T, Chalian M, 3-tesla magnetic resonance imaging evaluation of posterior tibial tendon dysfunction with relevance to clinical staging. J Foot Ankle Surg 2011;50:320–328
This article has been written with reference to the bibliography.

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