Tibialis posterior tendinopathy is an over-use injury or dysfunction of the tendon of same name. The muscle itself originates from the top of the tibia and the top of the fibula, both in a posterior or rear position. It inserts into the medial part of the foot at the navicular bone and the plantar aspect of the mid-foot. Like most tendons, the tibialis posterior tendon is generally poorly vascularised (Ling and Lui 2017). The chief function of the tibialis posterior is plantar flexion of the tibiotalar joint and inversion of the subtalar joint. One of the integral actions of the tibialis posterior tendon is to maintain the medial arch of the foot (Brukner and Khan 2012). Tibialis posterior tendinopathy is mostly experienced by middle-aged women, especially those diagnosed with diseases of lifestyle and rarely seen in  younger athletes. It is also a common injury experienced by ballet dancers (Brukner and Khan 2009).

sections of foot in skeletal form
(a). Surface anatomy of the medial ankle.
(b): Tendon insertions of the medial ankle (Brukner and Khan 2012).

What is tendinopathy?

Tendinopathy is an overuse injury, where repetitive increasing loads are applied to the tendon and it is unable to withstand repetitive loads placed on it. Typical symptoms are an increase in pain with more loading, local tenderness with palpation over the tendon and pain during or after activity. Some suggest that changes to the tendon structure associate with previous tendon repairs and tendinopathy injury occurs because of poor healing initially, thus leading to less ability to withstand the loads being placed upon the tendon. (Kountaris and Cook 2007)

tibialis posterior analysis of foot

 

Clinical Signs and Symptoms

Tibialis posterior tendinopathy is due to over-use, with a slow onset, and the mechanism of injury is due to increased running, walking or jumping activities (Brukner and Khan 2012). According to Kulig et al. (2009), posterior tibialis tendon dysfunction (PTTD) is the most common cause of developing a flat-foot deformity in adults, as the muscle is the main stabiliser of the medial longitudinal foot arch. Diagnosis is based on the clinical features seen on examination. The pathology is characteristic of degeneration, which practitioners can divide into four groups (Kulig et al. 2009).

site of tibialis posterior tendinopathyArrows in the image indicate swelling along the tibialis posterior tendon.

Stage 1: There is swelling around the medial malleolus, medial ankle pain along the medial malleolus extending towards the tibialis posterior tendon insertion at the navicular, mild pain on heel raises and no foot deformities (Kulig et al. 2009; Brukner and Khan 2012).
Stage 2: There is an increase in medial foot arch flattening which leads to mid-foot deformities and the hindfoot is still flexible. The tibialis posterior tendon is weak and unable to withstand the load placed upon it during repetitive unsupported single-leg heel raises (Kulig et al. 2009; Brukner and Khan 2012). The patient displays pain and/or weakness on ankle inversion (Kohls-Gatzoulis et al. 2004). The heel has also an increased valgus (angulation of an extremity of a joint or fracture site such as the distal part away from the midline as defined by Kohls- Gatzoulis et al. 2004).
Stage 3: Consists of all the clinical features listed in stage 2, although the deformity has now become fixed due to degenerative changes at the tendon (Kulig et al. 2009). Conservative management is less effective (Kohl-Gatzoulis et al. 2004).
Stage 4: We describe this stage as irreversible degeneration found within the hindfoot joints of the ankle. Patients will need surgical management at this point (Kulig et al. 2009).

Physiotherapy management and rehabilitation exercises

Kulig et al. (2009) found that a combination of eccentric exercises (controlled elongation of a muscle in a closed chain), calf stretching, education, a home exercise program specifically towards strengthening the tibialis posterior and prescription of orthotics specifically made to offload the muscle were effective in reducing pain, improving tolerance to loading of the tibialis posterior tendon and improving functional activity for those diagnosed with stage 2 and 3 PTTD. The researchers developed an eccentric exercise programme which has been found to be most effective in reducing pain and improving strength and function for those diagnosed with stage 1 and 2 PTTD.

The intervention includes:

  1. Fitting of a custom-made orthosis which is to be worn during all exercises and for 90% of the day, for 12 weeks.
  2. Stretching of the gastrocnemius and soleus (calf muscles) twice a day for 3 sets of 30 seconds.
  3. stretching exercises for PTTDProgressive resistive exercises: This exercise is to be performed whilst wearing shoes with the orthoses inserted. To perform the exercises at home and in a clinical setting, Tom Goom (aka @RunningPhysio, 2012) provided an example of how to load the tibialis posterior tendon in a lengthened position. He shows this in a YouTube clip.
    Resistance should start at 0.9kg and increased at 0.9kg increments when one can perform 3 sets of 15 repetitions in a controlled manner and symptom-free. To increase the resistance, one can use different coloured therabands, increasing the resistance using a band with stronger resistance. The exercise is to be performed twice daily with 1-2 minutes’ rest in between. Physiotherapists recommend following this treatment programme for about 12 weeks.
  4. In order to achieve pain reduction and improve the tibialis posterior strength so that the tendon can withstand a higher load, patients should carry out the above stretches and strengthen continuously for 12 weeks (Kulig et al, 2009).

As for stage 3 and 4 PTTD, there is little evidence available which describes effective management. Kohls-Gatzoulis et al. (2004) suggested that management aims at preventing symptoms and the dysfunction from getting worse. Non-steroidal anti-inflammatory drugs are beneficial in the management of pain. These authors have suggested prescription of customised footwear and corrective orthosis necessary to prevent further degeneration. Surgery is only recommended if conservative management fails.

Always listen to your body and respect it. It is your alarm signal notifying you that there is potential tissue damage and reminding you to seek help.

Henuti Daji, one of the physiotherapists at Lamberti Woodmead, submitted this article. Contact her by using this appointment form for an assessment.

References:

  1. Kountouris, A. and Cook, J., 2007. Rehabilitation of Achilles and patellar tendinopathies. Best practice & research clinical rheumatology, 21(2), pp.295-316.
  2. Ling, S.K.K. and Lui, T.H., 2017. Posterior Tibial Tendon Dysfunction: An Overview. The open orthopaedics journal, 11, p.714.
  3. Brukner, P. and Khan, K., 2012. Clinical Sports Medicine, 4th ed. McGraw Hill, Sydney.
  4. Kulig, K., Lederhaus, E.S., Reischl, S., Arya, S. and Bashford, G., 2009. Effect of eccentric exercise program for early tibialis posterior tendinopathy. Foot & ankle international, 30 (9), pp.877-885.
  5. Kulig, K., Reischl, S.F., Pomrantz, A.B., Burnfield, J.M., Mais-Requejo, S., Thordarson, D.B. and Smith, R.W., 2009. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Physical Therapy, 89 (1), pp.26-37.
  6. Kohls-Gatzoulis, J., Angel, J.C., Singh, D., Haddad, F., Livingstone, J. and Berry, G., 2004. Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot. Bmj, 329 (7478), pp.1328-1333.
  7. Goom T 2012 Shin Pain – Part 3 Posterior Tibial Tendon Dysfunction. Last update 8 June 2012 https://www.running-physio.com/pttd/ [Accessed 8 April 2020.