Posterior tibial tendon dysfunction Sports Podiatry
Tendinitis in the foot is a common problem because we use our feet continuously when playing sport. One of the most frequently affected tendons is the posterior tibial tendon, a structure that is normally hard at work, throughout the contact phase of gait (when the foot is in contact with the ground).
anatomy of the posterior tibial tendon
The posterior tibial tendon (below) runs behind the inside bump on the ankle (the medial malleolus), across the instep, and attaches to the bottom of the foot. It is held in place by thick fibrous tissues which form a lever behind the ankle bone. This lever creates tremendous force, effectively slowing the foot down when the heel strikes the ground.
symptoms of posterior tibial tendon dysfunction
The symptoms of posterior tibial tendon dysfunction include pain in the instep area of the foot and swelling along the course of the tendon. The athlete may also experience pain and swelling right behind the inner ankle bone. There is usually pain when the area is touched along the course of the posterior tibial tendon behind the inner ankle. There may also be burning, shooting, tingling, stabbing pain often because the main nerve is inflamed along the inside of the ankle. Athletes experience pain when exercising or even just walking, steadily worsening toward the end of the day. In severe cases there is significant pain when the athlete moves his/her foot, as well as pain upon passive stretching of the posterior tibial tendon, and on eversion or flattening of the foot. In some cases the tendon may actually rupture or tear, due to weakening of the tendon by the inflammatory process.
A definitive test to give an athlete indication whether they have a problem with their posterior tibial tendon is to stand on tiptoe on the affected leg. If pain is elicited in the inner ankle area then the tendon could be the route of the problem.
Posterior tibial tendon dysfunction treatment in the acute phase
P - R - I - C - E
Protection - Your ankle may be splinted, taped or braced to prevent further injury.
Rest - You should rest from all activities that cause pain or limping. Use crutches/cane until you can walk without pain or limping.
Ice - Place a plastic bag with ice on the ankle for 15-20 minutes, 3-5 times a day for the first 24-72 hours. Leave the ice off at least 1 1/2 hours between applications.
Compression - Wrap an elastic bandage from the toes to mid calf, using even pressure. Wear this until swelling decreases. Loosen the wrap if your toes start to turn blue or feel cold.
Elevate - Make sure to elevate the ankle above heart level
IF SYMPTOMS PERSISTS OR NUMBNESS/ DISCOLOURATION OF THE FOOT OCCURS CONSULT A MEDICAL PROFESSIONAL IMMEDIATELY.
Bracing- The posterior tendon is at risk of rupture when inflamed. Supporting the area with an ankle brace will give the tendon time to REST. These braces are designed to be worn under clothing and with normal footwear. On the left is the brace that sports podiatry.co.uk recommend. This can be worn continually in the initial phase of injury (to be taken off at night). Then once symptoms have subsided it can be worn during exercise and sporting activity to provide support to the posterior tibial tendon. This support was worn by Andy Murray tennis star when he damaged his ankle at Wimbledon in 2008.
To restore normal tendon function - Range of Motion Exercises
| Technique: | Sit with your knee straight and hold the foot position as long as possible. Do as frequently as possible for the first 3-10 days. |
| Pullback
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Flexibility (Stretching) Exercises
Loosen tight leg muscles. Tightness makes it hard to use stairs, walk, run and jump and puts stress on the posterior tibial tendon.
| Technique: | Hold each exercise 30 seconds at a gentle stretch. Do not bounce! |
| Frequency: | 6-10 repetitions/exercise, 5-7 days per week |
| Calf Stretch Basic: Sit with your knee straight and towel looped around the ball of your foot.
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| Calf Stretch Advanced: Once you can stand, try stretching with your hands on a wall.
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| Heel Stretch Basic: Sit with your knee slightly bent. Loop a towel around the ball of your foot.
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Heel Stretch Advanced: Once you can stand, try placing your injured foot behind the other with your toes pointing forward.
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strengthening exercises
Frequency: | Three sets of 20 repetitions, 5-7 days per week |
| Front of Shin Basic - Push Out
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| Front of Shin Advanced - Band
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Inner Shin Basic - Push In
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Inner Shin Advanced - Band
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Front of Shin Basic - Push Up
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| Front of Shin Advanced - Band
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to help prevent posterior tibial tendonitis from occurring
Remember that virtually all posterior tibial tendon problems happen at the contact phase of gait (when the foot hits the ground) due to increased biomechanical stress at this point. It is therefore vital to strengthen the ankle and control biomechanical forces
Golden rule- Don't ignore the problem, it won't go away!
The way we function biomechanically is predominantly controlled by genetics, its hereditary (runs in the family). The way you function is set and cannot be cured. What you can do however is control lower limb biomechanics by altering foot position during the contact phase of gait. This can be achieved by wearing a good shoe (see our shoe guide) with orthotics (foot beds), ankle strengthening and ankle support.
1. Check your footwear
Are your running shoes worn and in need of replacing? If so change them. Posterior tibial tendon dysfunction is made worse by high impact forces so a good shock absorbing shoe is a must. For more advice on running trainers our running shoe advice page is worth reading. Read more->
Below are a selection of trainers that are ideal for athletes.
Trainers for a neutral foot type
Trainers for over pronators
2. rectify Poor biomechanics with orthotics
The way your foot strikes the ground and the forces that are placed on it can have a direct effect on causing posterior tibial tendon dysfunction and also delaying healing times. Check our biomechanics page for detailed information. Read more->
3. Ankle strengthening
The single best exercise to improve the strength of the muscles around the ankle is eccentric loading. This is usually done none weight bearing, however the use of a wobbleboard is an excellent way to strengthen muscles around the foot and ankle in a controlled gentle manner. Whilst our clinicians have found it a brilliant way to strengthen ankle muscles, traditionally a wobbleboard was used to help balance (proprioception). Proprioception is the nerve connection from the brain to the foot. This is often damaged/ disrupted after injury and can increase the chances of injury from re occurring It can also significantly delay recovery.
Use of a wobbleboard therefore has a dual benefit in the treatment of posterior tibial tendon dysfunction.
4. Ankle support
Usually an athlete who has damaged their ankle only needs minimal support post injury, such as the support given by a neoprene brace. However it is our view that with posterior tibial tendon dysfunction, something more substantial should be worn when partaking in sporting activity. We recommend the air cast ankle support as it allows the patient to wear normal shoes/ running trainers and it can be worn when exercising. The support is also ideal for older people with chronic stage 2 PTTD.
Posterior tibial tendon dysfunction prevention checklist summary
returning to sporting activity
The goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Returning to your activity is determined by how soon your tendon recovers, not by how many days or weeks it has been since your injury occurred.
You may safely return to your sport or activity when, starting from the top of the list and progressing to the end, each of the following is true:
You have full range of motion in the injured leg compared to the uninjured leg.
You have full strength of the injured leg compared to the uninjured leg.
You can jog straight ahead without pain or limping.
You can sprint straight ahead without pain or limping.
You can do 45-degree cuts, first at half-speed, then at full-speed.
You can do 20-yard figures-of-eight, first at half-speed, then at full-speed.
You can do 90-degree cuts, first at half-speed, then at full-speed.
You can do 10-yard figures-of-eight, first at half-speed, then at full-speed.
You can jump on both legs without pain and you can jump on the injured leg without pain.
Chronic posterior tibial tendon dysfunction
This can often affect the older person and marked deformity of the foot may be observed with a fallen arch. Usually unless very severe the ankle joint will not be affected and provided there is a good range of motion at the joint the advice on this page will help.
Usually the person suffering from chronic PTTD would also benefit from wearing boots to provide stability and it would also be advantageous to have bespoke orthotics made.
Need to see a sports podiatrist for bespoke insoles? Click here