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).
 

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

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 ellicited in the inner ankle area then the tendon could be the route of the problem.

 

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. REMEMBER An area should only be immobilised in the acute phase (first few days). Once swelling has reduced passive stretching exercises should be started in order to prevent excessive scarring of the tendon. Bracing of a posterior tendon should only be done in conjunction with a course of rehabilitation exercises such as the ones shown below.

The recommended brace for posterior tibial dysfunction can be found in our store under PTTD braces but further advice can be accessed by emailing a specialist free of charge!

to restore normal tendon function

WARNING! EXERCISES SHOULD NOT HURT. IF THEY DO, STOP!

Range of Motion Exercises
Help you regain normal ankle motion.

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 Flex your foot back toward your body.

 

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. Slowly pull back until you feel your upper calf stretch.

Calf Stretch    Advanced: Once you can stand, try stretching with   your hands on a wall. Place the injured foot behind the other with your toes pointing forward. Keep your heels down and back leg straight. Slowly bend your front knee until you feel the calf stretch in the back leg.

Heel Stretch    Basic: Sit with your knee slightly bent. Loop a towel   around the ball of your foot. Slowly pull back until you feel a stretch in the lower calf and heel.

Heel Stretch    Advanced: Once you can stand, try placing your   injured foot behind the other with your toes pointing   forward. Keeping your heels down, slowly bend your back knee until you feel a heel stretch in the back leg.

 

strengthening exercises

Frequency:

Three sets of 20 repetitions, 5-7 days per week

Front of Shin   Basic - Push Out With your foot flat on the floor, push it outward against a wall, file cabinet or bookcase. Hold for three seconds.

Front of Shin   Advanced - Band Tie the band to a desk or dresser. Sit with your foot and knee in line and loop the band over the outside of your foot. Push your foot out against the band.

Inner Shin   Basic - Push In With your foot flat on the floor, push it inward against your other foot. Hold for three seconds.

Inner Shin   Advanced - Band Tie the band to a desk or dresser. Sit with your foot and knee in line, and loop the band over the inside of your foot. Push your foot in against the band.

Front of Shin   Basic - Push Up Place the heel of your other foot on top of the injured one. Push down with the top heel while trying to push up with the injured foot. Hold for three seconds.

Front of Shin   Advanced - Band Tie the band to a desk or dresser. Sit with your leg straight and loop the band over the top of your foot. Slowly pull your foot back against the band.

 

to help prevent injury

Remember however that virtually all posterior tibial tendon problems  occur at contact phase of gait (when the foot hits the ground) due to increased biomechanical stress at this point. No amount of exercising will influence what happens at the point of heel strike, mid-stance and toe off phases of gait. It is therefore vital to improve your biomechanics with orthotics designed for your chosen sport.

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 only be done by wearing a good shoe (see our shoe guide) and with orthotics  (foot beds). This is the cheapest and most cost effective way for any athlete to reduce the risks of injury from occurring and from helping to prevent re-injury. Overall costs for the average athlete will run into pennies per mile/hour of sport.

Orthotics are designed to alter the biomechanics during the time the foot is on the ground. They are also used to provide increased shock absorbency working in harmony with the sport shoe worn.

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. Return 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.

 

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