Posterior Tibial Tendinopathy

Posterior Tibial Tendinopathy is a common injury of the lower limb, affecting between 3% and 10% of people in the UK. It tends to affect women more often than men, particularly women aged 40-50 years.

The Tibialis Posterior muscle is a key inverter or supinator of the foot and has an important role in maintaining the medial (inside) arch of the foot, providing a supination moment about the subtalar joint, and controlling foot pronation. Tendinopathy of this muscle often manifests with symptoms of pain and inflammation along the pathway of the tendon, from its origin above the ankle joint (medial side), behind and under the medial malleolus, and its insertion onto the navicular and medial cuneiform bones on the medial aspect of the midfoot (see image above and below).

Symptoms will usually be worsened by running, jumping, and even walking, and better for rest.

For many people, the main cause of this condition is a “training load error”, sometimes called an “overuse injury”. A training load error occurs when the cumulative load on a tissue is greater than the tissue can accommodate without entering into the plastic or failure range, meaning that the tissue is being put under more stress than it can handle over a period of time without being deformed, injured or broken. A training load error therefore depends on two factors: the cumulative load (forces over time), and the capacity of the tissue to deal with those forces (staying within the elastic phase or moving into injury during the plastic or failure phase). It is possible to condition a muscle slowly over time so that it is able to deal with greater and greater loads. This has to be done in a structured way, gently increasing the loads over time and having sufficient rest and nutrition to allow the muscle to heal and recover between stressful periods. If you start a new exercise or increase your exercise routine without preparing the muscle for the increased loads it now has to deal with, then this can lead to injury, hence the “error” part of “training load error”. This error means that the muscle cannot heal fast enough before being injured again, progressively leading to tendinopathy, or even rupture of the tendon. The loads placed on the tendon will vary from person to person, and from activity to activity. In addition to the above, following are also considered as risk factors:

  1. Certain foot, ankle and lower limb biomechanical pathologies and alignment issues.
  2. Being overweight or obese.
  3. Old age.
  4. Poor nutrition.
  5. Diabetes (has been shown to have a positive correlation with risk of PTT).
  6. Prolonged use of corticosteroids and certain antibiotics (fluoroquinolones).
  7. Inflammatory conditions such as Rheumatoid Arthritis and Psoriatic Arthritis.

It is important to point out that running and high impact sports do not cause this condition, in and of themselves, as some sources state. If the muscle is properly prepared for the loads being placed on it, and the person trains correctly, and doesn’t have any of the aforementioned additional risk factors, then they should be able to exercise and play sport without developing PTT.

Another important point to mention is that Posterior Tibial Tendinopathy is not the same as Posterior Tibial Tendon Dysfunction, which includes flattening of the foot and possibly loss of function. In PTT there is no flattening of the foot, although it is possible to have both conditions at the same time.

Treatments involve rest, reducing activity or changing activity in the acute stages, as well as using oral non-steroidal anti-inflammatory drugs (NSAIDS), as well as “RICE” (rest, ice, compression, elevation). Orthotics can be very helpful in the early stages, as they can reduce the cumulative load on the tissue very quickly and effectively. Taping and therapeutic strapping and padding may also help in a similar way. Treatments that reduce pain and inflammation and facilitate healing are also helpful at this stage, including acupuncture and Shockwave Therapy. In the long term, many people will be able to correct the underlying causes of condition by taking part in a soft-tissue rehabilitation programme, possibly including gait retraining, losing weight, or changing their activities, and may not need to wear orthotics long term. However, some people will not be able to accomplish this, especially those with underlying structural biomechanical issues. These people will need to keep wearing orthotics if they are to continue their activities at the same or similar level.

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