The ankle consists of three bones that are attached by muscles, tendons, and ligaments that connect the foot to the leg. The lower leg includes two bones called the tibia (shin bone) and the fibula. These bones articulate (connect) to the ankle bone at the tibiotalar joint (ankle joint) allowing the foot to move up and down. Overall, the foot and ankle in the human body work together to provide balance, stability, movement, and propulsion.
The tibial nerve is a mixed nerve with both motor and sensory function, and part of the peripheral nervous system. Mixed motor and sensory nerves enable electrical impulses to travel between muscle cells and the spinal cord. Impulses from the tibial nerve then travel to the brain to help provide sensory information and manage the voluntary and involuntary movement of your lower limbs.
Branches of the tibial nerve connect to muscles in the back of the leg. This enables you to move your leg, foot, and toes. The posterior tibial tendon begins as a muscle in the calf and becomes a fibrous cord that stretches down behind the inside of the ankle and attaches to bones in the middle of the foot near the arch. This tendon helps hold the arch up and provides support when stepping off on your toes when walking.
Posterior tibial tendonitis (also referred to as posterior tibial dysfunction) is one of the several terms to describe a painful condition mainly in adults. It is an inflammation and / or overstretching of the posterior tibial tendon in the foot, thus causing intense pain coming from the inner ankle. Some patients exhibit pain in the arch area where that tendon attaches. Over time, it can lead to losses in the inner arch on the bottom of your foot and result in a complication known as adult-acquired flatfoot (AAFD).
This condition usually begins with pain and weakness of the tendon. As AAFD advances, the ligaments of the foot are affected. At that point, the foot joints might no longer line up correctly and may become set in the wrong position. For this reason, most physicians prefer early treatment before other complications begin to damage the tendon if left untreated.
Causes & Symptoms of Posterior Tibial Tendonitis
A patient who is living with flatfeet has a greater load placed on the posterior tibial tendon which is the main tendon unit supporting up the arch of the foot. Throughout life, aging leads to decreased strength of muscles, tendons, and ligaments. The blood supply diminishes to tendons with aging as arteries narrow. In some people, the posterior tibial tendon finally gives out or tears.
Posterior tibial tendonitis isn’t a typical sudden event in most cases. Rather, it is a slow, gradual stretching followed by inflammation and degeneration of the tendon. Once the posterior tibial tendon stretches, the ligaments of the arch stretch and tear. The bones of the arch then move out of position with body weight pressing down from above.
The foot rotates inward at the ankle in a movement called pronation. The arch appears collapsed, and the heel bone is tilted to the inside. The deformity can progress until the foot literally dislocates outward from under the ankle joint.
Generally, posterior tibial tendonitis is classified into stages from stage 1 to stage 4, such as described below:
Stage 1
Pain is present along the posterior tibial tendon without deformity or collapse of the arch. The patient has somewhat a flat or normal-appearing foot they regularly have.
Stage 2
A sudden deformity from the condition begins to occur, resulting in a collapse of the arch, which may or may not be visible or noticeable to you or others. You may experience it as simply a sensation of weakness in your arch. Most patients tend to not realize they have a problem until stage 2 because the ligament failure can happen at the same time as the tendon failure and therefore deformity can begin at the same time that pain in the tendon is first being felt.
Stage 3
The deformity has progressed to the extent where the foot becomes rigid in its deformed position.
Stage 4
In this severe stage, the deltoid ligament on the inside of the ankle fails, resulting in a deformity in the ankle as well as a deformity in the foot. Over time, this can lead to arthritis of the ankle, thus leading to serious complications.
Posterior tibial tendonitis can lead to a large number of painful symptoms, due to the result of deformity. Some of these symptoms linked to this condition include:
- Pain in the arch and pain behind the inside of the ankle. Trigger points will also be felt in the muscle belly of the posterior tibialis.
- Burning, shooting, and tingling pain may also be felt on the inside of the ankle because the posterior tibialis nerve is inflamed inside the tarsal tunnel.
- Swelling is worsened when walking and exercising, and usually gets worse as the day progresses.
- Unable to perform tip-toe raise on the affected foot.
Pain may develop on the lateral side of the ankle, especially as the foot becomes more deformed if left untreated.
Who gets Posterior Tibial Tendonitis?
Anyone may injure the posterior tibial tendon. However, posterior tibial tendonitis is often seen in women and adults over the age of 40. Risk factors also include having underlying health issues such as chronic hypertension or diabetes. Obesity may be a risk factor, as is participating in high-impact sports, such as basketball, football, tennis, and baseball.
How Does Posterior Tibial Tendonitis Affect You? How Serious is it?
If you are experiencing symptoms associated with posterior tibial tendonitis, there is a chance that surgery may be required to fix the tendon on the back of your calf that goes down the inside part of your ankle. A surgeon can do many types of surgery to fix this tendon.
Overall, the posterior tibialis tendon is a strong cord of tissue. It is one of the most important tendons in your leg. An injury might tear this tendon or cause it to become inflamed. Your tendon might also tear or become inflamed from overuse. Therefore, surgery carries a fortunate possibility to correct this damage.
Of course, every surgery includes its risks. Some risks for this surgery include:
Persistent ankle pain
Some patients tend to continue to have persistent ankle pain after an anterior tibialis tendon repair. When this happens, your doctor will work with you to create a treatment plan, which may include additional physiotherapy, cognitive behavioral therapy, or medicines to help you recover regularly.
Nerve or blood vessel damage
During surgery, there is a minimal chance that the nerves, veins, or tissue around your knee can be damaged. Damaged nerves or blood vessels can cause numbness, pain, or lower blood flow around the ankle.
Blood clots
Because an anterior tibialis tendon repair affects the way blood flows around your ankle, it can increase your risk of developing blood clots.
Recommended Treatment & Rehabilitation for Posterior Tibial Tendonitis
During a diagnosis for posterior tibial tendonitis, a physician will begin by performing a physical examination, alongside acquiring a detailed medical history, and if needed, diagnostic imaging tests:
Physical examination
Your doctor will examine the foot and lower leg and look for any signs of the condition. He or she may conduct a series of clinical assessments, such as the Thompson test (calf squeeze) to test the posterior tibial tendon. Your doctor may also ask you to perform a number of exercises such as leg lifts, hops, or jumps to gauge the level of activity-related pain, as well as exactly where it occurs.
Medical history
In addition to a physical examination, your doctor will ask you to describe the pain, what makes you feel better or worse, describe any changes in your lifestyle, and recent sports involvement.
Medical imaging is usually not required to arrive at posterior tibial tendonitis. However, in some cases, your doctor may order imaging equipment to get a clearer view of the tendon or to rule out other conditions, such as magnetic resonance imaging (MRI) and an ultrasound. X-rays aren’t normally used to diagnose posterior tibial tendon damages or tears but are helpful in identifying associated contributors to pain.
Rehabilitation of a damaged posterior tibialis tendon typically begins at approximately three or four weeks after injury. You may benefit from working with a physiotherapist during your rehabilitation. Your therapist can assess your condition and guide you during your recovery. Therefore, he or she may provide the following recommendations below:
- Muscle-strengthening exercises – Strengthening activities for any muscles affected by posterior tibial tendonitis in the back of your lower leg, can help alleviate further pain linked to this condition.
- Nerve gliding activities – Gentle exercises that move and glide the nerves may help reduce symptoms and improve function.
- Balance and coordination activities – Work to improve your balance and coordination, which are often affected by the affected tendon.
- Supporting equipment – It is recommended to apply ankle taping, a custom orthotic, or bracing to position the foot to decrease stress on the posterior tibial nerve.
Although there are no proven strategies for avoiding posterior tibial tendonitis, there are certain ways to help minimize stress to the foot and ankle, such as choosing appropriate footwear, wearing custom shoe inserts, minimizing the amount of time spent standing on hard surfaces, and improving and maintaining strength in the muscles of your legs, ankles, and feet.
Additionally, early detection of posterior tibial tendonitis signs will help you and your medical providers start the best treatment plan for the condition, which may increase your long-term well-being.
Below are a few exercises you can perform to help boost your recovery from posterior tibial tendonitis:
Heel-toe raises
Using the back of a chair or counter for support, lift the heels off the floor to stand on the toes. Hold for 5 seconds before slowly lowering back down to the floor. Repeat this exercise 15 times with two sets and a 30-second rest between each set. Once the injured foot becomes stronger, try standing on the injured foot only.
Calf stretch
Stand and face a wall with the hands placed on the wall at eye level. Next, take a lunge position by placing the injured foot slightly behind with the heel flat on the ground and the other leg slightly forwards with a bent knee. Turn the back foot inwards slightly. Then, gently lean towards the wall until there is a stretch in the back calf. Hold this position for 15-30 seconds, then repeat this method 3-4 times a day.
Balance exercise
Stand beside a chair, using it for support if needed, with the injured foot furthest from the chair. Stand on the injured foot and slightly bend the knee. Bend forward from the waist and reach forward with the hand furthest from the chair. Repeat this exercise 15 times with 2 sets.
Alternative & Homeopathic Treatment for Posterior Tibial Tendonitis
One of the most recommended homeopathic treatments for your posterior tibial tendon injury includes the PRICE principle, which stands for Protect, Rest, Ice, Compression, and Elevation:
- Protect – In more severe cases, it is necessary to protect the damaged area. This may be done through the use of a walking boot or in some cases, a cast may be necessary to restrict movement completely which allows the nerve, joint, and surrounding tissues a chance to heal.
- Rest – In this case, rest would indicate tapering down from your regular exercise activity and discontinuing running.
- Ice – Apply ice to the affected area. The rule for icing is to apply ice no more than 20 minutes per hour.
- Compression – This helps prevent and decrease swelling. Swelling can cause increased pain and slow the healing response, so limit it as much as possible. A compression stocking can help to limit the amount of swelling and promote blood flow back out of the lower leg.
- Elevation – Depending on your pain level and the amount of swelling present, this step may be more or less beneficial.