Posterior Tibial Tendonitis

What is Posterior Tibial Tendonitis?
"Post-Tib" Tendonitis or "Tib Post" Tendinitis, is an over use injury that leads to inflammation & over time can cause degeneration (tendinosis) of the posterior tibial tendon. The Posterior Tibial Tendon runs along the inside of the ankle and attaches to the foot under the medial arch. The posterior tibial tendon can be especially prone to tendonitis as it helps to maintain the arch of the foot and prevent excessive flattening (over pronation) of the arch while walking, standing or running.

The posterior tibial tendon starts in the deepest portion of the calf and runs behind the medial malleolus (the inner ankle bone). The tendon continues along towards the foot and inserts into multiple locations on the inside and the bottom of the arch. With each step a tremendous amount of tension and stress is placed is on the posterior tibial tendon as it helps to maintain the arch of the foot.

Progression of Posterior Tibial Tendinitis to Posterior Tibial Tendon Dysfunction.
Posterior tibial tendonitis can be a precursor to Posterior Tibial Tendonosis (degeneration) and Posterior Tibial Tendon Dysfunction (where there is progressive loss of strength in the tendon and a progressive flattening of the arch as the tendon degenerates and lengthens). Years of over-pronation (flat feet) or biomechanical abnormalities can lead to the progression from Tendonitis to posterior tibial tendon dysfunction if the muscle is continuously overused, and the damage to the tendon builds up over time. At first the pain or swelling may come and go quickly, but eventually the problem may become more permanent and is then classified as chronic.It normally develops as below:

Posterior Tibial tendinitis: usually short term after an injury, tear or when the pain in the tendon first occurs.
Posterior Tibial tendonosis: when the tendon pain has been present for some time. At this stage it is often no longer inflammed but degenerated and painful.
Posterior Tibial Tendon Dysfunction: when there is lengthening and degeneration of the tendon.
For more information see Tendinitis vs Tendonosis

Cause
Post-Tib Tendonitis occurs when the muscle is overused and its tendon is strained. As tendonitis is an inflammatory condition, posterior tibial tendonitis is often seen after a sudden increase in activity or exercise especially if not warmed up properly, after an injury, or when an old case of posterior tibial tendonopathy is re-injured and thus becomes re-inflammed. It can also become inflammed due to the repetitive strain of poor biomechanics, flat feet, or improper shoewear. Aging, arthritis and normal wear and tear can also cause some loss of elasticity in the fibers of the tendon which can cause some discomfort during excess physical activity.

Symptoms
Symptoms of posterior tibial tendonitis include pain and swelling along the inside of the ankle and arch along the course of the tendon. Pain is present with exercise, extended periods of walking or standing. This discomfort will usually increase as the disease progresses and is localized along the course of the tendon around the inside of the ankle or along the inside of the arch. This pain initially is absent when at rest but may progress to the point where pain is present even when not active. Pain and swelling are signs of injury to the tendon. The sheath or sleeve that surrounds the tendon will produce excessive amounts of lubricating fluid in an attempt to allow the tendon to glide easier during the healing process. This excessive fluid production results in the swelling the patient sees and feels on the inside of the ankle and arch. In advanced cases the injury to the tendon that started as tendonitis may progress to a full or partial tear of the tendon.

Treatment
Treatment depends on how long the symptoms have been present and the cause of the tendonitis/tendinosis. Treatment must take into account the cause of the problem and whether or not the tendon is inflamed &/or degenerated, how much strength lost has occurred (if any) and if there are any signs of posterior tibial tendon dysfunction.

Taking these factors into account, treatments such as non-steroidal anti-inflammatory medication, Achilles stretches (if required), rest, icing and orthotics are often first courses of treatment. Custom made orthotics help to support the arches of the feet. Wearing orthotics in your shoes may allow you to resume normal activities, but you should probably cut back on more vigorous activities for several weeks to allow the inflammation and pain to subside.

You can also reduce your symptoms by limiting activity to control the pain and swelling. Stay off your feet a few days, then slowly increase your activity. Rest allows the tissues in your foot to heal.

If rehab is required in later stages when the tendonitis has progressed to tendinosis, physical therapy treatments such as ultrasound, soft tissue massage, heat and strengthening exercises are often given. The exercises given to you by your podiatrist help to strengthen the posterior tibial muscle and the small muscles within the feet (the intrinsics) to help support the arch.

In more severe cases a "moon boot" or a cast from the knee down may be utilized from four to six weeks to allow the tendon to completely rest without placing the day-to-day demands of walking on it. If these measures fail to produce acceptable results surgical intervention may be necessary to clean around the tendon and repair any defects in the tendon. Surgical repair is more commonly needed when there is a progressive weakness and/or lengthening in the tendon and Posterior tibial tendon dysfunction occurs.

Listed below are tips to prevent Post-Tib Tendonitis from recurring:

Wear shoes that provide cushioning, support and shock absorption.
Use orthotics with sufficient arch support that are constructed from shock absorbing, cushioning materials.
Vary exercise routines. The variety will keep all groups of muscles from being under continuous strain.