Tibialis Posterior Tendinopathy

The tibialis posterior muscle attaches the calf muscle to the bones on the inside of the foot. The action of the muscle is to plantar flex (point foot downwards), to invert the ankle (turn the foot inwards) and elevate the medial longitudinal arch (inner foot arch). Tibialis posterior tendinopathy or posterior tibial tendon dysfunction (PTTD) is an injury to the tendon of this muscle.

The tibialis posterior tendon supplies power for controlling acceleration and deceleration in walking and running. Due to the important and repetitive role in foot mechanics, acute and chronic injury can happen in athletes ⁽⁸⁾.

When the tendon is injured and becomes inflamed this is called tendinitis, or tendinopathy. Historically, tendinopathies were referred to as ‘tendinitis’ based on the belief that the condition was caused predominately by inflammation. However, our understanding has improved, and it is now accepted that persistent tendinopathies are caused by tendinosis (tendon degeneration) ⁽⁵⁾.

Currently, the best evidence for treating tendinopathy is based on progressive and appropriate loading of the tendon. Avoidance of activities that aggravate the problem is important to allow healing to take place. Orthotics (splints and bracing) and analgesics can be effective in relieving symptoms ⁽²⁾. Most tendinopathies will respond well to gradual strengthening. A surgical procedure can be considered on an individual basis if all other treatment options have been exhausted ⁽¹⁾.

In tibialis posterior tendinopathy there can be inflammation and/or degeneration. It is credited to repetitive loading causing microtrauma (a very slight injury) and progressive failure of the tendon ⁽³⁾. This can occur in athletes due to the repetitive forces placed on the tendon during sports ⁽⁸⁾. Also, a lack of blood supply to this region can occur and may contribute to developing the condition ⁽⁴⁾.

The structure and location of the tendon can also be seen as a factor in developing tibialis posterior tendinopathy. This is due to the tendon wrapping around the medial malleolus (inner side bone of the ankle) which can put stress on the tendon during muscle contraction. The other tendons in this region do not take this sharp turn around the ankle, so are therefore less likely to become injured ⁽¹⁾.

Another cause has been attributed to pressure placed on the tendon by structures in the region, such as the flexor retinaculum, abnormalities of the talus bone, structural changes due to osteoarthritis and a pre-existing flat foot ⁽³⁾.

Tibialis posterior tendinopathy is a common condition of the ankle and foot. The true prevalence is unknown as no large studies have been undertaken but it is believed that the prevalence is anywhere from 3.3% to 10% depending on age and gender ⁽¹⁾. Persistent tendinopathies are more common in the middle-aged to elderly athletes. In younger athletes, acute tendinopathies are more common but persistent problems can also occur ⁽⁸⁾.

Your musculoskeletal physiotherapist can provide you with an accurate diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other conditions and gain a greater understanding of your physical abilities.

Your physiotherapist will ask how your condition affects you day-to-day so that treatment can be tailored to your needs. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment. Images like X-ray, magnetic resonance imaging (MRI) or ultrasound are usually not needed to achieve a working diagnosis but, in some cases, they may be needed to confirm tendinopathy.

As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your tibialis posterior tendinopathy. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.

For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to sport, a rehabilitation programme should incorporate plyometric based exercises; this might include things like jumping and running exercises ^{(5, 7)}.

As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from further assessment to ensure you are making progress and to establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.

• Orthotic devices or bracing – to give your arch the support it needs. Your foot and ankle surgeon may provide you with an ankle brace or a custom orthotic device that fits into the shoe.
• Immobilisation – sometimes a short-leg cast or boot is worn to immobilise the foot and allow the tendon to heal, or you may need to completely avoid all weight-bearing for a while.
• Physiotherapy – adjuncts to exercise may be used by your therapist to relieve symptoms.
• Medications – nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
• Surgery – for some advanced cases, surgery may be the only choice. Your foot and ankle surgeon will decide the best approach for you.

https://www.guysandstthomas.nhs.uk/resources/patient-information/therapies/foot-health/tibialis-posterior-tendon-dysfunction.pdf

https://lermagazine.com/article/management-of-athletes-with-early-stage-pttd