This spring many runners are training for upcoming races in Toronto and around the GTA with some even travelling to different cities and countries to participate in running events from 5-10Km runs to half-marathons, full marathons, ultramarathons, obstacle races or triathlons. A common condition that we deal with in this population of new and veteran runners is pain on the inside of the ankle and shin ‘Tibialis Posterior Tendonopathy’.
What is Tibialis Posterior Tendonopathy?
The tibialis posterior muscle is the muscle located in the back inside of your lower leg and calf that is connected to the foot by a tendon that loops down behind the medial malleolus (inner ankle bone) and inserts in the bottom of your foot. This muscle is responsible for helping point your foot, supporting and stabilizing the foot’s arch and helps with pushing off during running. Tendonopathy occurs when there is microtrauma, inflammation, degeneration or lengthening of the tendon due to over use or improper use of the muscle.
What are the Symptoms of Tibialis Posterior Tendonopathy?
- Pain on the inside of the shin and inner ankle bone
- Swelling on the inside of the shin and inner ankle bone
- Pain during walking and running, especially during the push off portion of the gait cycle
- Tenderness/pain when firmly touching the muscle and tendon
- Pain during single leg heel raises
What Causes Tibialis Posterior Tendonopathy?
- Repetitive and prolonged activities putting strain on the Tibialis Posterior (Running)
- Changes in foot wear
- Changes in training schedule – Increasing training too quickly or without enough rest time
- Poor biomechanics in the foot – excessive pronation (Flat footed)
- Muscle imbalances in the lower extremity including hip, pelvis and core
- Improper rehabilitation following a previous lower extremity injury
What can a Physiotherapist or Chiropractor do to Treat Tibialis Posterior Tendinopathy?
Visiting a Physiotherapist or Chiropractor will help determine the source of your pain in order to treat you and get you back to running sooner. Your therapist will investigate what factors led to the excess strain being placed on the Tibialis Posterior in the first place. Your rehabilitation will address those specific factors and root cause of your injury to avoid re-injury in the future.
Initially activity modification and rest is important. Soft tissue massage, taping, and modalities such as acupuncture, Shockwave, Ultrasound and Laser can help settle down the inflammation and help to reduce the pain. Stretching, balance, and strengthening exercises are initiated once symptoms settle. Gradual introduction of strengthening exercises that mechanically load the tendon are important for the tendon to heal and be able to withstand future stress. For example the progression of exercise may look like this:
- the early stages strengthening starts with isometric exercises
- then light concentric activation
- then eccentric strengthening
- then harder concentric exercises
- finally, plyometric or sport/activity specific exercises are introduced and progressed
How do I know if I have Tibialis Posterior Tendonopathy?
Sometimes the following conditions can appear to be a Tibialis Posterior Tendonopathy but are different issues that require very different rehabilitation
- Compartment Syndrome
- Stress Fracture
- Referral from the lumbar spine
- Deep Vein Thrombosis
The bottom line is that there are many issues that can appear similar to tibialis posterior tendinopathy so it is important to be properly diagnosed by an experienced health care professional. A physiotherapist, chiropractor or sports medicine doctor will be able to determine if you have tibialis posterior tendinopathy and treat you with a proper rehabilitation plan so you can recover quickly.
What are the Best Exercises to Help with Tibialis Posterior Tendonopathy?
Ankle inversion with a resistance band
To perform this exercise loop an elastic resistance band around the inside of your foot. The band should be anchored on a stabile structure like a table leg, perpendicular to your foot. Then turn your foot inwards so the sole of your foot is facing inwards, make sure your leg stays still and the movement is focused at the ankle and foot.
Repeat 20reps 3xday.
Up on 2 legs down on 1 while keeping your heel in line with your foot in a slow and controlled fashion.
Foot intrinsic muscle strengthening
Tibialis posterior stretching
For this stretch you will need a small folded towel placed on the outside edge of the foot. Having the towel here will place your foot in a slightly turned out position. Once your foot is in place, keep your leg straight and lunge forward as if you were stretching your calf in standing. You should feel a calf stretch that is more notable on the lower inside calf.
Hold 30 seconds Repeat 2-3x 3xday
How Can I Treat Tibialis Posterior Tendonopathy at Home?
Immediately after an aggravating activity, the area may feel warm, swollen and painful. If so, it is likely that you have inflammation around the tendons and we recommend applying ice to the area for 10 min ON/OFF 3x. This should be helpful and may need to be repeated a few times a day in the earlier stages.
Modify activity and cross train
In the early healing stage you are going to have to modify and stop if possible the aggravating activities that provoke your symptoms. This will allow your tissue to heal without being re-aggravated. Once the symptoms settle, you can start a gradual return to your activity. For the time being you may want to do another activity ie. Instead of running try biking or swimming. Both of these activities keep your cardiovascular endurance in check but do not involve as much pressure or force through your Tibialis Posterior tendon.
Do rehab focused exercises
Please see exercises above. As long as the exercises are not painful to complete and do not lead to more pain after you complete them. Often times, an individualized exercise regimen is required and your trusted physiotherapist will able to help with that. It is best to start the rehab exercises as early as possible and progress as you are able.
You can apply this stretchy tape under the arch and up along the path of the tendon on to the medial calf. You will want to apply approximately 50% stretch in the tape through the mid portion for best results. Your physiotherapist will be able to apply the tape for you and show you the correct application technique.
What Should be Avoided if I have Tibialis Posterior Tendonopathy?
Avoid pushing through the pain and continuing to participate with the aggravating activities. You may feel better once you have warmed up the tendon but it is still not recommend that you push through as you are likely putting additional stress on the tendon which will make the tendon more vulnerable to further damage. In some cases, tendon damage is irreversible and the damaged cells within the tendon will never heal. So tread cautiously, listen to your body and take this seriously.
Unsupported shoes and/or high heels should also be avoided if you are suffering from tibialis posterior tendonopathy. This type of footwear will place more demand on the tendon and delay heeling.
Lastly, you should most certainly avoid movements or activities that require power through the lower extremity such as sprinting or jumping. These movements will place too much load on the injured and compromised tendon and will not only lead to further tissue damage but may also put you at risk of tendon rupture.
How Long Does It Take to Recover From Tibialis Posterior Tendonopathy?
Normal recovery time for this injury is 6-8 weeks, however this is dependent on variables like the duration of symptoms and how much cellular damage has occurred in the tendon. If the tendinopathy is more chronic (meaning that you have been dealing with it for more than 6 weeks before seeking treatment) it may take up to 4-6months to heal and get you back to your activity. If this issue has been ongoing and you have experienced several flare ups, you may have permanent cellular damage in the tendon and although you may improve significantly with treatment, you may never reach 100% recovery status.
If you have an issue with your tibialis posterior tendon or any issue in your ankle region, don’t wait to see a registered physiotherapist or chiropractor. Get assessed and seek treatment as soon as possible for the best results and to ensure a speedy recovery!
If you are in downtown Toronto and are looking for the best, look no further. Our physios and chiropractors are the best in the city and have experience with a wide range of orthopaedic conditions including this one. Book your appointment today. Please call or request an appointment online.