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How Runners Fix Posterior Tibial Tendon Dysfunction

Let's start this blog post a little differently, running fit fam.


Don't worry, we'll get into the specifics and (limited) evidence behind treating posterior tib issues, but I wanted to start today with saying:

You're not alone.

Struggling with posterior tibialis issues (in general) is a royal pain in the booty.

And it can feel debilitating.

And frustrating.

And stupid, but painful and you can't ignore that there's something wrong.

And then add to that, kinda hopeless because you google exercises but everything's the same blah boring ones that you've already tried before


…or maybe…even the same blah boring ones you've done in physical therapy before?


*skr skrr!*

Let me stop you right there, just for 1 second.

  • Is your pain greater than a 4/10 for 2 weeks? Non-negotiable: go get that checked out by a sports doc, PT, etc. Go get the care you deserve.


  • Is your pain a lingering, nagging, annoying voice that's a stubborn 3/10 at the most, but enough to start messing with your training plan? If yes, then please proceed.

Because you're not alone.


Have you made

this mistake before?

Not to mention,

  • you've tried the towel scrunches

  • done the different barefoot pick-up exercises

  • and felt like they weren't doing anything to help your post tib issue?








What if I told you someone's been in your exact shoes?














One more, running fit fam!

I'm just so proud of these runners for putting in the work and being the hero of their own story.

These runners decided to take control.

To take action and get stronger.

And they did that by first starting with the foundation of the Stronger Feet Workshop.

I promise, this entire blog post is NOT a sales pitch. Stay with me, running fit fam.


This is me being honest and transparent.

Why bring all this up?

Because the exercises I'm about to give you below…they'll help.

But they WON'T help to their fullest potential if your foundation, your forefoot, isn't strong and activated.


It would be like only running a long run of 10miles for marathon training. It's helpful for sure! You *could* still finish your marathon, but you're not going to perform at your absolute best.

And the exact same applies to posterior tib exercises.

Because, DISCLAIMER…

When it comes to leg, foot, posterior tib injuries…it's still the wild west out here.

And the science and research community, we're still learning and putting together the puzzle pieces. And I want to show you the way I've found that works the best and MOST reliably for runners like you.


And that is by starting with the foundation of the Stronger Feet Exercises followed up with exercises we'll get into below.

But let me show you...

The Wild West of the Posterior Tib Meets Runner

"Several limitations are acknowledged.

First, this study did not include the classically defined posterior tibialis tendon dysfunction (PTTD) demographic of sedentary women over the age of 40, who are diabetic or obese.

However, the use of a younger, more active population is supported by previous research demonstrating PTTD that is a common injury among runners. It is also possible that stage I PTTD is distinct and only associated with tendon overload due to the altered rearfoot mechanics reported in the current study.

In contrast, tendon overload in stages II to IV PTTD may be associated with other factors, such as obesity, altered MLA and rear-foot mechanics, as well as neuromotor and muscular strength deficits."

Starting to see the grey area?

"The results of the current study suggest that runners with stage I PTTD are likely to present with normal inversion ankle muscle strength, significant differences in rearfoot pronation during walking gait, and no differences in foot posture as compared to healthy controls.

The increased foot pronation is hypothesized to place greater strain on the posterior tibialis muscle, which may partially explain the progressive nature of this condition."

What's this part mean?

It's summarizing how runners don't fit the "normal" expectation of WHO gets posterior tib issues. But we KNOW (because we're runners here) that it's super common!


So WHY are runners getting post tib issues if we're not all 40+ yr old, diabetic, obese women who DON'T run??

*shoulder shrug*

As far as research can tell, runners who do get post tib issues normally still have decent ankle strength but maybe their foot mechanics are affected, meaning maybe there's a little more collapse going on in the mid foot and more heel whipping out to the side?

So maybe all of this leads to:

"The increased foot pronation is hypothesized to place greater strain on the posterior tibialis muscle, which may partially explain the progressive nature of this condition. CAUTION: This study involved a group of healthy runners that does not represent the classic PTTD demographic of middle-aged, sedentary women with diabetes and obesity, which are often identified as primary risk factors"

Can you see how we've come full circle?

And how there's not a real, conclusive answer?

It doesn't mean we know nothing; it means there's a lot of gray area.

And that's why I want to help.


So what can you do according to the research and not just what @dr.whitt.fit says?

OLD vs NEW

The "old" way of treating PTTD:

  • "The mainstays of non-operative treatment: physical therapy, orthoses, braces"

The New-New methods according to up and coming research:

  • PRP, extracorporeal shockwave therapy

PRP and ESWT Defined:

What’s in a PRP (platelet-rich plasma) Shot?

  • "Plasma is the liquid part of your blood that’s mostly made of water and protein. It lets red and white blood cells and platelets move through your bloodstream. Platelets are a type of blood cell that makes your blood clot. They also play a role in healing. Doctors may use platelet-rich plasma (PRP) on injuries or damage to tendons, ligaments, muscles, joints, and skin."

What is Extracorporeal Shockwave Therapy?

  • "Extracorporeal Shockwave Therapy (ESWT) otherwise referred to as shockwave therapy, was first introduced into clinical practice in 1982…animal studies conducted in the 1980s revealed that ESWT could augment the bone-cement interface, enhance osteogenic response and improve fracture healing. While shockwave therapy has been shown to be beneficial in fracture healing most orthopedic research has focused on upper and lower extremity tendinopathies, fasciopathies, and soft tissue conditions."

But let me add in a little side note before you leave to chase down these latest and greatest shiny treatments…

As much as I've seen the new-new help my patients in the clinic…they've still been referred to PT for functional foot strengthening (a lot of times, exercises very similar to the ones in the Stronger Feet Workshop and the ones we'll explore down below).

Meaning…

these is no passive magic tool or treatment.

They can be extremely helpful! But you still need exercises, aka skillfully, therapeutically applied to increase your tolerance to the load/stress of running. You need something MORE to gain the most benefits from more passive interventions.

So…onto the part you're probably more interested in!

Exercises for PTTD

Foot Dome Exercise


Why this exercise?

"The collective muscle functions of the foot have been likened to the ‘‘core’’ of the trunk, whereby the intrinsic foot muscles and global muscle movers of the foot act to stabilize the body during dynamic tasks."


(oh hey, we've talked about this before in THIS blog!)

"Stability is especially important during the single-legged stance phase of running motion, jump landings, cutting, and change of direction. Poor foot strength and activation of muscles that create the arch can contribute to arch collapse and a variety of chronic musculoskeletal complaints in runners, including medial tibial stress syndrome and posterior tibial tendon pain."


(yup, there's post tib and shin splints again.)

Reps and sets:

As suggested by the authors: " 3 minutes a day for 4 wk"

Keeping with the theme of foot core, the majority of the exercises in this workshop are like "foot planks."

(I've recruited the husband to demonstrate some of the beginning of exercises for you. Ssshh, don't tell him I recorded it. ;) )



See?

Nothing wild.

Nothing crazy.

But crazy effective!


If you do the foot doming followed by these stair exercises, can you start to feel your foot wake up? Feel how activated it is as the forefoot tries to stabilize in the "single-legged stance phase" that's so important to the "running motion"?


That's the beauty of how these exercises flow together, work together, to compliment YOUR needs a runner.


Reps and sets: discussed in detail in the workshop

So let's say you've done all those and created your solid foundation.


You're at the point where there's no more pain, maybe a little soreness and quick fatigue, but overall, you're back and now you're ready to be stronger than ever!

What's next?


Now, it's time to level up and make sure you're strong enough to handle whatever intensity your running workouts throw at you.

DISCLAIMER #2. The following exercises are not specifically supported by the literature.

Aka, there is NO handbook, manual, how-to guide out there (at this time) that says "this is how you fix post tib issues".


This exercise is my professional, clinical opinions and an exercise I do myself to keep my feet strong.

The Curtsy Lunge

Why is a supposed glute-leg exercise important for your post tib?

What am I talking about? CLICK HERE!

  • Your post tib is responsible for pointing your toes, scooping your foot inward, and support your arch (plantar flexion, inversion, and supporting the medial longitudinal arch).

  • When you perform a curtsey lunge, it’s the stance leg we care about, especially doing it barefoot.

  • What's happening here, is as you reach back behind you with the other leg, the stance leg and foot have to ground, stay stable.

  • You are working the posterior tib relatively, asking it to remain strong in an eccentric (or opposite) manner compared to it's actual actions (or normal job).

The real magic happens when you come back to the starting position.


You are actively pointing your toes into the ground and scooping your foot inward, you just don't know it.

But your foot does.

Your post tib does.

It's actively doing the job it was created to do still in a runner-specific manner requiring:

  • Forefoot activation

  • Single leg stability

  • With same-sided glute activation (because we're all about the glute-ankle connection over here).

I know, how can so much be going on with one exercise?

Well, it's possible haha.

And it's the magic of physical therapy and movement.

So what do you do with this ONE exercise?

Anything you want! The world is your oyster!

  • Start with just mastering the movement.

  • Add some weights.

  • Add a jump at the end! (suggested: NO weights)

  • If you're feeling confident from taking the Stronger Feet workshop, do this one on the stairs just like the other ones (that’s my FAVORITE option! Obviously, no weights or jumping…just to clarify).

Did you notice something about my list of exercises?

No calf raises or towel scrunches in sight.

And like we've talked about before, these aren't "bad" exercises!. But these alone…aren't specific enough to your needs as a runner.

And you deserve runner-specific exercise and the success that comes with them.

I can't wait for you to get back to running again, feeling confident, strong, resilient, and empowered.


All because, you Dared to Train Differently.

Until next time,

Marie Whitt, PT, DPT //@dr.whitt.fit

Resource:

@runningexplained + @dr.whitt.fit podcast episode -where the stronger feet workshop was born!

 

References

Milani, C., Vyas, K., & Malik, G. (2022). Evidence-Based Diagnosis and Treatments of Posterior Tibialis Tendinopathy. Current Physical Medicine And Rehabilitation Reports. doi: 10.1007/s40141-022-00366-3


Rabbito, M., Pohl, M., Humble, N., & Ferber, R. (2011). Biomechanical and Clinical Factors Related to Stage I Posterior Tibial Tendon Dysfunction. Journal Of Orthopaedic &Amp; Sports Physical Therapy, 41(10), 776-784. doi: 10.2519/jospt.2011.3545


Ross, M., Smith, M., Mellor, R., Durbridge, G., & Vicenzino, B. (2021). Clinical Tests of Tibialis Posterior Tendinopathy: Are They Reliable, and How Well Are They Reflected in Structural Changes on Imaging?. Journal Of Orthopaedic &Amp; Sports Physical Therapy, 51(5), 253-260. doi: 10.2519/jospt.2021.9707


Vincent, K., & Vincent, H. (2018). Use of Foot Doming for Increasing Dynamic Stability and Injury Prevention in Runners and Athletes. Current Sports Medicine Reports, 17(10), 320-321. doi: 10.1249/jsr.0000000000000522



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