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Still NOT Shin Splints: Posterior Tibialis Tendon Dysfunction

It can start as nagging, aching almost in your heel, but not quite.

Sometimes lingering in towards the inside of your calf, but not really.


Or other times it starts to pinge and twinge and loop underneath your inside ankle bone and then starts up the aching again around your inner ach.


This last part: you're freaking sure of!

And you're sooooo over it.

But you still have no answers, no clue, and no idea where to start with this changing-pain-game you're just not winning.

Until now.





Running fit fam, meet your posterior tibialis.

He's the forgotten second cousin to anterior tibialis who gets waaaay more attention because he's the blame for everyone's favorite, shin splints.

Party in the front: anterior tib with MTSS

Party in the back: posterior tib with Posterior Tibial Tendon Dysfunction.

Please don't leave yet! I know, that name sounds way scarier than it actually is!


Because in reality, PTTD is an umbrella term for the different ways one muscle (and tendon) can become irritated, inflamed, and cranky and all the sequelae that can follow (yes, more fancy medical words.)

You might be more familiar with battling:

  • Posterior Tib tendonitis

  • Post tib tendinosis

  • Or flat fleet…

Starting to see why we're gonna stick with the umbrella term for today?

Makes life easier, and still gets all your questions answers.


Speaking of which, let's dive into another elusive, confusing, foot issue that can slow down and even stop some runners in their tracks.

Because that WON'T be you by the end of this ;)

What is Posterior Tibial Tendon Dysfunction, where is this muscle, and what's going on?

Anatomy & Physiology

PTTD, like we talked about above, is an umbrella term to describe how the loooong tendon of this particular muscular can get irritated to different degrees. (I won't bore you with the details of grade I, II, III etc, but knowing those exist helps to flesh out the picture; there's different levels and severities).

The reason this tendon has a proclivity to irritation and flaring up is because of the route it travels. Check out the picture below.


anatomy of posterior tibialis wrapping underneath the medial malleolus
https://www.hss.edu/conditions_posterior-tibial-tendon-insufficiency-overview.asp

Can you see how many turns and structures the tendon has to navigate its way through?

  • It's sitting under a whole lot of other muscles in a tight space

  • It has to navigate behind the medial malleolus (your inner ankle bone)

  • And then navigate underneath too...

  • on top of plugging into that foot bone, your navicular at the navicular tuberosity

It's got a lot going on.


Not to mention, it's activating, firing, and working hard every time you push off of your toes while your running.

It's doing a whole lot of work in a small amount of space.

So when it comes to the question of "how do post tib injuries happen?"…

Can you guess the favorite evidence-based answer?

Yup, that's right: we don't know.

Or in more fancy words, it's "mulifactorial", meaning, there could be a lot of different reasons (these are called risk factors) some of which include:

  • flat/flat-ish feet

  • up to 10lbs overweight (meh, don't sweat this one)

  • increased age

  • possible increase in rearfoot eversion (see hindfoot valgus in the picture above; same difference)

For runners, those risk factors don't help a whole lot.

From what I've seen in the clinic, runners who develop PTTD may have increased mileage too soon, switched shoes, tried new shoes with less arch support and shorter heel stack, or maybe they are or were pregnant…


Like I said, multifactorial. We'll come back to this…

If I have pain here, do I have post tib issues?

One thing that is more consistent with post tib disorders is that the location of pain and symptoms. The only other problem is, there's a whole lot of other structures presents along the same route (go look at the picture again for reference).

But consistently, post tib symptoms or pain...:

  • "presents as pain on the medial side of the midfoot to rear foot and/or ankle, and is associated with difficulties during activities that load the tibialis posterior tendon…characterized by pain localized to the tendon that increases with loading"

What this means:

  • Pain on the inside portion of your arch which could travel to around your heel, under your inner ankle bone and occasionally up into the calf, but not too far. And it hurts most with more intense activities (we'll talk about what those are down below).


area of pain for posterior tibial tendon
https://www.foot-pain-explored.com/posterior-tibial-tendonitis.html
So I know what it feels like now, but what could it look like?

"Clinical features" of post tib issues include:

  • "inclusion criteria were tenderness on palpation, swelling along the tendon, poor plantar flexion inversion strength, and difficulties performing an single leg heel raise"

What this means:

  • When you feel around the area in the picture above, it's tender.

  • The tendon-area looks swollen

  • And these other things down below that translate those medical words into running words…

You might feel your post tib acting up during or after these runs:

  • Sprinting or any kind of high-pace speedwork

  • Steep hill repeats

  • Jumping or skipping type running drills

How to test yourself so you "know"?

Ask yourself these questions:

  • Is the inside of your ankle and foot more swollen than normal?

  • Do any of the running activities listed above tend to bring on symptoms?

If your answers to those are a little iffy, that's ok!


In one article, the authors found THIS test we'll talk about below to be waaaay more reliable and accurate in helping to determine if any posterior tib issues were going on. So let me pass it on to you.

TEST: Single leg calf raise

  • Do a single leg heel raise.

    • Hold on lightly to a chair, the wall, whatever, just to steady yourself.

    • Do it on both sides and compare R vs L. (to do that, you might need a running buddy or even just film yourself with your phone. easy peasy!)

Assessment Time:

  • Notice how high you got on your heel raise.

  • Did the injured side get as tall as the other side? Or were you unable to perform a single heel raise on the injured side?

  • Was the injured side painful?

If you're answering yes to 2 out of 3 of these (especially being unable to perform a single heel raise), then keep reading, running fit fam.

So Now What?

If you said yes to 2 out of 3 of those questions from your heel raise test AND this has been going on for 1-3 months:

  • get your runner's hiney to physical therapy….stat! (no, we don't have to amputate, but it's definitely time. You deserve medical care. You deserve to run pain-free.)

The only way out of this is…
  • If you've gone to PT before and/or have reliable exercises from another health care provider which are effective for you!

  • In that case, put them on the calendar. Make it a priority to do those exercises every day. Because by being in pain and not taking advantage of the exercises you have, is just a disservice to yourself.

If you said yes to only 1 out of 3 questions from your heel raise test,

AND you've been noticing a little soreness/tenderness after those specific running workouts we mentioned,

AND this has ONLY been going on 1-3 weeks max...

  • It's time to take this seriously and rest and recover as appropriate.

  • Do you have a running coach?

    • go tell them about what's going.

  • Are you doing your strength and mobility work like you should be?

    • Make sure those get on your calendar.

  • Do you have foot exercises that you know work for you?

    • Time to start using those again!

    • If you don't have any, I have some if you'd be interested! I've used these Stronger Feet Exercises repeatedly in the clinic for my runner-patients who have struggled with posterior tib issues just like you. You can check those out here now if you're ready to get going ASAP!

In case you're still not sure where you fall with these tests (because that's completely ok!)...

  • then stick around for next week too. I'll be dropping some more foot exercises that are specific to helping out your posterior tib.

This blog post was a little more fast, furious, and to the point.

Wanna know why?

Because this is (again) one of those situations we're still learning about from a research perspective. Not because we know "nothing", but because it's like a spiderweb


...looping back to that multifactorial part we mentioned at the beginning.

Running injuries aren't normally black and white. There's usually a lot of little things that add up to result in an injury, and a posterior tib issues falls in that same category.


That being said, don't sweat it, obsessing over small details, nit picking the when's, how's, and why's of a post tib tendinopathy.


What matters now, is that you know.

You have the knowledge.

You understand which muscle is affected.

Why you have pain.

And you even have some immediate action steps you can take.

And that's a whole lot more than when we first started this blog post ;)

Stick around for next week, running fit fam and deep dive into even more!


Until then, Dare to Train Differently,

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

P.S. don't forget to take a peek at the Stronger Feet Workshop if you're a real action taker and want any post tib issues gone NOW!



 

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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