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Posterior Tibial Tendonitis

The suffix ‘-itis’ denotes inflammation; so posterior tibial tendonitis describes inflammation of the posterior tibial tendon.

Tendons are found at either end of each muscle, and their function is to attach muscles to bones. The posterior tibial tendon runs from the posterior tibial muscle in the calf, down behind the inner anklebone (the medial malleolus), and across the instep where it divides into three parts, each of which inserts into a different bone or bones of the middle and hind foot. One of the main functions of the posterior tibial tendon is to support the medial arch in the foot. It also assists the foot to turn inwards, and to point the foot and ankle downwards.

Tendons are formed from strands of a strong connective tissue called collagen. The strands are bundled together rather like a rope. With age and use, some of the strands become frayed or broken, weakening the tendon. The process of repair causes scar tissue to form, which leads to a gradual thickening of the tendon. Accumulated scar tissue can form nodules in areas of the tendon, a process called tendonosis. Areas of tendonosis are inherently weaker than the original collagen tissue, increasing the risk of rupturing the tendon.

Areas of tendonosis can become inflamed, leading to tendonitis. It often begins where the tendon passes through a tunnel behind the medial malleolus. The outer covering of the thickened tendon rubs against surrounding structures and becomes irritated.

The main symptom of posterior tibial tendonitis is pain felt in the inner lower leg, the ankle and the instep of the foot. Symptoms usually develop gradually and are felt after activities that include repeated contractions of the posterior tibial muscle, such as running or jumping. There may be swelling along the path of the tendon. If the tendon is ruptured the foot will have a clearly visible flat arch.

Diagnosis is usually made by way of a physical examination of the foot, noting where pain and swelling is present. Very occasionally an MRI (magnetic resonance imaging) scan is required to view the soft tissues.

Successful treatment of posterior tibial tendonitis largely depends on the willingness of the patient to comply with medical advice. Early treatment is preferable, as good results can be obtained within a few weeks, whereas ignoring the condition for a long time may mean treatment lasting for several months.

Conservative (non-surgical) treatment consists of resting the foot by avoiding time spent on your feet and completely avoiding any activity that aggravates the condition. This will decrease the amount of stress on the tendon and allow the tissues to begin healing. When you do have to walk, it may be necessary to use crutches, and use firm arch supports in your shoes.

Over-the-counter pain medications such as ibuprofen (Advil and others), naproxen (Aleve and others) or aspirin, may be recommended by your doctor to relieve pain and inflammation.

Elevating the foot above the level of your heart whenever possible will decrease pressure on the tendon and relieve swelling.

Your doctor may provide a treatment called iontophoresis. This procedure administers cortisone medication (a pain-relieving anti-inflammatory substance) through the skin to the tissues of the tendon, using gentle electrical currents. This treatment runs less risk of rupturing the tendon than a traditional cortisone injection.

A physiotherapist might administer ultrasound and massage to relieve pain. You will be shown how to do exercises to stretch and strengthen the calf and foot muscles.

Surgery may be necessary if conservative measures fail. The surgeon can remove areas of thickened tendon sheath tissue in a procedure known as debridement. Alternatively, tears in the tendon might be repaired with sutures, or the tendon might be strengthened with a tendon graft. If the medial arch is flat, due to a ruptured tendon, and the resultant misalignment of the bones is causing pain and cannot be remedied in any other manner, several bones in the foot can be fused together by the removal of the joints.

Rehabilitation after surgery will depend on the particular procedure you had, but soft tissues will take about eight weeks to heal. You may wear a walking boot during this time, and use crutches when walking. A graduated program of exercise will be developed for you.

These should only be done with the approval of your health care practitioner. Always exercise both limbs to avoid developing an imbalance between the legs.
Towel stretch:
Sit on the floor and stretch one leg out in front of you. Loop a towel around the ball of your foot and your toes and, keeping the leg straight, pull on the ends of the towel to draw your foot towards you. Hold the stretch for 15-30 seconds. Repeat 3 times.
Calf stretch:
Stand facing a wall and place hands on it for support. Lean forwards until stretch is felt in the calves. Hold for 30 seconds. Bend at knees and hold for a further 30 seconds. Repeat 3 times.
Calf raise:
Stand with your feet shoulder width apart. Lift your heels off the floor as high as possible then slowly lower to the ground. Repeat 10 times for 1 set. Build up to 3 sets.
Side leg raise:
Lie on your side with the injured leg uppermost. Keep the leg straight. Tighten the quadriceps (thigh muscles) of the upper leg and slowly raise the leg about 10 inches. Slowly lower again. Repeat 10 times for 1 set. Do 3 sets.
Balance 1:
Begin by standing on one leg for 1 minute. When you can do this easily, progress to doing it with closed eyes.
Balance 2:
Stand on one leg and pass a ball around your back. When this becomes easy, do it with closed eyes.
Balance 3:
Stand on one leg and pass a ball under the other (raised and bent) leg. When this becomes easy, do it with closed eyes.
Wobble board:
A wobble board is very effective for balancing exercises, but can be tricky, so if possible have a physiotherapist show you how to use one properly.

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