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Tibialis Posterior Tendinitis

(Also known as Tibialis Posterior Tendiopathy, Posterior Tibial Tendonitis, Tibialis Posterior Tendinosis)
Note- Although recent research suggests that 'tibialis posterior tendinopathy' is the more appropriate term to describe overuse injuries to the tibialis posterior tendon, we will use the term 'tibialis posterior tendinitis' in this document as it is more widely known.

What is tibialis posterior tendinitis?
The tibialis posterior muscle originates from the back of the tibia and fibula (lower leg bones), it then travels down along the inside of your lower leg and ankle where it inserts into various bones in the foot via the tibialis posterior tendon. The tibialis posterior muscle is responsible for moving the foot and ankle towards the midline of the body (inversion) and pointing the foot and ankle down (plantarflexion). It also helps to maintain the normal arch of your foot.
Whenever the tibialis posterior muscle contracts or is stretched, tension is placed through the tibialis posterior tendon. If this tension is excessive due to too much force or repetition, damage to the tibialis posterior tendon may occur. Tibialis posterior tendinitis is a condition where there is damage to the tendon with subsequent inflammation and degeneration. This may occur traumatically due to a high force going through the tendon beyond what it can withstand or more commonly due to gradual wear and tear associated with overuse.

Signs and symptoms of tibialis posterior tendinitis

Patients with tibialis posterior tendinitis typically experience pain in the region of the inner lower leg and ankle. In less severe cases, patients may only experience pain with rest following activities requiring strong or repetitive contraction of the tibialis posterior muscle such as running (especially uphill or on uneven surfaces), jumping, hopping etc. They may also experience pain and stiffness upon waking the following morning. As the condition progresses, patients may also experience pain during these activities affecting performance. The pain associated with this condition tends to be of gradual onset which progressively worsens over weeks to months with continuation of aggravating activities. Patients with this condition may also experience pain on firmly touching the tibialis posterior tendon.

Diagnosis of tibialis posterior tendinitis
A thorough subjective and objective examination from a doctor is sufficient to diagnose a tibialis posterior tendinitis. Diagnosis may be confirmed with an MRI scan or ultrasound investigation.

Treatment for tibialis posterior tendinitis
Most patients with tibialis posterior tendinitis heal well with an appropriate rehabilitation program. The success rate of treatment is largely dictated by patient compliance. One of the key components is that the patient rests sufficiently from ANY activity that increases their pain until they are symptom free (crutches may be required). This allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the condition becoming chronic. Once chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence. Immediate appropriate treatment in all patients with tibialis posterior tendinitis is vital to ensure an optimal outcome.
Following RICE with regular icing and anti-inflammatory medication may help to significantly reduce inflammation in the initial phase of this condition. A graduated flexibility, balance and strengthening program under direction from a physiotherapist is vital to ensure an optimal outcome.
In the final stages or rehabilitation, a gradual return to activity or sport should occur under guidance from the treating practitioner and provided there are no increase in symptoms.

Contributing factors to the development of tibialis posterior tendinitis

There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a practitioner and may include:
  • poor flexibility
  • inappropriate training
  • poor foot biomechanics (especially flat feet)
  • inappropriate footwear
  • muscle weakness
  • inadequate warm up
  • inadequate rehabilitation following previous injury
Physical therapy for tibialis posterior tendinitis
Therapy treatment is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of injury recurrence in all patients with tibialis posterior tendinitis. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • joint mobilization
  • taping
  • bracing
  • the use of crutches
  • ice or heat treatment
  • exercises to improve strength, flexibility and balance
  • education
  • activity modification advice
  • biomechanical correction
  • footwear advice
  • a gradual return to activity program
Prognosis of tibialis posterior tendinitis
Most patients with this condition heal well with an appropriate rehabilitation program. This, however, can be a lengthy process and may take several months in patients who have had their condition for a long period of time. Minor cases of this condition that are identified and treated early can usually settle within a few weeks. Early therapy treatment is vital to hasten recovery and ensure an optimal outcome.

Other Intervention for tibialis posterior tendonitis
Despite appropriate management, a small percentage of patients with this condition do not improve adequately. When this occurs the treating doctor can advise on the best course of management. This may involve further investigation such as an X-ray, Ultrasound, CT scan or MRI, corticosteroid injection, autologous blood injection, pharmaceutical intervention or a review by a specialist who can advise on any procedures that may be appropriate to improve the condition. A review with a podiatrist for the prescription of orthotics and appropriate footwear advice may also be indicated.