• Lionel Pannunzio PT / SCS

Inner Ankle Pain ? Posterior Tibial Dysfunction

Introduction


Some people will develop pain in the inner aspect of the ankle which is called Posterior Tibialis Dysfunction in reference to a tendonitis along the Posterior Tibialis Tendon



WHAT IS POSTERIOR TIBIAL DYSFUNCTION ?


Posterior tibial tendon dysfunction (PTTD) is characterized by pain and at times swelling along the medial (inner) aspect of the foot and behind the medial malleolus (inner ankle bone/bump).


The pain is usually aggravated by prolonged standing, walking, running, or jumping.


1. Posterior Tibial Muscle Function:

The posterior tibial muscle and tendon help stabilize the ankle.

It is responsible for pointing the foot in and down and elevating the arch


2. Posterior Tibial Muscle and its role in Flat Foot deformity:


The tibialis posterior tendon is also the primary dynamic stabiliser of the medial longitudinal arch ( the main arch of the foot )


Without the tibialis posterior, the other ligaments and joint capsules gradually become weak, and thus flatfoot develops.


This later action allows the gastrocnemius muscle to act with much greater efficiency during gait. Furthermore, without the tibialis posterior the gastrocnemius is unable to act efficiently, and therefore gait and balance are seriously affected.


Causes of Posterior Tibial Tendon Dysfunction:


The main cause of this  dysfunction is a Tendinopathy.


Posterior tibial tendinopathy includes both “tendonitis” (a condition involving inflammation of the tendon) and “tendinosis” (a condition involving degeneration of the tendon over time).

For the majority of athletes, such as runners, dysfunction of the tendon occurs gradually due to overuse and over-pronation.


Less commonly, such as in dancers, it can occur suddenly due to overloading of the tendon.

In both cases, individuals with flat feet (a condition known as pes planus) are more prone to this condition.


In advanced posterior tibial tendon dysfunction, the arch of the foot may be collapsed.


Initially, this "flat foot" is flexible (the person can still voluntarily make an arch), but in more-advanced stages it can become fixed


However, even if this occurs, progressive loading/strengthening of the posterior tibialis can be helpful in improving function and reducing pain!




Posterior tibial tendon dysfunction (PTTD) - How does it feel ?




The symptoms of PTTD may include pain, swelling, a flattening of the arch and an inward rolling of the ankle. As the condition progresses, the symptoms will change.


For example, when PTTD initially develops, there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm and swollen.


Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward.


As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably, and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle.


Common symptoms are:

  • Pain or tenderness occurs on the inside of the shin, ankle or foot with walking or standing for long periods

  • Swelling is seen along the course of the tendon towards the foot, which can often be seen as a thick cord when the foot is turned inwards.

  • In longstanding cases the arch along the length of the inside foot will gradually collapse, and as this occurs the foot appears to become flat as the ankle rolls in and the toes turn outwards. This is called an acquired flat foot and is quite different to those in people who are born with flat feet.

  • The person will be unable to raise their heel and go onto their tiptoes on the affected side



Posterior Tibial Tendon Dysfunction - Treatment


Physical Therapy is the first treatment option in PTTD .


1. Pain control

If condition is inflammatory Modalities to address this process are necessary like Iontophoresis or Phonophoresis. When condition is mainly degenerative use of a Tens Unit for pain control may be used..


2. Strengthening of Ankle and foot muscles

Exercises to strengthen the tibialis posterior muscle can be prescribed by a Physical Therapist.


The posterior tibial tendon is as a dynamic support of the medial (inner) arch of the foot. It also inverts (move foot inward) and plantarflexes (point toes downward).


Progressive loading/strengthening of the posterior tibialis can be helpful in improving function and reducing pain.


The emphasis here is to strengthen the posterior tibialis tendon as an ankle mover but also as an arch stabilizer.


When loading a tendinopathy it is fine to have tolerable pain during the exercises, but it should return to your baseline quickly (within 1-2 hours), and should not be increased the next day.


3. Other treatment

Sometimes a walking boot is needed for a few weeks to rest the tendon.


Orthotics to reposition the affected foot and take the strain off the tendon may be required and should be worn in the supportive shoe.



If left untreated, this injury may lead to irreversible damage, such as a flat foot, painful degenerative arthritis and mobility problems.


In advanced cases, or those that have not responded to conservative measures after 3 months or more, surgery may be recommended.


Cortisone injections are generally not recommended as they are associated with a risk of

tendon rupture.





In patients with PTTD, it seems to be that progressive loading/strengthening of the posterior tibialis can be helpful in improving function and reducing pain


The following videos are the exercises I usually prescribe my patient in the treatment of PTTD


Video 1 Heel Raise - 2 Leg - Ball between Heels

In this video the use of Ball ( big then small) will force the heel raise to use the Posterior Tibialis tendon as a medial ankle and foot stabilizer




Video 2  Single Leg Stance

Finally we put the tendon to work with these Balance drills. Be sure you maintain the arch of the foot at all time during the single leg balance exercises



Heel Raise - 1 Leg - Band around Heel

This is a progression from we showed last time.

In this case to challenge the Posterior tibialis Tendon we use a band around the ankle to force the heel raise to use the Posterior Tibialis tendon as a medial ankle and foot stabilizer



Single Leg Stance - 3 Way Toe taps and Lateral Band Slider

More balance drills with emphasis on keeping posterior tibialis active to maintain foot arch.







Conclusion:


  • Posterior Tibialis Tendon Dysfunction is a term used to describe pain in the inner aspect of the foot when walking or running.

  • This is a Tendinopathy and solving this condition requires a comprehensive approach to correct all deficits that can be causing the pain .

  • The best approach to treating PTTD is to unload the tissue, increase the strength of the muscles affected ( Tibialis Posterior), as well as a well roundup hip and core strengthening program to finally load the tissue again with running program that progresses slowly to allow tissue adaption to the load of running

Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located  in the beautiful City of Weston,  where he treats Soccer Player, Runners and Athletes of all ages

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Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy

“Keeping Athletes in the game”

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