Description: Tendons are fibrous tissue bands that connect muscles to bones. The Posterior Tibial Tendon is a strong band of fibrous tissue. It connects the Posterior Tibial Muscle to multiple locations on the inner and bottom sides of the arch. The function of this tendon is to help maintain the arch height (keep it from collapsing), and to help prevent pronation (a rolling out of the foot at the ankle, forcing one to put abnormal amounts of weight on the inner surface of the foot when walking). When this tendon becomes swollen, inflamed, and painful it cannot function properly. The terms for this condition are Posterior Tendonitis and Dysfunction.
Anatomy: The Posterior Tibial Muscle is situated on the back of the leg. Just above the prominent inner ankle bone, the medial malleolus, the muscle turns into a fibrous tissue band called the Posterior Tibial Tendon. This tendon runs behind the inner ankle bone, and enters the foot, traveling forward along the inner edge of the arch. Its main insertion is into the inner and bottom surfaces of the Navicular bone. The Navicular is a key structural component of our arch. The Posterior Tibial Tendon helps to maintain the height of the arch, and to prevent the foot from pronating, by pulling on the inner and bottom sides of the Navicular. This stabilizes and supports the foot in its normal or neutral position.
Symptoms/Diagnostic Signs: The most common symptoms, or diagnostic signs, of Posterior Tibial Tendonitis/Dysfunction include:
- Pain and swelling along the inner side of the arch and ankle, and along the course of the tendon. At first, these symptoms are only present with exercise and extended periods of standing or walking. With rest, the pain and swelling will subside. As the inflammation of the tendon becomes worse, the pain will not subside, even with extended periods of rest. In the later stages of this disease, the pain and swelling are almost always present.
- The height of the arch begins to fall. This will cause the foot to flatten and in later stages of this condition, the arch collapses completely. When this occurs, the entire foot begins to ache and will feel weak.
- Inability to resist pronation. When the tendon is inflamed and painful, it cannot function properly. One of its main functions is to pull on the inner side of the arch and prevent the foot from rolling out (pronation). When it is inflamed, it cannot do this, so the foot begins to roll out, or pronate. In later stages, it appears as if the foot is so turned outward, one is walking only on the inner part of the ankle and arch, rather than the entire foot. This will eventually cause heel pain, ankle pain, shin splints, knee and hip pain, and lower back pain.
- Inability to rise up on the toes without pain. The Posterior Tibial Tendon stabilizes the arch and foot, especially when we try to stand on our toes. When this tendon is inflamed, it has difficulty stabilizing the foot, so it must work harder to do so. This extra exertion on the tendon's part will cause it to become painful when trying to stand on one's toes.
- A "popping" sound can occur during activity if there is a sudden tendon tear.
It is important to note that Posterior Tibial Tendonitis/Dysfunction may affect just one foot, while the other foot remains normal.
Causes: The most common causes of Posterior Tibial Tendonitis or Dysfunction include:
- Injury of the tendon. This can occur in the following ways:
- Direct injury to the tendon (such as a blow to the tendon, or a fall resulting in a sprain or tear to the tendon).
- Micro-trauma. An example would be an overuse injury due to excessive repetitive movements (always running in the same direction on a track with a pitch).
- Age-related changes of the tendon. As people age, the tendons lose their elasticity and ability to glide as smoothly as they used to. Thus, older individuals are more prone to developing symptoms of tendonitis, due to the impaired gliding motion of the tendon. . When the tendon no longer functions properly, it becomes swollen, inflamed, and painful.
- Hereditary Defects are those defects that we are born with, which predisposes us to Posterior Tibial Tendonitis/Dysfunction:
- Flat feet place excessive loads or pull on the Posterior Tibial Tendon. As the foot flattens, it stretches this tendon. The tendon, in the meantime, is over-working because it is trying to prevent the arch from collapsing further. This stretching or thinning of the tendon, along with its over-exertion will produce inflammation and pain in the tendon. If the arch is not properly supported, small tears will eventually appear in the Posterior Tibial Tendon. This will lead to almost constant pain and swelling of the tendon, along with a complete collapse of the arch and foot.
- Pronation causes the foot to be turned outward at the ankle, causing one to walk more on the inner border of the foot than is normal. This will place an abnormal strain on the Posterior Tibial Tendon, which attaches to the inner border of the arch, and tries to prevent the foot from pronating. This constant failure of the tendon to prevent pronation causes the tendon to over-work. This will eventually result in: swelling, inflammation, pain, tearing of the tendon, and instability of the entire foot.
- An Accessory Navicular Sesamoid (Bone) is a small loose bone that some people are born with. When it is present, it lies in front of the area where the Posterior Tibial Tendon would normally attach to the Navicular Bone. So, instead of attaching to the normal Navicular, the tendon attaches to the Accessory Navicular Bone. This prevents the tendon from pulling on the true Navicular and maintaining the arch height and normal foot position. Pain, swelling, and tendon tears occur due to the tendon over-working and trying to accomplish its functions.
- Over-weight or Obese individuals place abnormal amounts of weight on the arch, forcing it to eventually collapse, no matter how hard the Posterior Tibial Tendon tries to prevent this collapse. Obesity may be considered one of the more frequent causative problems for Posterior Tibial Dysfunction. As this tendon over-works, trying to maintain the arch height, it eventually becomes inflamed, swollen, and painful. The end results are:
- Tears within the tendon
- A completely collapsed arch
- A pronated and unstable foot
- Constant pain along the course of the tendon
- Self-Treatment or Prevention: The old adage, "An once of prevention is worth a pound of cure," is most apropos when trying to prevent the devastating effects of Posterior Tibial Tendonitis/Dysfunction. If this disease is not prevented or treated in its earliest stages, it will produce such debilitating deformities that surgery will be required to allow the foot to function normally again.
- Long Term Treatment must be directed towards:
- Reducing the excessive and abnormal pull on the Posterior Tibial Tendon. This will prevent inflammation, swelling, pain, and tears within the tendon.
- Supporting the arch at its optimum height, and preventing further collapse. This will reduce the abnormal pull on the tendon, and allow it to function without pain.
- Stabilizing the foot. When the foot is maintained in its normal, or neutral position, it cannot pronate and roll out. Thus, pain and swelling are reduced, and the foot is allowed to function, as it normally should -- a pain free, supportive, and efficient part of our body.
- Providing shock absorption for the arch. The arches of our feet are our body's main shock absorbers. As we take each step, the arch and the Posterior Tibial Tendon help to absorb and disperse the tremendous force that occurs when our foot strikes the ground. This force can equal 3 to 7 times our body weight, depending on whether we are walking or running. When the arch is lower than normal, and the Posterior Tibial Tendon has been stretched, shock absorption by the arch is reduced. When this occurs, the foot, ankle, leg, knee, hip, and lower back must absorb this shock. This may lead to: stress fractures of the foot, heel and arch pain, shin splints, and knee, hip, and lower back pain.
Custom-Made Orthotics is useful especially in the prevention and early stages of Posterior Tibial Tendonitis/Dysfunction. Our custom-made orthotics for this condition are constructed of thin, comfortable, shock absorbent materials, which gently and effectively:
- Stabilize the foot by using uniquely placed medial wedges, deep heel cups, and "posts" (stabilizers). When the foot is stabilized, it is brought back to a neutral or normal alignment. When the foot is in its normal alignment, pronation is reduced or completely corrected, and, the abnormal pull on the Posterior Tibial Tendon is reduced. This will allow the tendon to begin to heal. When the tendon is healed and functioning normally again, Posterior Tibial Tendonitis/Dysfunction will be alleviated, along with its pain and swelling.
- Provide the specific amount of arch support that your foot requires. Our custom-made orthotics support not only the arch as a whole, but each individual bone and joint that forms the arch. Due to Posterior Tibial Tendonitis/Dysfunction, each person's arch collapses differently and to different degrees. The only way to provide the support that you need is with a custom-made device that raises your arch to its optimum height.
- Aid in shock absorption. The primary shock absorbers of our feet, and therefore our body, are the Posterior Tibial Tendon and the arch. To aid these structures, we construct our custom-made orthotics so that they provide semi-flexible support to the arch by "giving" to absorb the shock of each step, rather than our foot absorbing the shock (our orthotics act in the same way a shock absorber does on an automobile). When your weight is removed from the orthotic, the arch returns to its original height since the material we use has a built-in "memory." This action will help to keep the tendon and arch healthy and pain free.
Custom-made orthotics for Posterior Tibial Tendonitis/Dysfunction are constructed of durable, comfortable, shock absorbent materials. From the impressions of your feet that you make with our Foam Impression Kit, and the information you provide us with, we design and construct a pair of orthotics that will help to stabilize your feet, reduce your pronation, reduce the abnormal pull on the Posterior Tibial tendon, and help to alleviate your foot pain. These orthotics will fit in most shoes with a heel height up to 1 1/2 inches. For information on how to order these uniquely effective custom-made orthotics, click here
We have found that the Stromgren Double Strap Ankle Brace helps to reduce Posterior Tibial Tendonitis pain. This brace helps to provide some stability to the foot and ankle, which in turn reduces the abnormal pull of the Posterior Tibial Tendon on the foot. When the pull is reduced, so is the pain. While this brace may reduce your pain, it does not offer the long-term benefits that custom-made orthotics provide.
The nylon/lycra sock of the Stromgren Ankle Brace comfortably supports the ankle and the Posterior Tibial Tendon. Additional stability and support is provided with the two attached straps that are wrapped in opposite directions around the ankle, and are held in place with hook and loop fasteners. This is a thin, low bulk brace that will fit in most shoe styles with a low heel.
Immediate Treatment must be directed towards reducing the inflammation, swelling, and further tearing of the Posterior Tibial Tendon. In the early stages of Posterior Tibial Tendonitis/Dysfunction, the suggested care is R.I.C.E.:
- Rest the foot by keeping weight off of it. Each time you step down, the tendon is aggravated and abused. It cannot heal if you do not keep weight off of the foot.
- Ice that is carefully applied to the inner arch and ankle will help to reduce pain, swelling, and inflammation. Do not freeze the area…you just want to achieve a mild cooling effect. Do not apply the ice to the toes. Use ice every few hours for about 15 minutes each time. If the ice increases the pain, stop immediately.
- Compression (mild) will help the Posterior Tibial Tendon support the arch. Mild compression will also help to reduce swelling. An elastic bandage wrapped around the foot and ankle will help to achieve compression. If the bandage is too tight, it will not only reduce the circulation to the foot and toes, but it will not allow the tendon to heal. Apply the elastic bandage so that it is comfortable. Check the color of your toes to make sure the bandage is not too tight.
- Elevate the foot and leg. This will help to reduce the swelling within the tendon and foot.
- Anti-inflammatories if well tolerated.
- If very acute, may also benefit from a walking and immobilizing cam walker or boot. An "Active Ankle" support is also very helpful when acute. This type of support is often a first treatment for an acute Posterior Tibial Dysfunction. It allows the patient to be able to ambulate for comfortably and with some stability allowing the continued use of shoes.
If the pain becomes worse, the foot more swollen and unstable, or if you think that you have a serious problem, see a doctor immediately.