• Posterior Tibial Tendinopathy

    (Posterior Tibial Tendonitis; Posterior Tibial Tendinosis)

    Definition

    Tendinopathy is an injury to the tendon. It can cause pain, swelling, and limit movement. The injuries can include:
    • Tendonitis—an inflammation of the tendon (Although this term is used often, most cases of tendinopathy are not associated with significant inflammation.)
    • Tendinosis—microtears (tiny breaks) in the tendon tissue with no significant inflammation.
    The posterior tibial tendon runs from the posterior tibial muscle to the inside of the ankle and the arch of the foot. The main job of this tendon is to support the arch of the foot. If the tendon is injured or weak the arch of the foot can collapse. This will make the foot pronate (roll outward). These injuries can make it painful to walk.
    Tendonitis
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    Causes

    The tendinopathy is caused by overuse of the posterior tibialis tendon. This most often occurs due to:
    • Running and jumping
    • Dancing, for example ballet pointe work and excessive foot rotation
    • Trauma with high impact

    Risk Factors

    Factors that increase your chance of posterior tibial tendinopathy include:
    • Chronic inflammation—history of rheumatoid arthritis or other arthritic conditions
    • Obesity
    • Diabetes
    • Hypertension—high blood pressure
    • Previous surgery or trauma
    • Local steroid injections
    • Having pronated feet (rolled outward)
    • Aging—tendons may become weaker with age

    Symptoms

    Symptoms may include:
    • Pain and swelling near the arch of the foot and on the inside of the ankle
    • Pain that increases when standing on the ball of the foot or if the foot is flexed
    • Pain that increases with activity
    • Tiredness in the foot after little activity
    • Pain that becomes more disabling
    • Later in the course of the tendinopathy, a flattening of the arch of the foot and pronation
    • An inability to push off well when running

    Diagnosis

    The doctor will ask about your symptoms and medical history. A physical exam will be done, paying special attention to the foot. Pain in the ankle and foot can be due to many causes. Posterior tibialis tendinopathy can be difficult to diagnose.
    The doctor will try to feel the tendon through your skin. He will note how the foot moves and handles resistance to moving the foot inwards. The doctor will look at the foot from behind and from the side and see how flat the arch is. You may be asked to try to stand on the ball of your foot. If you cannot do this you are likely to have a problem with your posterior tibial tendon.
    To confirm changes in your foot and exclude other causes, your doctor may order:
    • X-rays —a test that uses radiation to take a picture of structures inside the body
    • MRI scan —a test that uses magnetic waves to make pictures of the inside of the body
    • Tendoscopy—a small lighted flexible tube is inserted into the tissue surrounding the tendon to view the area

    Treatment

    The goals of treatment are to:
    • Prevent the foot from pronating
    • Decrease inflammation and prevent deterioration of the tendon
    You may be referred to an orthopedic specialist. Early treatment and correction of the underlying cause improves the prognosis. Treatment may include:
    • RICE—rest, ice, compression, and elevation
    • Anti-inflammatory and pain medicines
    • Strapping or taping the foot; some people need a cast or a brace
    • Physical therapy, including:
      • Exercises to strengthen the posterior tibial muscle
      • Correction of poor dance or exercise techniques
    • Custom-made orthotics—These are shoe inserts that can decrease tension on the tendon, reduce pronation, and help support the foot.
    • Surgery to repair the tendon

    Prevention

    To help prevent posterior tibialis tendinopathy, practice good foot care:
    • If you notice you are walking on the inner aspect of your foot, consult a doctor. Early care leads to better prognosis.
    • If you have a foot or ankle injury, get medical care.
    • Wear good, supportive shoes that provide arch support.
    • Obtain proper training for sports and dance activities.

    RESOURCES

    American Academy of Family Physicians http://www.aafp.org/

    American Academy of Physical Medicine and Rehabilitation http://www.aapmr.org/

    American Orthopaedic Foot and Ankle Society http://www.aofas.org/

    CANADIAN RESOURCES

    Canadian Orthopaedic Association http://www.coa-aco.org/

    Canadian Orthopaedic Foundation http://www.canorth.org/

    References

    Campbell's Operative Orthopaedics . 10th ed. Mosby Inc.; 2003.

    Campbell's Operative Orthopaedics . 9th ed. Mosby Inc.; 1998.

    Christensen JC, et al. Tendoscopy of the ankle. Clin Podiatr Med Surg . 2011;28(3):561-570.

    Gluck GS ,et al. Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon. Am J Sports Med . 2010;38(10):2133-2144.

    Mazieres B, et al. Topical ketoprofen patch in the treatment of tendinitis: a randomized, double blind, placebo controlled study. J Rheumatol . 2005;32(8):1563-1570.

    Posterior tibialis tendinopathy. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php . Updated June 2008. Accessed May 11, 2009.

    Emergency Medicine: Concepts and Clinical Practice . 6th ed. Mosby-Year Book, Inc.; 2006.

    Emergency Medicine: Concepts and Clinical Practice . 4th ed. Mosby-Year Book, Inc.; 1998.

    Kelley's Textbook of Rheumatology . 7th ed. WB Saunders Co.; 2005.

    Kelley's Textbook of Rheumatology . 6th ed. W.B. Saunders Co.; 2001.

    Pediatric and adolescent sports injuries. Clinics in Sports Medicine . 2000.

    Textbook of Primary Care Medicine . 3rd ed. Mosby Inc; 2001.

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