Tibialis posterior tendinopathy

Tibialis posterior tendinopathy or tendonitis occurs in the tendon that runs around the inside of the ankle joint. The tibialis posterior muscle is an important stabiliser of the foot and helps maintain the arch of the foot. It also turns the foot in (inversion) and assists in pointing the foot down (plantar flexion).

What is tibialis posterior tendinopathy?

Tendinopathy is a failed healing response of the tendon. Rather than the normal healing taking place to where the tendon is healthy the repaired process fails with disruption of the tendon structure leading to pain and swelling

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Causes and symptoms

Causes of tibialis posterior tendinopathy

Our tendons (which attach muscle to bone) undergo various stress and strain during our day to day activities. They adapt and recover from these on a daily basis. When the demand placed on these tendons exceeds their recovering capability they can become painful.

We understand that multiple aspects affect the demand as well as the recovery of these tendons. If the demand we place on the tendon is higher than its capacity to recover in the given time, the tendon can become painful. As we get older the recovery of the tendons slows down too.

We also know that a lack of muscle tone, stretching and compression of the tendon can make the pain worse.

Conditions such as diabetes, hypothyroidism, obesity, previous surgery and ankle trauma can contribute to developing a tendinopathy.

Symptoms of tibialis posterior tendinopathy

Pain and swelling over the inside of the ankle joint, that can run down to the arch of the foot
This is often worse first thing in the morning, or after a period of rest, and can ease after a short period of activity
Prolonged standing or walking can make the pain worse
There may have been an increase in activity, such as walking, before the pain starts
There may have been a change in footwear
Sometimes the tendon can rupture, particularly in diabetic patients which will cause a sudden collapse in the arch, or a flat foot

Diagnosis of tibialis posterior tendinopathy

The diagnosis of tibialis posterior tendinopathy can be made on examination, looking for pain and swelling over the course of the tendon. Occasionally an ultrasound scan can be useful in confirming the diagnosis if there is any doubt.

Self management of tibialis posterior tendinopathy

Initially, reducing the demand that is placed on the tendon is important as it helps the tendon to recover, e.g. limiting running distance, certain exercises as well as daily activity that causes pain.

Gradually reintroducing the demand on the tendon and exercises in a graded fashion helps to increase the tendons capacity to deal with the demand.

In chronic tendon injuries, making the tendon work (mechanical loading) has also been shown to stimulate the healing process which promotes repair and remodeling of the tendon structure back to a healthy state, although this can take a long time.

Progressive graded exercises that load the tendon at the rate it can tolerate are very important. As tendons do not have a good blood supply they are slow to respond to treatment and may take a number of months to get better.

When can I return to sport with tibialis posterior tendinopathy?

When comfortable to do so and under guidance from your physiotherapist.

What other measures can I take?

Weight loss with link
Ice
NSAID
Footwear with link
Insoles
Modification of work or activity

Exercises for tibialis posterior tendinopathy

Exercise 1: ankle inversion – exercise band

Start by lying on your back or sitting
Cross your unaffected leg over the unaffected leg
Place a looped elastic band around both your feet
Next, turn your target ankle away from the other foot and pull the band
The other foot doesn’t move, it just acts as an anchor

Exercise 2: single leg heel raises

Put your hand on a wall or other stable surface for balance
While standing on one leg, raise up on your toes as you lift your heel off the ground
Keep your knee straight

Exercise 3: single leg balance

Stand on one leg
Hold your balance in this position
Perform this next to a table or other sturdy object

Exercise 4: calf stretch

Stand with your injured leg back, in a step standing position
Stretch your leg, keeping your knee straight
Fell the stretch in the back of your calf
Hold for 30 seconds

Exercise 5: toe curl with towel

Sit on a chair
Smooth the towel out and place one foot on it, flat
You are going to be moving the towel toward yourself, so have extra fabric in front of your toes
Keeping the heel still, pull the towel toward you by scooping it in with your arch and toes
Use both sides of your foot (all five toes) and try to create a deep dome under the arch area
You will only get a little bit of the towel to move each time you extend and pull back

What next?

If you are still experiencing symptoms despite following the above advice, it is important you seek advice from your GP. Your GP may decide to refer you to the musculoskeletal clinic or to a physiotherapist.