Posterior Tibial Tendonitis
Posterior Tibial Tendonitis
By Kyle Kingsley MD
Posterior tibial tendonitis is very common injury and athletes and non-athletes alike. Posterior tibial tendonitis is inflammation of the posterior tibial tendon and its sheath. The posterior tibial tendon, also known as the tibialis posterior tendon runs behind and under the prominence on the inner side of the ankle. An athlete experiences pain just under this “bump” in most cases. This tendon takes significant stress each time you push off your toes, so they can be injured in nearly any sport, but injuries tend to occur more frequently with endurance sports such as running. Inflammation can occur anywhere along the course of the tendon. The pain is often worse just after waking in the morning or after sitting/inactivity for a prolonged period. The pain can also be worse while running or other athletic activities, often when pushing off. Sometimes the pain eases after you “warm-up”, but the pain may return by the end of the workout. The pain also tends to lessen over the course of the day with everyday mild activity.
Posterior tibial tendonitis can be characterized as either acute or chronic, although this is a continuum and arbitrary time divisions are just that. This is a common injury in runners and other endurance athletes. Several things can predispose athletes’ development of posterior tibial tendonitis. Rapid increase in workout mileage, workout intensity or hill-training can increase an athlete’s risk of posterior tibial tendonitis. Lack of flexibility is also a possible contributor, so those of us trending toward middle age are more inclined to experience posterior tibial tendonitis.
Treatment of acute posterior tibial tendonitis is quite simple in theory, but difficult for type A athletes in practice. Rest is absolutely vital to recovery. This is the most difficult for endurance athletes who cannot stand “doing nothing” for any amount of time. If you do too much, too soon, the injury will recur. If you feel discomfort in the location described above, my recommendation is to immediately take two weeks off from strenuous calf-associated activity such as running. You should avoid any activity that makes your injury hurt. If this includes walking, you can even consider short-term crutch use. In two weeks you should attempt a light run (or other activity). If you continue to have pain, I recommend three weeks of complete rest before again attempting athletic activities. It is key to be proactive with rest in preventing long-term tendon problems. Do not try to shorten these recovery periods. Development of chronic tendon problems can be much more difficult to treat. I have seen many runners and other athletes have this problem recur again and again, however, I have seen great results in treatment and prevention using our recommendations.
In addition to rest, the use of ibuprofen or other NSAIDSs is advocated by some. I am not a fan of using ibuprofen for this type of injury—mainly because I think it clouds the picture. The argument can be made for its anti-inflammatory properties, but I am not convinced that this actually works well or promotes healing in the setting of posterior tibial tendonitis. In my experience, many athletes have horrendous rebound pain after the effects of ibuprofen wear off. As a physician I am also jaded from all of the bleeding ulcers and kidney problems that I have seen following the prolonged use of ibuprofen and other NSAIDS. My recommendation is to forgo ibuprofen for posterior tibial tendonitis, unless under the supervision of a physician.
Icing has been the single greatest aid for my past problems with posterior tibial tendonitis and it seems most runners and athletes have the best luck with this treatment. I recommend the use of ice for ten minutes after each and every workout. Ice packs, ice cubes and ice massage are better than nothing, but ice baths are by far superior. Ice cubes, packs etc. do not get every nook and cranny of your foot, and I found that my soreness would frequently migrate to spots that were iced least. Ice baths cool everything, equally well, equally quickly. Ice baths seem to make the greatest difference in recovery. When one has active posterior tibial tendonitis, 10 minute ice baths (of the legs only) five to ten times per day, should help substantially with the discomfort and may speed recovery. Since my last episode of posterior tibial tendonitis several years ago, I have started a maintenance treatment after every workout. I perform ice baths for ten minutes after every workout, no matter how light or short the workouts. Studies seem to indicate that ten minutes is the ideal time for ice therapy. Longer than ten minutes may not be as helpful although 15-20 minutes is also frequently recommended by other sources. Some also recommend the use of ten minutes on, then warm up out of the ice bath for ten minutes, followed by another 10 minutes of icing. I have used both, but I prefer the 10 minutes alone for maintenance therapy as I find 30 minutes is too long (strictly from a practical standpoint).
Eventually ice baths may get to you. I have used the rectangular plastic trash cans filled with 100 or so ice cubes and water. Most of the trashcans would only fit one foot, but with some you can manage to shove both feet in. Now things are much easier with the MarathonBoot. Do trashcans work as well for ice baths? Absolutely, yes. The trashcan is more affordable (as long as you’re not buying ice) and works very well. For me convenience is the key. If you are on a very tight budget, the MarathonBoot is probably not for you, although it is just a onetime expense and relatively affordable. For the cost of a good pair of running shows, you can add this convenient tool to your injury-prevention armamentarium. If you want instant setup after your workout, minimal water usage and reusable frozen inserts for added convenience you should give MarathonBoot a try. I believe the key is rapid, immediate cooling following your workouts.
After posterior tibial tendonitis pain has subsided, additional long term treatment components should include a gradual easing back into activity. Take your time getting back. I recommend that at no time should you increase workout intensity (be it weekly mileage, distance of longest run, or weight lifted etc) by more than 10% in any given week. In fact, 5% may be superior. Rushing “recovery” has been the most consistent mistake I have seen in athletes with similar injuries. Cut back to very short, easy workouts and very gradually come back when you are ready.
Another important long-term fix is opposing muscle-group weight training. Increasing your calf strength and tibialis anterior strength (the muscle in the front of your lower leg– by walking on your heels) will help substantially in preventing recurrence of injuries. Any calf exercise will do, although you should start modestly. As for the tibialis anterior training, I recommend walking on your heels for 50 meters between calf sets. This will also help to prevent the dreaded shin splints. Stretching of the calf muscles in those athletes that are not very flexible may also be helpful in preventing recurrence of posterior tibial tendonitis. This should be gentle stretching before and after workouts.
Massage and ultrasound has also been recommended by some sources to help with both acute and chronic posterior tibial tendonitis. My experience has been mixed at best in athletes with posterior tibial tendonitis.