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Posterior Tibial Tendonitis
Tendonitis can be a common problem in the
foot as we continuously walk and use our feet on a daily basis. The
posterior tibial tendon can be especially prone to tendonitis as it
helps to maintain the arch of the foot and prevent excessive flattening
(pronation) of the foot while walking, standing or running. Posterior tibial tendonitis can be a precursor to posterior tibial tendon dysfunction where there is progressive loss of strength in the tendon and a progressive flattening of the arch. Anatomy The
posterior tibial tendon starts in the deep portion of the calf and runs
behind the prominent bone on the inside of the ankle. The tendon
continues along towards the foot and inserts into multiple locations on
the inside and the bottom of the arch. With each step a tremendous
amount of tension and stress is placed is on the posterior tibial
tendon as it helps to maintain and recreate the arch of the foot. With
each step there is a natural depression and recreation of the arch that
allows for shock absorption. The amount of shock absorption or
depression of the arch is variable from person to person depending on
the architecture of their foot (flatfeet versus a very high arch). It
would seem that only a flatfooted person would get posterior tibial
tendonitis but this is not always the case. It can happen to people
with any foot type, weight or activity level. Symptoms Symptoms
of posterior tibial tendonitis include pain and swelling along the
inside of the ankle and arch along the course of the tendon. Pain is
present with exercise, extended periods of walking or standing. This
discomfort will usually increase as the disease progresses and is
localized along the course of the tendon around the inside of the ankle
or along the inside of the arch. This pain initially is absent when at
rest but may progress to the point where pain is present even when not
active. Pain and swelling are signs of injury to the tendon. The sheath
or sleeve that surrounds the tendon will produce excessive amounts of
lubricating fluid in an attempt to allow the tendon to glide easier
during the healing process. This excessive fluid production results in
the swelling the patient sees and feels on the inside of the ankle and
arch. In advanced cases the injury to the tendon that started as
tendonitis may progress to a full or partial tear of the tendon. Diagnosis The diagnosis can often be made from your doctor by the history and physical exam. In many instances a MRI or ultrasound
will be performed to determine the extent of damage to the posterior
tibial tendon. A simple assessment of tendon strength can be performed
by standing on the "tip of the toes" on each foot. The affected foot
may feel weak and painful in cases of tendonitis. In advanced cases the
patient may not be able to lift the heel from the ground as much or not
at all in comparison to the unaffected foot. Treatment Treatment
can depend on how long the symptoms have been present and if the amount
of strength that is lost (if any) in the tendon. Non-steroidal
anti-inflammatory medication, physical therapy, rest and orthotics are often first courses of treatment. Injections of cortisone
type medications are performed on rare occasions and often accompanied
by cast immobilization. These are all designed to decrease the
inflammation in and around the tendon and to decrease the stresses
placed on the tendon. In more severe cases a cast from the knee down
may be utilized from four to six weeks to allow the tendon to
completely rest without placing the day-to-day demands of walking on
it. If these measures fail to produce acceptable results surgical
intervention may be necessary to clean around the tendon and repair any
defects in the tendon. Surgical repair is more commonly needed when
there is a progressive weakness in the tendon. As mentioned earlier
this loss of strength is called posterior tibial tendon dysfunction and is covered in detail in that section.
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