The most common cause of pain along the inside (medial) portion of your ankle when running may also be associated with the most common reason for adult acquired flatfoot.
It’s likely something most of us haven’t ever heard of before. Posterior tibial tendon dysfunction (PTTD), also known as posterior tibial tendon syndrome or tibialis posterior syndrome, can develop into a tibialis posterior tendon insufficiency which causes a fallen arch.
How to Self-Treat Posterior Tibialis Pain
The posterior tibialis muscle is a particularly important muscle in runners as it is used in plantar flexing the ankle (pointing the ankle/toes downward) and inverting the ankle (rolling it inward). More importantly, its role is to support the arch of the foot. Injury to this muscle is common in runners as well as those who play sports, such as basketball, involving high foot impact. It can be associated with a fall or can generally develop overtime depending on your risk factors and the strain your foot has taken.
Typically, PTTD begins as an overuse injury. It is almost always progressive in nature. It begins with pain in the ankle, and then progresses to a more serious condition, such as a falling of the arch. When left untreated, this can cause adult acquired flatfoot. A fallen arch is also a common cause of plantar fasciitis.
Common risk factors for posterior tibial tendon dysfunction (PTTD) include:
- Gender. It is more common in women.
- Those who are 40 years or older.
- Hypertension (high blood pressure).
- Flat feet, which cause overpronation while running.
- Poorly fitting or worn out shoes.
- Weak ankle muscles (particularly, the posterior tibialis or the foot intrinsic muscles that help to support the arch of the foot).
- Weakness in the hip, pelvic, and/or core muscles can lead to faulty gait mechanics.
- A change in running surfaces or environments. This is most evident when transitioning from a softer running surface, such as dirt, to a concrete running track or running downhill. This causes overuse or overtraining of the tendon.
- Training overload. Performing too high of training intensities and volumes. This overuse or overtraining of the tendon causes inflammation, swelling, and pain.
Symptoms of PTTD:
- Pain is typically located along the length of the tendon (which is located on the inside of the foot and ankle near the bump known as the medial malleolus). Pain may also occur in the foot where the tendon attaches to the navicular bone near the arch of the foot.
- The area around the tendon is usually red, warm, and swollen due to an active inflammatory process.
- Pain located along the tendon is worse with activity. The higher the impact, the worse the pain.
As the condition worsens, the arch will begin to flatten. The ankle and foot begins to roll in as the toes move outward with each step.
Once the arch has fallen, pain is more commonly felt on the outside of the ankle (as the posterior tibialis tendon has usually ruptured at this point). In this stage, arthritis typically begins to set in and develop in the ankle. The calcaneus (heel bone) usually shifts outward at this point.
A common indicator of an advanced condition is known as the “too many toes” sign. When looking at the heel from behind, the third, second, and sometimes, the big toe are visible. Use a mirror to view your affected foot or enlist your spouse or friend’s help. How many toes are visible from behind? Typically, you should see only the pinky and/or second toe.
In addition, perform the following test. While standing, balance on your affected foot. Can you stand on your tip toes? In the case of PTTD, one will struggle to move on to his/her tip toes if it’s even possible.
Initial Treatment for PTTD:
This condition typically begins as an overuse syndrome with an active inflammatory cycle occurring. The initial course of treatment includes RICE, which stands for Rest, Ice, Compression, and Elevation.
- Rest. In this case, rest would indicate tapering down from your regular exercise activity and discontinuing running (for the short term).
- Ice. Apply ice to the painful area. The rule for icing is to apply ice no more than twenty minutes per hour. Do not place the ice directly against the skin, especially if you are using a gel pack style. A bag of frozen peas can be ideal. Individuals with poor circulation or impaired sensation should take particular care when icing.
- Compression helps to prevent and decrease swelling. Swelling can cause increased pain and slow the healing response, so limit it as much as possible. A compression sleeve/stocking can help to limit the amount of swelling and promote blood flow back out of the lower leg. This insures better nutrient exchange, waste removal, and limits the swelling. I particularly recommend wearing a pair during your rehabilitation phase and when tapering back into full activity. Although there are many different styles of compression sleeves/stockings available, always be sure to choose a pair that is at least knee high. I have had luck using the Vitalsox graduated compression socks.
- Elevation. Depending on your pain level and the amount of swelling present, this step may be more or less beneficial.
How to Self-Treat Posterior Tibialis Pain:
Self-mobilize the tissue. Be sure to mobilize the tissue in and around the shinbone (tibia). You could also use a tennis or lacrosse ball to aggressively work out the tissue along the shin (as demonstrated in Posterior Tibialis Tendon Dysfunction Exercises.pdf). Take care not to be too aggressive when mobilizing the posterior tibialis tendon initially or you may make the pain worse. Instead, initially focus on any other mobility and myofascial restrictions in the lower legs. Utilize a foam roller to address any lower leg tightness or restrictions. I tend to use the foam roller for the larger parts of the leg including the thigh, back of the leg, calves, and buttock muscles. Please refer to Lower Extremity Mobilizations using a Foam Roll.pdf.
Mobility bands, such as the Rogue Fitness VooDoo X Bands or EDGE Mobility Bands, are a novel way to self-mobilize the tissue of the calf, foot, and ankle. The use of mobility bands affects blood flow to the area and speeds up healing. Mobility bands also help reset some of the receptor cells in the muscle tissue that cause excessive muscle tightness.
Application of the band starts at mid foot, and then wraps directly over the ankle. You will then pump your ankle back and forth for as much motion as possible in each direction (as demonstrated in Posterior Tibialis Tendon Dysfunction Exercises.pdf). Typically, the mobility band is in place for one to two minutes. If you experience numbness or tingling, please discontinue the treatment. (If you suffer from any form of blood clotting disorder or are on blood thinning medications, I would advise against utilizing mobility bands for any type of deep compression.)
Strengthen your foot and ankle complex. Weakness in the foot and ankle muscles is a major risk factor in developing PTTD. I recommend initiating a complete ankle and foot strengthening protocol (as demonstrated in Posterior Tibialis Tendon Dysfunction Exercises.pdf).
Improve your balance. Poor balance is often associated with muscle weakness in the foot and ankle as well as the knee and hip musculature. Weakness and balance deficits can lead to poor foot mechanics, which can lead to excessive strain on the posterior tibialis tendon. Practice balancing on one foot.
If you change running surfaces, progress slowly. If you typically run on softer surfaces, such as dirt or a running track, progress carefully and slowly to running on a harder surface (like concrete). Over all, softer running surfaces are better for your body. If your job requires that you stand on a hard surface, adding a foam pad or rubber mat can decrease the strain on your foot and arch.
Avoid training overload. Don’t progress your training volume and/or intensity levels too quickly. PTTD is most commonly diagnosed as an overuse injury. Proper training is very important to avoid overloading your body. Improper progression of training volume and/or intensity can easily lead an overuse injury like PTTD, Achilles tendinitis or other lower extremity injuries.
Add an orthotic. Additional foot control is often needed to normalize gait mechanics. Many running stores sell an over-the-counter orthotic such as Superfeet Blue Premium Insoles. The blue tends to fit most feet, but a variety of options are available for customization. In my experience, these insoles can last 1,000 to 1,500 miles easily.
If you continue to experience pain related to your foot or footwear, then you may need to consult with a physical therapist that specializes in feet and orthotics. A custom orthotic may be necessary to correctly support your foot and insure proper foot mechanics. Seek assistance from a professional who is a runner and has experience with treating other runners.
Immobilization. Sometimes you may need to wear a walking boot in order to immobilize the foot and ankle complex to allow the tendon to heel. In very severe cases, you may need to completely avoid all weight bearing activities. Please seek instruction from your medical physician. If the condition worsens, it’s pertinent to intervene prior to tendon failure.
Ask for help. If you’re still experiencing pain after implementing these self-treatment strategies, then it may be time to seek additional help. Other medical conditions can mimic or be associated with PTTD. Your medical physician or physical therapist can help to determine if your pain is associated with a stress fracture, plantar fasciitis, shin splints or another condition. Your physician could also prescribe a stronger anti-inflammatory medication if necessary. The American Physical Therapy Association offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical physician’s referral (although it may be a good idea to seek your physician’s opinion as well).
RETURN TO RUNNING
As you return to running and your normal training activities, insure the following:
- Your involved leg is as mobile and flexible as the other.
- Your involved foot and ankle is as mobile and flexible as the other.
- Your involved foot and ankle complex is as strong as the other leg.
- Your ability to balance is equal in both legs.
- You can jog, run, sprint, and jump without pain.
If you are not progressing after 3-4 weeks of implementing these treatment options, speak to your medical professional. Do not take this condition lightly. Be sure to properly address it so you don’t lose too much time with your training. As you taper back into your running program, follow these guidelines:
- Although you will need to progress and train on uneven ground and hills, initially start with level terrain only.
- Initially limit your running distance. I recommend starting with a distance approximately 50-75% of your pre-injury distance.
- Initially start with a slower pace. Don’t immediately progress back into very intense running activities, such as interval or hill training, until you have worked back up to your previous running distances and paces without pain.
PTTD most commonly starts out as an over use injury. Although more common in runners and those who are involved in high impact sports, this condition can affect anyone. If the condition is left untreated, the end result is usually a falling of the arch which causes adult acquired flatfoot. When this condition is caught early, it can be self-treated. Once the arch has fallen, surgery would most likely be indicated. For additional information on common running injuries and how to self-treat, please visit www.thePhysicalTherapyAdvisor.com.