Posterior tibialis tenosynovitis

Findings

An athlete gives a history of medical calf pain, which may extend around the medial maleolus to the navicular tubercle, or even under the transverse arch of the foot. Swelling over the line of the posterior tibialis may be present, is tender to touch, and crepitus may be felt posterior to the ankle. There may be tenderness to palpation over the navicular tubercle and under the transverse arch. Resisted posterior tibialis is painful and weak. A weak, painless posterior is dysfunctional, and rarely ruptured(unless there is marked swelling of the sheath) and the problem follows failed ankle rehabilitation or chronic overpronation.

Cause

The chronic pronated foot does not produce a posterior tibialis tendinopathy as in these cases the posterior tibialis has an inhibitory weakness that avoids stress. Pain appears in the acute or subacute overload of the posterior tibialis tendon, which, in the absence of trauma, is from functional overpronation. It may therefore occur following Achilles injury, when the patient externally rotates the foot to achieve propulsion, unfortunately from the posterior tibialis, but thus avoiding stressing the Achilles. The same happens if the athlete normally runs with externally rotated feet, or strives for foot propulsion from pronated feet. Semi-acute collapse of the longitudinal arch, or the avoidance of weight over the first two rays of the forefoot, provokes a protective posterior tibialis activity and overload, especially seen in dancers on pointes. There may be a tenosynovitis, or even a rupture of the tendon.

Treatment

a)      Strapping or bracing of the ankle for support.

b)      RICE – beware of the posterior tibial nerve, which can be damaged by ice that is below 0 degrees.

c)      Correct any technique that promotes functional pronation. Check the heel cups have not broken in the running shoes.

d)     Correct any functional genu valgum.

e)      Corrective orthotics, or orthotics to reduce functional pronation.

f)       Electrotherapeutic modalities to settle inflammations and reduce adhesions, such as ultrasound and laser.

g)      Massage techniques to reduce adhesions, such as frictions.

h)      Cortisone to any tenosynovitis or the navicular insertion.

i)        Posterior tibialis isometrics.

j)        Achilles ladders.

k)      Surgical repair of a total rupture.

Sports

a)      Change of direction sports cause more of a problem, requiring ankle braces and supportive orthotics until the lesion is better.

b)      Running – the foot that is on higher part of the road will be overloaded if the road is cambered. Rough ground will produce some moments of excess pronation, and uphill running, bend running, sprint start drills and a windmilling style of running can all produce this problem. In fact, the psoas and rectus femoris are often weak in these individuals, so the treatment should include high knee drills to encourage a longer stride, which allows time for the foot to complete its swing phase and impact on the heel in supination. If possible, correct any externally rotated foot style of running or block functional pronation with orthotics. Stop hill running until recovered.

c)      Fell walking – edging the outside of the boot for a long time when walking along slopes

d)     Rolling over plies at ballet – dancers without full turn-out should be permitted to reduce turn-out. They are never going to make professional ballet dancers so they should be permitted to dance, and enjoy themselves, without getting hurt. Correct the technique to eliminate “fishing the foot” for demi-pointe work because this fault overloads the posterior tibialis strength.

Posterior tibialis problem epitomize sports medicine, where the anatomy can promote overpronation and an inhibitory weakness, with overuse of the posterior tibialis in trying to correct the problem. The orthotic “corrects” the anatomy of the first and minimizes the skill fault in the second. Running must be taught, because it is a skill. These faults, which start at the foot, may then transfer stresses onto the knees and so the athlete presents with knee pain rather than foot pain. Tenosynovitis improves dramatically with cortisone to the sheath, allowing rehabilitation of the muscle tendon, which is often inhibited by pain. The presence of an accessory navicular suggests the injury will take longer to recover.

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English