Monday, August 15, 2011

Posterior Tibialis Irritation

This is an injury which continues to annoy me as a clinician.  At it's worst, it requires prolonged immobilization and/or surgery.  In the physically active population, it can be a nuisance for those who experience pain and discomfort, yet can still perform a portion of their activities.
The Posterior Tibialis Tendon (PTT) is an interesting structure which runs along the medial and posterior aspect of the lower leg.  It originates on the lateral aspect of the posterior component of the tibia, runs posteriororly just behind the tibia, and snakes down behind the medial malleollus where it inserts on the navicular tuberosity.  I should note here that most muscles/tendons have multiple attachment points, however I am listing the major areas of  attachment for ease.  This places it in the posterior compartment, along with the flexor digitorum longus and flexor hallucis longus (taught to many of us as the group acronym  Tom, Dick and Harry or TDH for Tib Post, Digitorum and Hallucis; get it?) Due to it's location, it has a notorious reputation for having a poor blood supply, thereby inhibiting it's ability to heal.  It's prime functions include providing medial ankle stability, inverting and plantaflexion.  The main concern here is a fallen medial longitudinal arch; and we all know that a "flat foot" or pes planus is associated with lots of other issues.  Avoid it at all costs.

The main issue for athletes here is that immobilization or surgery might not be an attractive option.  So how to manage?  Well, for this you can travel down several paths.
It's used for a reason; RICE.can work well.
Rest when you can; get off your feet for awhile.  You might be bored, but do you want to get better or what?
If effused, ice and elevate.  But do it the right way; after combining icing and elevating simultaneously for a period of time (a topic for another blog, lots of schools of thought on this, but 20 minutes is  a good starting point) take the ice off and keep the lower leg elevated for another 30 minutes.  That's right.  Lie down for an hour; keep the limb above the athlete's heart; remember that even while sitting effusion will have to work against gravity.  Repeat several times daily.
I have seen a variety of supportive taping and bracing options work; from kinesio tape running directly over the PTT, to a Low Dye arch taping technique, to simply inserting an over the counter orthotic with a slightly pronounced arch to help maintain natural foot shape. 
If NSAIDS are your thing, then they can take over the counter ibuprofen per the label; or see your team physician for something stronger.  I say this with the utmost caution though; it is a medication and should be used carefully.  I have seen an increase in the topical anti-inflammatories (Voltaren is one brand) recently, as well as the advent of Arnica Gel.
Lastly, if you have access to a walking boot; get your athlete in one.  They can wear it to help adequately rest the PTT, as the rigid or stiff sole will aid in limiting motion.  It's not uncommon to see athletes walking around in boots, in order to conserve for game day competition. A regimen of eccentric exercises can also help aid in balancing out immobilization and activity.
Remember to evaluate the other foot prior to making modifications.  As I remind students; Always compare bilaterally!

1 comment:

  1. I would recommend looking at doing some deep tissue work to the hip rotatores on the same side as the TP irritation. Often the injury, IMO, is a result of to much torque (speed or ROM) because the hip is to weak/tight.