Hello Dr. Blake,
I am orthopaedic nurse and also a marathoner. I've been dealing with posterior tibial tendonitis now for going on 4 years...it has never really been 100%, but has times of intermittent improvement. I have a flexible flat foot and I wear custom orthotics.
Anyway, I just completed a trail marathon yesterday and it flared out of no where in the first mile...it had been doing just ok and now it's swollen again and pretty painful to walk.
Dr Blake's comment: You do know that you should have pulled out of that marathon??
I am to call my doc whenever I want to proceed with an MRI (we talked about this months ago) since I've had it for so long. I've tried obviously the orthotics + stability shoes, PTT bracing (which does help-but I've worn it so long I was getting peroneal nerve irritation!), physical therapy and I've been on diclofenac BID for almost a year now and have even tried a medrol dose pack. I've also of course taken rest time from running and didn't run for almost 2 months...did only pool running and it just came back again when I started running.
Dr Blake's comment: For the bracing, try placing some padding between the skin and the brace to protect yourself. Also, if you are going to be on any anti-inflammatory drugs, like diclofenac, for a long time, always pulse it (like 10 days on, 4 days off, or 5 on 2 off) to give your body a rest from the toxicity.
I'm going to get the MRI to see what the tendon health is like...but we've talked about debridement before and was wondering you thoughts on that. I am nervous that it will just give me lots more downtime and then it will just come back again. I'm not sure what to do at this point and was looking for some good advice!
Arleen (name changed)
Dr Blake's comments:
Thanks for the email. I am glad you could run a marathon, especially on trails, with your injury. Normally means you have a first degree tendon injury, not a partial tear (2nd degree). The second degree and third degree need surgery so much more frequent than first degree. First of all, if you felt pain at the first mile and continued to run another 25.2 miles, then you deserve this flareup. That breaks so many rules of injury rehabilitation. Since I am now recovering from my own stupidity, which made my back so much worse, I will not cast the first stone however. I do know how frustrating it can be when you have had this for 4 years!!!
The posterior tibial tendon unfortunately plantar flexes the ankle along with stabilizing the subtalar joint. It is the subtalar joint that is protected with orthotics and stable shoes. The posterior tibial tendon still can get irritated when it assists the achilles tendon in pushing you off the ground. No brace, orthotic, or shoe can help that. So, if you have posterior tibial tendon problems, and if you want to run, you have to be on a great posterior tibial strengthening program. You did not mention these in your email, and they are vital to be able to run along with the shoes, braces, and orthotic devices. The following link may help you with your rehabilitation.
The MRI will really tell us a lot more about the tendon than we know now. But, MRIs with tendon disease are only a part of the picture. Your job right now is to get over the flareup. You are probably in a removable boot I hope speeding up the calming down of the tendon. You should also be icing 3 times daily. And figuring out which of the 6 types of posterior tibial strengthening you can do without irritating it. These are:
Strengthen a tendon from the minute you hurt it. But, it can not hurt while you are strengthening. Does your orthotics stabilize you well? That could be an area to improve. So many different designs on orthotics. You want to feel that it supports you well and your weight is very centered through your feet. Make sure you combine stable orthotics with stable shoes that are power laced. Make sure, even though you are frustrated with your injury, that you do not function with pain (this can only make things worse).
What do I know about debridement? Tendon surgery is very successful in general, but the surgeon and team of physical therapists must understand tendon physiology and function. This is vital in the days after tendon surgery with the initial advice given to you by the surgeon. Achilles tendon rehabilitation is the same and yet different than posterior tibial tendon surgery. Both tendons, yet very different functions. Where debridement goes wrong, is typically in the understanding of its rehabilitation. Before surgery on the posterior tibial tendon, the patient must have great orthotics, not just orthotics, understand the subtleties of posterior tibial strengthening, not just have a theraband in the house, know how to differentiate when to ice and when to heat, not just read a handout on icing, and select a physical therapist knowledgeable of this surgery so that after surgery when the time comes, physical therapy can be started.
Arleen, I know this is alot to deal with and I am sorry. Calm yourself down and allow the tendon to become pain free again. Understand that surgery on a tendon takes 2 years to rehabilitate, with typically no running at all for 9 months up to 15 months. You will have alot of time to cross train, to strengthen. Most patients can make any tendon 3 times stronger than it is, but do not give themselves a chance. After going through surgery, most patients want to give themselves that chance finally. And it definitely helps in their recovery. I hope this helps. Rich