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Thursday, March 28, 2013

Posterior Tibial Tendinitis: Email Advice

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!

Thanks,

Arleen (name changed)

Dr Blake's comments:

Dear Arleen, 

     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:

  1. Isometric
  2. Active Range of Motion
  3. Progressive Resistance
  4. Isotonic
  5. Functional
  6. Muscle stimulation 
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
   
Hi Dr. Blake,

    Thank you so much for taking time out of your busy day to choose to answer my email question, I really do appreciate it.  My ankle is improving and I'm not having much pain now at all walking just wearing my stability shoes with new orthotics.

     I definitely knew what I was in for when I continued to run, but marathoners do tend to be a stubborn bunch!  :)  My MRI actually showed PTT tendonosis/tenosynotivits as well as some other minor tendonitis and a small partial tear of my achilles.  So we are thinking now that it's possible that some of the pain was radiating from my achilles injury as well. 

    Throughout my training I would have some tweaks here and there posteriorly, but didn't think much of it...but now it makes sense that it was both the PTT and achilles contributing and why my orthotic adjustments didn't totally fix the problem.  I understand very well that these are also overuse/wear and tear injuries from training and that I need to rest. 

    I haven't run in 2 weeks (for my ankle as well as a chronic knee injury in the opposite leg that is flared).  I'm icing both areas multiple times a day.  I have actually tried PT for my ankle PTT, but it seemed like all the exercises that I did just made it worse...then I would wait until it was pretty much pain free and try again with less reps and resistance and again it would cause another flare up...so I'm really not sure what to do there.  I questioned my podiatrist about this and he said that it is not a strength issue with me, but instead structural and orthotics were the main solution...so he says PT won't really help me much (which I can't say I agree).  I would still definitely like to continue to at least try some different PT exercises and will watch your video.  Thank you so very much once again for your time.  I'm still not sure what you mean by power lacing though...I tried to look it up online and all I could find is for high-top style shoes. 
Dr Blake's comment: Definitely you need a skilled PT to be able to help you learn how to strengthen the Posterior Tibial Tendon. The MRI shows you do not have an injury that you should not be able to strengthen the tendon. Below is my link on power lacing. 

Thanks again,
Arleen (name changed)


4 comments:

  1. Hi: my sister is one of your patients and as I have been dealing with foot issues for much longer and am in the eastern U.S. I thought I would look at your blog. Very impressive. I have posterior tibial tendonitis -- both feet -- first one injured on left running, right one jumping down from wall in an emergency situation. Do not have pain and stopped running about a decade ago. I also have: bunions, Morton's neuroma, genetic additional accessory bones both feet, hammertoes both feet but worse on right. Was in pain and did therapy for about four years and for past 7 or 8 years generally pain free -- anyway, to get to my question: I cycle and swim instead of my running regimen and what is important to me if it is possible would be to do long hikes again (just four or five hours) and also be able to walk same amount of time in New York or traveling. Will the posterior tibial tendon strengthening exercises you mention contribute to my ability to do those two activities in the same way that they help people who want to keep running? Thank you! From Barbara

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    Replies
    1. Definitely. You need to go slowly, but you should be able to triple the strength easily from where you are now (first goal). Let me know if you are having any problems. Rich

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  2. Hi. I was diagnosed with posterior tibial tendonitis in Jan 2016. I'm not a runner. Before I started having problems I did the stair climber and elliptical everyday. I stopped doing the stairclimber in Jan and saw a podiatrist. I was given new orthotics and have been wearing brooks stability sneakers for pronation. My pain got worse in late April. I not only had pain in the Ptt but also on the lateral outside of the foot. Walking can be painful now. The lateral side seems a little worse than the medial side. I was diagnosed in PT with fallen arches. I'm almost done with PT but still don't feel any relief. I was thinking that maybe the boot might be a good idea.Do you know of anybody oth this condition that the boot helped. Also I really want to get back into cardio. I recently tried the elliptical and couldn't do that for more than five min with no incline. I had a lot of pain after. Is there any type of cardio I can do that won't make my condition worse? Thanks

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  3. Allyson, I am so sorry for you problem. You definitely need to find a way to create the 0-2 pain level healing environment. That probably is a boot for now. I have so many questions. Do you hurt when you do the posterior tibial exercises? Do you have pain non weight bearing? Is there swelling, etc? Does not sound like weight bearing is good, you may be able to bike with the seat adjusted and low tension. Email me at drblakeshealingsole@gmail.com with a fuller description. Thanks

    ReplyDelete

Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.