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Sunday, June 23, 2013

Posterior Tibial Tendinitis: Email Advice with Further Response

Dr. Blake,

I have struggled with bilateral posterior tibial tendinitis for a long time.  The first bout I had for roughly three to four years.  It had a devastating impact on my life.  It finally went away for a couple of years, only to come back about six weeks ago.  Since the latest onset, I have done a great deal of research.  Your blog is far and away the most helpful and hopeful resource I have found.  Thank you for taking the time to help educate and inform people about this condition.  Your generosity is apparent when one considers that the vast majority of people reading your blog will never become paying patients.
Dr Blake's comment: Thank you for your kind words. It has been as rewarding for me as helpful for others. It definitely forces me off my butt at night and to sit down at the computer. Please tell me where the pain is in the posterior tibial tendon, and whether that point of maximal soreness is on both sides. This would be the weakest link in the chain. 
Also, what factors do you think helped it go away? It can help in the present rehabilitation. 

The pain is always present on the posterior side of my ankle bone—that is the point of maximum soreness.  The pain creeps a couple inches up the tendon towards my calf.  When it is bad, it goes all the way up the tendon, and around the bottom of the ankle bone into the arch.  The area around the navicular is very tender when you palpate it.

Rest and ice help the pain go away.  I’m currently icing my feet three to four times a day.

I have had a complete work up of my condition through a variety of doctors.  This includes an MRI of the left ankle, and a series of plain films of both feet.  These were done in the last couple of weeks.  Three years ago I had an MRI of the right foot.  I have been through the full panoply of conservative treatment: multiple orthotics, RICE, PT, walking boot, nightly interferential current, NSAIDs, etc.  There also was a suggestion that I might have ankylosing spondylitis, but that recently was ruled out by a rheumatologist.
Dr Blake's comment: I am assuming that your tests were negative. Make sure you get copies of all these tests for your records. What did the reports say?

The May 5, 2009 MRI report is included in the Rebound records I sent you.  I had forgotten that the MRI was of both feet.  The impression of the left foot is:  “OS naviculare edema consistent with os naviculare syndrome.”  Interestingly, that condition was not found in the right foot, yet my symptoms in both feet are generally identical.  The report also indicates on the left foot a peroneus longus tendon partial tear.  My doctor minimized this finding—I think he said it might have been an artifact.

This week I went to a new podiatrist to address this new onset.  The podiatrist said that I have an accessory navicular bone and he saw a small amount of edema in that area.  However, he is perplexed as to how I could have PTT.  He said there is no arthritis in my foot, good joints spaces, good alignment, good arch, etc.  The posterior tendon is intact.  He doesn’t see any reason for putting unusual stress on the posterior tibial tendon.  He also said that I have essentially exhausted all the treatment options he would consider.
Dr Blake's comment: An accessory navicular can give chronic pain at the insertion of the tendon into the arch. Is this where you hurt?

Yes, I do hurt there.  But the pain is more consistently present on the posterior side of the ankle bone.  I apparently don’t have an accessory navicular on the right side, but I have the same problems on the right side.
The rheumatology angle warrants a little more discussion.  I saw two rheumatologists during my first bout with the condition.  The first one said I do not have AS.  I then had a complete work up with an orthopedic surgeon specializing in foot problems.  He finally concluded that I might have some type of autoimmune condition.  So, at his suggestion, I saw a second rheumatologist.  That doctor made a tentative diagnosis of AS.  I was put on a trial of Humera.  The PTT finally resolved some time later.  Whether or not that was related to the Humera, I cannot say.  Now, after the latest bout, I contacted that second rheumatologist only to learn that he is about to retire.  So I recently went to a third rheumatologist.  She is the one that said I do NOT have AS.
Dr Blake's comment: A diagnosis of Ankylosing Spondylitis is made by symptoms and a positive HLA-B27 blood test. What were those findings? Any back pain associated with this pain syndrome?

I do have a positive HLA-B27.  This was re-confirmed recently.  I occasionally have mid-back pain, but it usually resolves in four or five days after I start doing yoga each morning.  Then it won’t come back again for months.  Every several months I have some low back pain, but it also goes away after yoga.  So, I don’t really have consistent back pain.  I’ll get you the records from the rheumatologists.

Part of the frustration of dealing with my condition has been proceeding along the dual track of working up the mechanical tendon etiology vs. autoimmune etiology.  This most recent bout was precipitated by two things.  One, I modified my running style to a short stride and higher cadence.  I’ve since learned this puts more pressure on the posterior tibial tendon.  Second, I went on a very vigorous up-hill mountain bike ride that required a great deal of standing up on the pedals.  I haven’t ridden a mountain bike in 10 years.  It is my feeling that these activities started this new bout.  Therefore, I do think there is some kind of mechanical problem going on.  I also think that I tend to have a higher-than-usual inflammatory response to trauma, which might be contributing to the problem.
Dr Blake's comment: So, are you do anti-inflammatory things to help this recent bout? 
The posterior tibial tendon is an ankle plantar flexor, an ankle and sub talar joint supinator or pronation decelerator, and a midtarsal joint stabilizer. So, you can have normal foot mechanics, but dramatize the posterior tibial tendon by getting off the seat of a bike too much. 

I took two Aleve twice a day for several weeks.  I now take the Aleve only occasionally after the rheumatologist cautioned me about side effects.

I would like to come see you.  I live in Portland which is an easy flight.  I’m going to be in San Francisco on July 22 and July 23.  I could also come sooner which, in fact, I would prefer to do if possible.  What I would like to do is to first get you all the existing imaging studies and chart notes.  I realize that it would probably take you a lot longer than the amount of time you are allotted on a typical new-patient office visit to thoroughly review all the records and then see me.  So, I am happy to pay you for the extra time as you see fit.

Thanks so much for taking the time to read this far.  Please let me know if and when I can make an appointment to see you.  I very much look forward to it.
Dr Blake's comment: I will be honored to see you. Mail all of the images and records to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109 and we will go from there. Call my front desk at 415-353-6400 and arrange a one hour appt for one of those days. Bring all your orthotics. Thanks Rich
PS. Please email me with more answers to the below questions. 

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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.