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Monday, September 25, 2017

Posterior Tibial Tendon Injury: Email Advice

Good afternoon Dr Blake. I am writing you from New York City. First I want to say THANK YOU for the wonderful blog that you have created. I will be as short and concise with my situation. Like you I have a long history of playing basketball and also running wind sprints. I have sprained my ankle numerous times from basketball. This current injury is different as its the inside side of my left ankle that has PTT (posterior tibial tendon). 

In January I was running wind sprints up a hill in the park on concrete. After my workout, I felt some pain and swelling. I thought it odd that it was the inside side and I don't recall twisting my ankle.  I went to the doctor and he prescribed physical therapy. I went to 5 sessions over 3 weeks and all the pain went away. I did NO home exercises. Fast forward to July and I did the hill workout again. I felt tightness in my calves and some slight swelling but not pain. 2 weeks later I did a sprint workout at a soccer field. After my 4th sprint, my foot locked up on me. I thought it was the dreaded Achilles tendon tear and it hurt and I could barely walk. I elevated a few days, not too much ice. Went back to the doctor. Got a script for physical therapy. I STOPPED all jogging, skipping rope, doing wind sprints.  I went to one clinic 4 times over 2 weeks. I wore no brace. The therapist didn't believe in braces. I took Aleve for 10 days. I switched to another physical therapy clinic. Went there 5 times over 2 weeks. I wasn't getting better. I then went to an orthopaedic surgeon. I believed I needed an MRI. He took Xray and said no stress fracture. He did some manual tests and concluded I had an Unstable Ankle and Posterior Tibialis Tendonitis. He suggested one of the more expensive over the counter Orthotics(hard plastic type). He said I had flat feet but only when standing. He said I might only need the Orthotic for 3-4 weeks. He did not think I needed surgery at all anytime soon. He said 3-4 sessions of physical therapy would be beneficial. 

After 2 weeks of the swelling/inflammation not going down, I went to a new physical therapist. He concluded I didn't have swelling/inflammation and needed heat and home exercises. Things like calf raise (2 sets of 12 twice per day). Theraband for inversion (2 sets x 12 twice per day). The one legged balance for 30" (2 sets x 30" twice per day). Stretch the calves and soleous twice per day for 30". After 2 weeks of still the swelling not going down I went to a podiatrist. He ordered MRI and after the MRI he got me a knee high walking boot. He said to use the boot for 3 weeks (follow-up visit after the 3 weeks

Highlights of MRI:

Chronic postraumatic deformities of the tips of the medial and lateral malleolar are noted 
There is a chronic full-thickness tear of the anterior talofibular ligament 
There is marrow edema within the talar head and neck. Different considerations include a bone contusion or stress reaction. 
There is increased fluid in the posterior tibialis sheath consistent moderate tenosynoviitis with intermediate signal in inframalleolar component of the tendon consistent with mild tendinosis. 
A type 2 accessory navicular is noted with marrow edema within. 
A ganglion is noted with Kager's fat pad measuring 1.9 x 1.1 x 1.4cm 

I have yet to find a physical therapist who actually knows what to do for PTT. Also as nice as the podiatrist was I dont think he fully understands/emphasizes with my frustration as to what to do at home to best heal, strengthen, stretch.

The last physical therapist session was with a new person who suggested to STOP doing calve raises and to stop doing the soleous stretch. To do the theraband in the 2 directions that dont put any strain on the Posterior Tibialis Tendon. I am to return to that therapist in 2-3 weeks. They also said do NOT use heat but to ice 1-2/day. 

I dont know how long to wear the boot. I also dont know what is safe to do strengthening wise. My frustration is not getting the inflammation/swelling completely gone

Have you heard of Tendex Fast surgery?

Oh yeah

What specialist would be able to tell if I have muscle weakness or tightness in my hips, thighs, hamstrings, or calves? I think the PTT is the result of some other problem in the chain.

I have placed the Orthotic in my walking boot. I will be watching all of your youtube clips regarding PTT. I wonder if even walking in a boot puts some stress/pressure on the PTT. Currently its is around a portion of the ankle bone where I still feel inflammation/swelling and some pain. The pain flares up when I walk too long. I am wondering if staying at home just reading and watching movies for say a week or two would be truly resting the PTT.

THANK YOU for your time. I appreciate any and all feedback

Dr Blake's comment: Thank you so very much for emailing. I will try to give you my impressions with the info you provided. The MRI was very helpful, and you need another one 6 months from now to check on the edema. I see no place now to consider a surgery. Surgery typically would be a year from now if you are not able to get back. I know it sounds long, but you have to get rid of the underlining talar head and neck bone edema due to impact stresses. It probably is the cause of all your pain with secondary posterior tibial tendon issues. If you rush a talar injury, the stress fracture or stress reaction which is there now could become a full-blown fracture. I have seen fast recoveries from these, but I can not predict. You have to go one month at a time. You want a 9-month course of Exogen bone stim, and a current bone density and Vit D test. You should avoid all impact for 9 months and work on your ankle strength. The ankle sprains could be coming back to haunt you with instability and abnormal stresses. As long as you can avoid painful exercises, do the posterior tibial strengthening program, also Single Leg Balancing, and the peroneus longus and brevis therabands. Do contrasts each evening as a good flush to the superficial and deep bone swelling. 
     The basic routine is to avoid deep ankle flexion as with landing from a jump or deep plie in ballet. Avoid stretching your Achilles for the next month, then one month only with the knee straight, and no negative heel stretching where you drop the heel off the stair. Contrasts each evening, and evaluate bone density for issues. Bone stim for 9 months, and repeat MRI in 6 months. Start a super strengthening program. Stay in the boot 3 months, and then transition to shoes. Monthly evaluations should be done to check progress. I hope this helps. Rich. 

Jay just answered. I read this as a talar injury first and foremost, with secondary PT changes. Keep me in the loop. Rich

Hi Dr Blake
Thanks for reading my email. Do you know of any good podiatrists or Orthopedic foot surgeons in the New York City area?
Dr Blake's comment: In the New York area, I tend to recommend Karen Langone, David Davidson, Tom Conenello, and Joseph D'Amico. I know Joe is in New York City at the podiatry school there. 

I have read quite a bit on your blog regarding Posterior Tibialis Tendonitis. 

Right now I am in a walking boot (for at least 3 weeks). I have Spenco orthotic inserts in the boot. I am icing 2-3 times per day.

What, if anything, would you recommend in terms of healing and recovery? Is the swelling/inflammation from the issue with the PT or the talar?
Dr Blake's comment: I think addressing the talus is the most important right now, although any inflammatory measures will affect both areas. Contrast baths each evening are great for deep swelling. A bone stimulator from Exogen will help with bone flow. I try to get patients doing some form of strengthening of the area, without producing pain, and some sort of both core and cardio work. 

Is there anything I can do for healing the talar? Maybe stay in boot longer than 3 weeks
Dr Blake's comment: The talus finding directs healing right now. The boot will be for 3 months with a new MRI to check progress. Can not see past that. One of my blog patients just told me about a good boot. Check out 

If there are any posts on Talar in your blog I can read em too.

Do you take Medicare by any chance? Physical therapy for the Talar issue?
Dr Blake's comment: Yes, I do take Medicare. Physical therapy once a week to help you decide on exercises, cardio, anti-inflammatory is a good idea. 

I will be getting your book. 

Thanks again


  1. Dr. Blake
    Thank you for your feedback. I would like clarification on some points:

    1. No impact for 9 months means no jogging, no jumping rope, and no wind sprints? What about biking?

    2.Do the ankle strengthening exercises on your youtube? How many days per week and how many sets/reps?

    3. What exercises for the Posterior Tibialis? How many day and sets?

    4. How many days and sets for the One legged balancing?

    5. Whats the Peroneous Longus and Brevis therband exercises? How many days and sets?

    6. Where does calve raises come into play?

    7. Would Graston technique or Activated Release technique help regarding swelling/inflammation?

    8. No calf stretching while sitting on floor(with towel wrapped around foot) ?

    Thanks again. I am currently in the East coast.

    1. Biking should be fine. See the posterior tibial video that I did last year. It talks about 3 times a week, going through the 6 levels of resistance, gradually going from 2 sets of 10 to 2 sets of 25 at each level. Single leg is 2 minutes each evening. See the ankle strengthening video from 2010 for the peroneal ones. I just listed on my videos on a recent post to find them easier. You can do calf raises but not where your heel drops off a stair. Activated release can help, I do not think Graston would. The calf towel stretch is probably the safest one you can do. Rich

  2. Will insurance pay for the Exogen bone stimulator?

    I will be taking a calcium/magnesium/Vitamin D supplement.It has 600mg of Vitamin D

    Have a great weekend. if I amable to visit San fancisco for 2 weeks would physical therapy visits help with speeding up recovery? I ask because I did physical therapy before getting the Walking Boot and felt it accomplished nothing in terms of reducing the swelling and inflammation. Have a great weekend

    1. Most insurance will pay if they think it is a stress fracture that is not healing. The PT would be to make sure you were properly doing your exercises, and how to cross train safely. Rich

  3. If insurance will not cover your Exogen, contact they rent and sell pre-owned Exogen systems. I believe they provide a guarantee with each one, so that you can exchange it if it doesn't function. I know people who have bought them on ebay and received units that didn't work or failed after a little while. These people make sure you have a good system for as long as you need it.

    1. Thank you for all my patients for this bit of information on the bone stim units. Rich

  4. Dr. Blake. Thank you for taking the time and making the effort to help me in my recovery. This is a difficult injury to deal with when one is an athlete and has to shut down ALL exercising. This blog is a God send for all those that are dealing with foot challenges

  5. Dr. Blake. Again THANK YOU for me time and effort in helping me. I will review your video clips. Few quick questions:

    1. How long (weeks or months) at each level? i.e. Use the Red theraband at 2 sets of 10 per exercise say 2 weeks then 2-4 weeks at 2 sets of 25 then go onto next color?

    2. I dont know if my doctor looked at the MRI disc or simply read the report. He said no go on the bone stim because report says stress "reaction" . Also insurance usually needs 90 days between tests. I will ask for another MRI 90 days after first one to see if no improvement. I will also ask podiatrist to look at the actual images to see if its a fracture or reaction. If there is no edema(swelling) around talar then am I correct I wouldnt need the bone stim?

    3. Initially you said no impact training for 9 months but recently suggested start with a few activities at say 50% (based on Vitamin D results being low at 27). The activities I usually do are skipping rope, running wind sprints, long walks, . I am afraid to do any of these activities until walking boot comes off in another 2 months.

    4. What type of specialist can help me figure out WHY I got the stress reaction(fracture)? meaning figure out imbalances, weaknesses etc.

    5. 50,000IU of Vitamin D for 3 months sound good?

    THANK YOU. You simply ROCK!!!!!


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.