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Monday, December 13, 2021

Posterior Tendon Dysfunction: Email Advice

Hi Dr Blake,

I’ve been reading your blog all day, thank you for proving this invaluable resource. I’ve been doing lots of research into posterior tibial tendon dysfunction and your site is a wealth of knowledge.

So I’ve been having some PTTD type problems. I ran an 73 mile ultra in July this year and really damaged the posterior tibial tendon. So much so I haven't been able to run properly since the injury. I’ve done some downhill walk running which was ok 5km ish.  I have undergone reasonably intense physio protocol since September and I am now at the point where I am pretty much pain free day to day. I walk to work 45 minutes each way without pain, or with mild 1 or 2 pain on pain score.

Unfortunately my medial ankle started making a snapping sensation, which is worrying me. It feels like a ligament, possibly the PTT is snapping across the medial malleolus. Although it could be something to do with the deltoid ligament, this is where I notice the snapping sensation most, I am not sure of the cause.  My PT gave me stretches and strengthening exercises, but the snapping only started occurring after I started rehabbing the injury. Now I am at the point where I am not sure if the tendon is loose and that’s causing the snapping or if it’s tight and that’s causing the snapping. There’s never an audible click as much, it’s more of a sensation you/I can feel. It can only be felt when the foot is dorsiflexed and inverted from the normal position upwards and inwards in that order. I sometimes notice the snapping when walking up hill. If the foot isn’t dorsiflexed and inverted then the snapping doesn’t happen.

My PT has helped, but isn’t a specialist in foot injuries, I can’t see a podiatrist until February and I am a mountaineer keen to get out as soon as possible. I was wondering if you had any advice regarding the snapping or ways to make the snapping stop? Everything I’ve found online in relation to snapping talks about the peroneal tendon, but that’s on the outside of the foot, and isn’t the source of my problem. I can’t find anything that specifically helps my inner foot snapping issue.

Best regards,

Dr Blake's Response:
     Thank you so much for your question. This occurs to my patients all the time, so I am hopeful you can resolve this. There are alot of things that happen when the ankle collapses inward in the case of posterior tibial problems. Tendons get stretched, ligaments stretched, and inflammatory builds up in the the joints and soft tissues. Typically, if you are non weight bearing, and you move your ankles around in all directions, if a tendon or ligament was loose, you should be able to duplicate the snapping sound, and see something dramatic happen. In your case, it sounds like it is only with weight bearing, where the snapping is due to fluid trapped in joints and ligaments. The snapping sound is the fluid escaping as you move much like the snapping of finger joints. I would attack this hard with anti-inflammation, even if you can not see the inflammation. Icing twice daily, contrast bathing each night, 3 advils three times a day, etc. Then get back to me in one month and remind me of this blog post (attach the link). Rich 

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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.