Posterior Tibial Tendon Injury and Long Term Concerns

Hi Dr Blake,

I've been reading your blog archives since I first started having
problems with my foot.  It's kind of a long story, so I apologize in
advance for the length.

I am/was a runner.  I ran anything from 5K through ultras.  I had been
running in the same pair of orthotics for 4 years at that point and
never had a problem.

Then last May (2015) I developed PF in my right foot.  I rested, iced, rolled
and it wouldn't go away.  I saw a Sports Med Doc who eventually gave
me a US guided steroid shot into the PF.  He had me run on it within
three days.  I was fine until two weeks later when the shot wore off
and then I was worse than before.

Dr Blake's comment: Patients get cortisone shots for plantar fasciitis all the time when a plantar heel bursae forms. So, the shot is into the bursae, not the plantar fascia. It is always risky to inject right into the plantar fascia with cortisone, for fear of causing a rupture. The odds of a rupture are small, but it can happen. If the pain intensifies following a cortisone shot in the bottom of the heel, assume that the plantar fascia tore, and start plantar fascia tear protocol of 3 months in a removable cast. 

The pain was still bearable, I could walk but not run.  In September,
one month after the shot, I was hiking and felt a pop in my arch just
in front of the heel but more towards the outside of the foot.  The PF
got a lot worse after that.

Dr Blake's comment: This is when it completely tore.

I saw a podiatrist right after that.  The area was red and puffy and
he noted that my ankle rolled in a little more on that side.  I have
very high arches and roll in a little on both sides so I didn't make
note of that.

He had me fit for corrective orthotics.  When they came back, they
inflamed my heel really badly.  I started aggressively rolling and
stretching my arch (I think this is part of where I went wrong and
tore or worsened the tears).  I kept having the orthotics adjusted
because they really hurt my right foot.  They adjusted the left to
match, even though I was fine on that side.

Dr Blake's comment: So you are in the Immobilization Phase. This is the time you should be in a removable boot with heel cushion, or modified arch support to transfer weight into your arch and cushion and protect your heel. 

https://youtu.be/g0sD0gUbEMU

About this time, this is late November now, I was at the gym and
couldn't do a heel rise.  My foot was in almost constant pain, my
podiatrist was very dismissive and told me I was fine.  He didn't
really seem concerned with my pain or inability to do a heel rise.  He
told me that I shouldn't be doing them anyway with the PF (??) but
sent me for an ultrasound "for my peace of mind".

Dr Blake's comment: The inability to do a heel raise indicates the arch has been compromised. As you begin to lift your heel, all the weight goes from the heel to the supporting structures of the arch, and eventually to the ball of the foot. But when you can not lift your heel off the ground, some structure(s) has been injured that helps lift up the arch (Plantar Fascia, spring ligament, posterior or anterior tibial tendons, etc). 

It showed that I had a full thickness partial tear of the PF and split
tear of the PTT.  He put me in a boot and wanted to see me the
following week.  Immediately the boot hurt, it had no arch support so
he put in lifts.

Dr Blake's comment: It is good to have an arch support inside the boot in situations like this. 

By the next day, my foot started to swell and the

pain was excruciating. 

Dr Blake's comment: There are 3 sources of pain: mechanical (due to the injury), the inflammatory reaction to the injury, and the gradual onset of nerve hypersensitivity for your body's protection (the worse of all the pain sources). You were now really triggering nerve pain affecting the sympathetic nervous system with some swelling and possible skin discoloration. Ideally, this gets everyone's attention by now. 

I started using crutches the following day.
By the time I saw him the next week, my foot was painfully swollen and
it was discovered that I developed a blood clot in my calf.  He took
me out of the boot and had me NWB.  This was mid December.  After that
he took one phone call from me telling me to stay NWB and that he
wouldn't see me until I was cleared by a vascular surgeon.  I was
cleared, but that podiatrist didn't take or return my calls after
that.

Dr Blake's comment: I apologize for my profession. It was clearly over his head, but you had a bad reaction, and doctors are human and can behave badly. 

In the beginning of January, I started seeing a new podiatrist.  She
ordered an MRI that confirmed the PF tear and showed a small
insertional tear of the PTT.  She thought I needed surgery but her
colleague came in and said that it was small and he thought most of my
problem was from atrophy.  He wanted me to go from the crutches to my
sneaker.  In a matter of five minutes I had gone from needing surgery
to needing nothing, not even a boot.

I was confused and still in pain so I decided to see an orthopedist
foot and ankle specialist.  He had me go from crutches to a boot,
which I thought was reasonable.  He said that the PTT tear was small
and most of the problem was from the large PF tear.  My arch still
hurt in the boot so he had me wear the orthotics I had gotten in
Nov/Dec in the boot.

Dr Blake's comment: Thank you, finally some reason applied to this. 

Around this time, I started getting tingling and pain in my left PTT.
We thought it was compensation. Mid February I came out of the boot.
I was doing physical therapy twice a week and things seemed to be
improving.  The PF pain was gone.  I was able to do weak but pain free
single heel rises.

Dr Blake's comment: I am so happy when the pain got out of control, with the swelling, that you do not develop a condition called "Complex Regional Pain Syndrome". The Golden Rule that applies here is to get the pain level between 0-2 as quickly as possible. That just did not happen. Pain syndromes from the Posterior Tibial Tendon tend to always be on both sides, with different starting dates, so after you identify the posterior tibial tendon as a source of pain, immediately start doing some preventative things for the opposite side (orthotics, strengthening, or simply just icing). 
I kept having medial ankle pain whenever we would do any balance
exercises.  I took a day trip walking around a city and afterwards I
had swelling all long the left PTT.  I was very concerned and went
back to the orthopedist.  He put me in an aircast PTT brace and told
me that he'd send me for an MRI if it didn't improve.  I asked him why
this was happening and he said he didn't really know.  I have very
high arches and that should protect the PTT.

Dr Blake's comment: High Arch feet have worse problems with posterior tibial tendons if the arch starts to fall. High Arch Feet are more unstable in general than pronated flat feet, which can have more alignment issues. High Arch Feet need more muscle/tendon strength around the ankles to keep upright. High Arch Feet never get good arch support from shoes, OTC arch supports, and even most custom foot orthotic devices, so relie on tendon and ligament strength. When these are compromised, even by simply favoring one foot for awhile, pain begins.  

Sorry, I know this is long, I'm almost at present day.

The symptoms calmed down and I stopped using the brace after about a
week.  I kept trying to figure out why the left was hurting me.  I
decided to try my old orthotics again, the ones from now five years
ago, and my left PTT calmed down immediately.  The right one
aggravated the heal and irritated my ankle.

Dr Blake's comment: Good detective work!! Something is off. 

I thought the problem was that they were old and needed some tweaking.
I dug around and found the name of the podiatrist who had made the old
orthotics.  He took x-rays and discovered that I have an accessory
navicular, which, he says, is very uncommon in high arched feet.  He
has scheduled me for shockwave treatment on my PTTs.  He wants to have
the old orthotics refurbished and has me wearing them with a gel heal
cup.

Dr Blake's comment: I have no experience with shockwave, but it is to break down scar tissue, and there is good scar tissue presumably helping heel the Posterior Tibial issues. 

The shockwave won't fix the right foot where the arch falls a little
but he thinks that it will help heal the damage.  The plan is to try
to stop it from falling further with my old orthotics.  I've tried
wearing just the old orthotics but on the right foot, the one that
tore, they cause my arch and ankle to ache badly, and the outside of
my foot to hurt.  Yesterday I was limping, my ankle swelled and
something by my lateral ankle sounded like a knuckle cracking when I
walked.  Today I'm wearing the orthotics that hurt the left foot
because they are better, but not perfect, on the right.

Dr Blake's comment: Definitely, you can temporarily wear 2 different generation orthotics on the right and left, or a custom and OTC, on each foot, to handle the pain aspect. Without more complex information, we have to listen to your body and let pain be your guide. 
My questions are:

Can they make me one orthotic to deal with the PTTD on the right side
but not make the same adjustment on the left?  I think that's what
caused the problem on the left side.

Dr Blake's comment: Yes they can. You have very different needs for each foot, so the orthotics made should reflect that with different support. If you were in my office now, before I made anything else, I would try to understand why one orthotic feels good, and one causes problems. It is in knowing that info that you can redesign a new pair to help. 
Can orthotics really halt the progression of my arch falling?

Dr Blake's comment: Never on there own. Orthotic devices are used to stabilize the foot, along with taping, bracing, and good shoes. Then, foot strengthening exercises like the ones in the video below, can triple the strength on the tissue. What you do not know is if there is a degenerative process that will continue in the ligaments or tendons. You have to set a one year goal to perfect your orthotics, your ability to tape as needed, and triple the strength of your ankles and feet. 

https://youtu.be/w3FXx4OFqec

Will I be able to run again if I have proper orthotics?  Will anything
get me back to running?

Dr Blake's comment: Without knowing everything, my expectation would be that you could run again. Once you can walk 30 minutes for 2 weeks without pain, you can start a Walk/Run program with stability shoes, power lacing, great orthotics, and some version of posterior tibial taping like in the video below. I love having you begin to run as soon as possible, when walking is fine, because your feedback is crucial to modifying your orthotics, changing shoes, perfecting taping, etc. 

https://youtu.be/e1JAewWT9Fc

https://youtu.be/AcSSyBfFocE

Is having the accessory navicular removed a reasonable option?  From
what I've read, they anchor the PTT down where it should have been
instead of doing a tendon transfer.  If that's true, wouldn't it be
better to have that done before the tendon stretches out even further?

Dr Blake's comment: I understand completely what you are saying, but right now it is preventative surgery, and that does not sit well with me. I would have a better feel  for that based on the ease or difficulty getting back to running, the level of pain is have to constantly deal with, a repeat MRI and even CT scan looking at the tissue. I have seen plenty of accessory navicular bones that cause no problem whatsoever. I hope this has been somewhat helpful. Rich

I'm really starting to lose hope that I'll ever be able to even go
about my day without one PTT or the other bothering me, let alone run
or hike or any of the other things I love.

Thank you so much for taking the time to read this.  I appreciate any
advice you may have to offer.

Thanks,

Posterior Tibial Tendon Treatment Advice

I just updated the video taken on a trip to Maui on the treatment of posterior tibial tendinitis. I hope you enjoy and it helps you. Take this injury seriously, and get the right treatment quickly to get the symptoms down to 0-2 pain level. 

https://youtu.be/T47lVsjMEJg?list=PLuAexfdWrwEzPU7t9GErZEa0KabjoDPnY

Water Brace for Ankle Rehabilitation: Posterior Tibial Tendon Injury

This patient of mine is currently recovering from a posterior tibial tendon injury. Her MRI showed inflammation without tears, so we are moving her along in the rehabilitation process. We had discussed no kicking in the water at this point due to the added stress on the tendon, and definitely no fins of any form.

Hi Rich,

I apologize again for being late this morning, after asking you to

be on time.  Thanks so much for your patience and understanding.

Re: swimming (no fins) being stressful on my ankles

1.  Would this, or something like it, allow me to swim w/out putting

that float thing betw my legs?

http://www.braceability.com/waterproof-ankle-brace

2.  Would it work for water aerobics?  Can I go to water aerobics in another month or 2?

   (it does involve some jumping, etc) What if I use one of those wrap-around-your-waist float things and my

    feet don't touch bottom?

3.  Were you saying that I should NEVER swim w/out that float thing?

I made an appt for a month from now.  Hope it's not too much trouble to respond to these ???s.

Thanks again!

Best,

Dr Blake's response after reviewing the link:

Thanks, that looks great. It will help the biofeedback loop telling your brain that you are protected and that you can swim, while you still must avoid excessive kicking in the pool. Still go easy and ice for 15 minutes after swimming whether it hurts or not. Your MRI was too good to have any permanent restriction on activity, but it will take you 6-9 months to get that injured posterior tibial tendon super strong. Yes, you can begin water aerobics in 2 months, just start with brace and no weight bearing for the first month. And we will see how it goes.Hope this goes well. Rich

Posterior Tibial Tendinitis with Accessory Navicular: Email Advice

Dear Dr. Blake,

     I have been following your site for a few months now and I am blown away by your kindness and generosity in answering the questions of strangers. It is an amazing blessing that you are giving to others and the sense of hope I have received from some of your entries is enormous.  I also read that you recently lost some people who are close to you and I wanted you to know that I'll be keeping you and your family in my prayers.  I was touched by the video you posted on June 1st and will certainly forward it to others.

Although I'm in Boston and can't come to CA to see you, I would be happy to pay you for email advice, so just let me know what your policy is. I would also be happy to send payment along with copies of x-rays, MRIs, etc. if you think it is necessary. I spent a few days writing and editing this to keep it concise and "calm" so I don't come off as a crazy patient! Although we distance runners ARE a bit crazy :) 

Dr Blake's comment: I can not thank you enough for your kind words. I have never charged for this service, but hope it is worth more than what you pay. I have to deal with crazy runners all the time, and because I am a crazy basketball player/athlete, we tend to get along just fine. I am needing time to review another patient's scans that she sent (sorry Sue, but I am slowly getting to yours), so I may not be able to review for a while. You can definitely send.  

     I am a 26 year old female runner - I absolutely love running half and full marathons, and this fall ran a full marathon that made my dream come true- qualifying for the 2015 Boston marathon. I have had no foot pain in my past 10 years of running about 35-40 miles a week, every week, except for some mild pain when I was about 16  which led me to get custom orthotics (they have been great for over a decade with zero signs of pain! BUT I've been wearing the same running orthotics for over a decade). Through my career I've had some minor problems that always resolved quickly with PT and cross-training (knee, hip), but never anything in my foot. I did once have a really bad sprain in my right ankle (not my currently affected side) that took over 6 months to heal. I do over-pronate and have somewhat low arches, but I'm certainly not flat-footed. I am petite at 5'2" and 103 lbs. (so I don't think I have much extra mass that is causing problems). 

     Mid-April while training for another marathon, I started getting some tightness/soreness in my left inner arch. I did a lot of icing, took days off of running here and there, but continued to train. I successfully ran my 20 mile training run on April 18th with some tightness, but not really pain. On April 25th, I took a short 4 miler and had a moment of sharp pain near my navicular, and limped the last 1/4 mile home. I put myself on a running hiatus for a full week. On the 8th day, I decided to "test" running again to determine if I needed to call off the marathon and cancel my travel and hotel. I successfully ran 10 miles with zero pain. However, that night my foot was stiff and sore.  Since then, I have not run a single mile - 40 days so far. Obviously I chose to sit out the marathon.  I wanted to be very cautious and not make my recovery any longer than it needed to be which is why I stopped running completely.

     The pain in mid April- early May was initially  at the accessory navicular, although I didn't know what that was at the time. I could produce pain when I pressed anywhere on it, with stiffness more generally around the arch. Further down in the email I'll give an update on where the pain is now. At no point did I have severe pain - I don't think it ever went beyond a 3 on the 1-10 scale. 

      I have iced in an ice bucket 2-3 times a day all 40 of those days that I have not run, and I have been cross-training with zero pain (bike, elliptical, etc.). Like many athletes,  I tend to run through A LOT of pain (including a stress fracture once!), but something in my heart and mind told me to STOP when it came to this particular injury. My heart is broken without running, although I'm trying to keep it in perspective. Lots of prayer!!  It has been emotional but I am grateful that I can at least cross-train but I'm living in fear of "will this ever heal?"

     I am a researcher by training, so of course I got onto PubMed and downloaded every medical journal article I could find. I diagnosed myself (haha) with an accessory navicular and posterior tibial tendonitis. 

     I saw a general sports doctor at Prominent Boston Hospital #1 in early May (omitting name out of respect for the doctor/hospital) who was largely dismissive of my injury and seemed totally un-sympathetic, but he told me my self-diagnosis was totally correct after looking at the x-rays (PTT and accessory navicular). He tested my feet and said my foot muscles were super weak so PT would be helpful. I had to basically get on my knees to BEG him for an MRI, because I knew I couldn't sleep until I got it. I had been making myself sick with worry.  He was frustrated with me but finally prescribed one (I was in tears at that point).

     I then saw a foot and ankle surgeon at Prominent Boston Hospital #2 yesterday, June 4th, 2014, who was kind, sympathetic, and seemed encouraging. He thought that it might be time for new orthotics since I've run in mine for so long, and having ones with a medial post would help with my overpronation, rather than only supporting the arch with a wedge. He prescribed PT and said we could meet again in 6 weeks to see how things were and re-evaluate if surgery is really necessary. The idea of surgery plus 6-8+ weeks in a cast, plus all that rehab, totally terrifies me, especially given that I'm not in severe pain.

Dr Blake's comment: The chance of you needing surgery is probably 2%. 

     At the same time, I so desperately want to be a "real athlete" again, and if the surgery afforded me that, I would do it. He definitely had limited experience with patients with this problem (he was in his fellowship in foot/ankle surgery, but I found him to be patient, understanding, and deeply caring) but his supervising surgeon had plenty and he would talk to him about it. He looked at my MRI and x-ray and said he didn't see much that was concerning, except for a tiny bit of fluid around the PTT. He was expecting to see much more irritation around the accessory navicular, but it didn't look bad at all.

Dr Blake's comment: This is a good sign. When the accessory navicular is a problem, there is more fluid around and/or in it. Hopefully, you have posterior tibial tendinitis mainly. 

     When I got home yesterday evening, my MRI report was finally in my mailbox- would have been helpful if I had it before I saw the surgeon! Maybe I'm reading into it too much, but the report from the radiologist seemed worse than what the surgeon told me today (he didn't think things looked too bad).

Imaging results: X-rays of foot and ankle showed accessory navicular. MRI report for the ankle said:

1. 11 mm multiloculated ganglion cyst between the spring ligament and talus

2. Mild tenosynovitis along mid to distal aspect of posterior tibialis tendon, with mild tenodonitis at its insertion on a type 2 os naviculare

3.  Mild degenerative changes along the articulation between the os naviculare and navicular bone

Dr Blake's comment: This mainly shows tendinitis. The treatment of tendinitis is very conservative--PT, orthotic devices, anti-inflammatory, taping, and strengthening. The ganglion cyst and degenerative changes make this interesting. 

     Other text on the report on foot and ankle: "normal alignment, joint spaces are preserved, no fracture is appreciated. The anterior ankle tendons are intact with normal signal intensity. Mild tenosynovitis along the mid to distal aspect of the posterior tibialis tendon. The tendon is normal in morphology and signal intensity, except at its attachment to a type 2 os navicularis where there is mild tendonosis. Normal fat signal seen within the sinus tarsi. The anterior and posterior talofibular ligaments are in tact. The anterior talofibular, posterior talofibular, and calcaneofibular ligaments are in tact, the deltoid ligament is intact. Deep to the spring ligament and overlying the talus there is a multiloculated ganglion that measures up to 11 X 6 mm in the axial plane. The subtalar joint is unremarkable. The articular cartilage throughout the midfoot is intact. The marrow signal is normal. There is no talar dome osteochondral defect. There is no acute dislocation, marrow edema, erosion, or cortical thickening. The flexor and extensor tendons about the foot are  intact, with normal signal intesity. No intermetatarsal bursitis is appreciated. No significant subcutaneous edema."

Dr Blake's comment: No significant change here. The ganglion is interesting if it is involved with your pain. 

     I'm thinking I might mail this report to the surgeon I saw yesterday so he can review it with the supervising physician (chief of foot and ankle surgery at the biggest Boston hospital) before my follow-up in 6 weeks. He reviewed the MRI and said nothing about the ganglion cyst, which I am in a complete panic attack about. I don't even know what this cyst is, but I assume it is horrible, terrible news. I'm avoiding googling it out of fear. 

Dr Blake's comment: Ganglion cysts arise from herniations of the ligaments from a joint. Sometimes they need to be removed. We always try injecting them and draining if possible. Some of them cause pain, most do not. 

     My pain these days: At no point since the initial onset of pain, up to today, have I been in incredible pain, thank God. I almost feel embarrassed that this has caused me so much distress, but I've been in very little pain this entire time. I can walk to and from work (about a mile each way), go about my daily activities, etc. with little or no pain. Cross training has been fine- no pain or stiffness during or after whatsoever.  The reason I have not run a single mile in 40 days is primarily because when I wake up in the morning, I have pain/stiffness in my foot for a few minutes. As an athlete, I take this as my body's message of "something is damaged," so I don't want to risk it. The  surgeon I saw yesterday said I could try some light running (but I refuse out of fear until I get my new orthotics). 

Dr Blake's comment: You are showing great wisdom at your young age. Definitely, this is an arch problem, and perfecting the orthotics first makes sense. Learn how to do some version of arch taping. I have the kinesio version and the low dye versions on my blog. These should be done with the orthotics for several months until your running is back up to normal. 

     The pain/stiffness upon waking is sort of difficult to localize and feels "deep" in my foot, but generally in the area of the navicular. Sometimes when I am sitting at my desk at work or get up after sitting for a while, there will be some stiffness in the arch, and there is often tenderness in the area of the PTT near the ankle  but more of an annoyance, not serious pain. As I mentioned, originally (in April/early May) I could produce pain on the accessory navicular when pressing it. Now, it is quite difficult for me to produce pain on the accessory navicular, and it almost never hurts. But the mild PTT tenderness, and particularly the tightness/pain in my arch upon waking, makes me worry. I am quite sure that if I went running, I'd spend the evening with a very stiff and sore foot. Right now, I mainly am limping during my first 3 or so  minutes out of bed, plus occasionally rubbing/flexing my foot during the day to test for stiffness/soreness. I'd say my pain on waking up in the morning is about a 3, the rest of the day I'm at a 0 or 1. Given this relatively low level of pain, it seems crazy to risk going through a major surgery. Honestly, if I were not a runner, I probably would not have even seen a doctor for this. But as an athlete, it consumes most of my thoughts, and makes me lose sleep! 

Dr Blake's comment: I have seen too many surgeries by great docs go wrong to say something but any thought of surgery  (if needed) should be 2 years from now. This means you do everything possible to avoid surgery. Again, the ganglion is a little unusual, and could be removed with minimal problem if we could prove it was your problem. Ganglion cyst are injected with cortisone all the time, but if placed too close to the posterior tibial tendon, could cause a rupture. If these things were easy a monkey could design a treatment plan. 

     I am scheduled to get casted for new Orthotics (the first appointment I could get for casting the orthotics is July 14, ugh!) and I will have my first PT session on June 16th (also the soonest I could get in).

So my question is... in your experience, do you really think there is a possibility of ridding myself of my PTT/accessory navicular pain with continuing rest, ice, and PT, even if 40 days off of running hasn't healed it?

Dr Blake's comment: Yes, orthotics with more support, a great strengthening program, icing, taping, activity modification, gradually increase running every other day with new orthotics (the new orthos should be more supportive and comfortable in the area of the accessory navicular), should all help. 

     Do tendons just sometimes take this long to heal? My concern is that if my accessory navicular is causing my PTT pain, how will I ever resolve it if I don't get the accessory navicular OUT of my foot? I guess I need to hear that other athletes out there in the world struggled with this for MONTHS but eventually returned to sport without surgery but plenty of PT and patience. The other part of me thinks "I had this bone for 26 years with NO pain, so what's to say I can't go back to being pain-free even if the bone is still in my foot?"  I dread a lifetime of just wondering when I'll need to have major surgery on this, and long for the days just a couple of months ago when I could easily run 40 miles a week, wear flip flops, go hiking, etc., without giving a single though to my feet. It seems like this came out of nowhere. I have been a serious runner for so long, with basically no change in what I was doing.  Do you think this very surprising finding of the ganglion cyst is related (a cause or a result?) of the navicular/PTT issues? Am I totally doomed?

Dr Blake's comment: 3% of the population have accessory naviculars. Our sports clinic which is geared more towards rehabilitation, does one of these removals every 2-3 years. Probably on 1% of the patients presenting like you. So, I feel comfortable that your chance of needing surgery for the accessory navicular over the next 40 years, with high level sports is probably around 2% at most. That being said, the ganglion cyst is more likely a cause of problems and needs long discussions with your docs. We really do not know where you are, so after you get the new orthos, and after you need that they give great support, along with taping, begin running every day with your foot taped, while you start PT. It sounds like it will take until September to get a great feel of where you are going with this. Keep me in the loop. 

     Second, is it bad that I'm still doing the ice baths, 40 days later? Should I also be doing heat baths of some sort on it? I just want to make sure there isn't the possibility that I'm over-icing, if that is a thing!

Dr Blake's comment: Definitely I would have you ice pack 10 minutes only 2 times a day, especially after exercise, and do one session of contrast bathing each evening. 

     Third, although I'm sure the Physical Therapist I'm going to see will be fine (I live in Boston with good access to medical professionals), my assumption is that PTT and accessory navicular issues are rare. I doubt they will know much about a ganglion cyst in the spring ligament.  Is there any information I should bring him/her about which specific areas I need to be strengthening? I don't want to make it worse with PT! Are there additional types of therapy, massage, medication I should be trying?

Dr Blake's comment: The ganglion is something for you and your doc to work on, and to decide if it is related to your pain. There is nothing that the PT does for this. The PT should painlessly strengthening the posterior tibial tendon in particular, the rest of your foot and ankle tendons in general, and work on your core strength, cardio, cross training. They will also do anti-inflammatory modalities. Definitely run while you have PT to get an honest feel of how you are doing no matter what they say to do. 

     I am totally dedicated to staying away from running as long as I need to in order to get through this without surgery (though praying I will be able to run the Boston Marathon in 10.5 months!) but you can be honest with me if you think surgery is going to be the only true option to "fix" me.

Dr Blake's comment: It is actually unfortunate that you have any running goals ahead of you. They sometimes get in the way to common sense. I am hopeful with the taping, PT, new orthotics, and return to running goes smoothly. We will see if there are any glitches over the next few months. Keep me in the loop. Rich

     The one blessing in this is that it has helped me re-evaluate my focus on faith, family, friends instead of just running, and it has encouraged me to cross-train and strength-train more (which I almost never did). I am an obedient PT patient and will follow my PT orders religiously. I want to come out of this healthy and strong, able to enjoy my feet and where they take me well into my nineties.

Thank you SO much for your kindness, I am praying for hope and perspective on this since it has been very tough to keep the tears back during the past 40 days.

Sybil (name changed)

Boston, MA - Age 26

Varus Wedging for Excellent Pronation Control

Posterior Tibial Tendinitis: Some Key Points

Algorithm of Treatment for Posterior Tibial Tendinitis from diagnosis to immobilization to re-strengthening to return to activity. 

Posterior Tibial Tendinitis: Some Key Points

 Posterior Tibial Tendinitis: Key Points

 ■ This tendon moves the ankle, prevents over pronation, and supports the arch
 ■ Treatment of this tendon at times requires stabilization of all 3 areas with ankle bracing, inverted orthotic support, and arch support
 ■ As soon as treatment is started to immobilize the injured tendon, both anti-inflammatory and some form of strengthening should begin
 ■ MRI should be used initially to rule out an actual tear, or if the treatment seems to hit an impasse

Posterior Tibial Tendinitis: Brief Video Discussion on Treatment

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. 

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: Isometric Active Range of Motion Progressive Resistance Isotonic Functional 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)

Posterior Tibial Tendinitis: Email Advice

Dr. Blake
Thanks for the opportunity to seek your opinion.

My 18 yr old daughter has an ongoing foot problem.  She is depressed, sad, has given up hope, ... every day she struggles with the physical pain and is emotionally crushed.
She has changed from a happy kid to a sad, depressed teenager with a foot injury that never ends!
The current diagnosis is Posterior Tibial tendonitis.  She had surgery 16 months ago to remove an accessory navicular ... which they thought was causing the dysfunction in the foot??

She originally twisted her foot in a basketball game when she was 13. The foot seemed to heel ... but she re-injuried it,  and the foot (left) started to collapse if she were to start running again.

It was 2 years before we started to learn about the Posterior Tibial tendon - and made efforts to strengthen and re-train this tendon.  Seemed that the accessory navicular was creating an unstable attachment for the tendon to do its job supporting the foot.  Finally, surgery was suggested - and performed on May 31, 2011. 

 Casted for 6 weeks, rehab for several ... when she tried to run, the pain and problem returned - and has been problematic for the last year!  Recent MRI shows some tendonitis in the Posterior Tibial Tendon. 

 She struggles every day with pain (and dysfunction) ... and the mental toll of missing sports for 4 years has been heart breaking - she was an absolute star runner, basketball player, tennis - a real all-around star ... and LOVED to play!  Four years on the sidelines - our family life has been transformed ... daily sadness, despair.

We are lost with what to do.  Doctors seem stumped, PRP 8 weeks ago - no response. Physiotherapist don't know what to do.
Try again with different orthodics?
Immobilize to settle tendon - (she swims, strength trains, bikes, walks to classes at U)
I can send more details?
I have copies of the MRIs.
Thanks for your time and consideration.
Dan 

Dr Blake's Response:

     Dan, I am honored to share some of your burden. Thank you so very much for contacting me. 

     First of all, posterior tibial tendinitis does not cause this, but posterior tibial tendon dysfunction can. The MRIs should give us a clue to her pain, but she may need some diagnostic injections into the various joints in the area to see where her pain originates from. The two Golden Rules of Foot that initially apply are: Find the Source of Pain and Create A Painfree Environment. Please fed ex any tests to Dr Rich Blake 900 Hyde Street San Francisco, Ca, 94109, USA for my review. The tests available for this syndrome are MRIs (so I should look at what you have), X-rays with obliques to pick up that side of the foot, bone scans, ultrasonography, CT scans, diagnostic injections, nerve conduction tests, thermography, and exploratory surgery. The last I would save until the other tests have been done. Your daughter has all the right to be very depressed, but you guys must be her strength and fight to get these tests done, etc. Make this a project for the next few months to begin to get a handle on this.

     Secondlly, immediately Create A Painfree Environment. If this requires a removable cast, a more inverted orthotic, a Ritchie Brace or another AFO, a Roll A Bout, crutches, whatever, and in what ever combination it is crucial. It is crucial to know right now what it takes to make her pain free all day long. That is vital information for the treating physician. 

     Thirdly, the past is the past, and right now we do not need to focus on the last 4 years, but I do need to know what the docs or the PTs are finding (i.e.. collapsed arch only on that side, positive tinell's sign at the tarsal tunnel, limited subtalar joint motion, inability to contract the posterior tibial tendon, etc). Basically, what are the clues she is giving us that we can use to help her. 

     So Dan, I will put any new correspondence, etc on this same post. Let us see if we can begin the process logically. This is so highly unusual that I know something is being missed. Hopefully we can find out. Please send me a photo of her standing of the back of her heels from about 3 feet behind her centering the camera in the middle of both legs.

      Finally, I am attaching a medical history form for her to fill out and email back. I only need to know what is happening now that is not enabling her to walk without pain. Thank you Rich

http://www.drblakeshealingsole.com/2010/06/giving-good-medical-history-for-pain.html

Dr. Blake

Thank you for the quick reply.

I am very appreciative of your caring attitude and willingness to help my daughter.

I have the MRIs and reports ready to send.  My daughter will work on the history later today.  I'll also get a few photos taken to send as well.

Next ... will be getting some of the testing done.  I will try with the doctor who has been working with her this summer; he tried the PRP injections in July - can likely get the testing ordered.

Also, we'll explore some of the solutions to get the current pain under control.

As things move forward, if you need to see her we can arrange to do that.  We are in Ontario.  Flights typically out of Detroit.

THANKS AGAIN.

Dan

This video sent shows the common area involved by the posterior tibial tendon.

This photo shows a slightly more pronated left foot, but only slightly. That gives us great hope that the injured left foot can be supported by standard orthotic devices with some inversion in the RX well.