Our feet are some of the most important parts of our body – we’re constantly using them to stand and walk, and can sometimes take them for granted. However, due to that usage, tendonitis in the foot can become a problem. The most commonly affected tendon that suffers from the ailment is the posterior tibial tendon.
Our guide is made to help you understand:
The posterior tibial tendon is the tendon that’s behind the inside bump on the ankle (also called the medial malleolus), across the instep and runs into the bottom of the foot. This tendon helps support the foot’s arch and turns it inward while we walk.
Tendons are made up of collagen, an abundant protein that helps our connective tissues strengthen and cushion the organs and body parts they support. A tendon functions similarly to a rope, and collagen can be considered its strands. As we get older or stress the tendon out excessively, strands of the tendon can start degenerating, “untangle” due to its
Your body naturally heals itself, but as the tendons attempt to heal from that wear and tear, scar tissue forms which thickens the tendon. If the process continues, a nodule (or knot) can form in the tendon and causes the tendon to change its structure. In this stage, tendonitis becomes tendonosis. According to recent research, in tendonosis, inflammation does not occur unlike in tendonitis. However, because of the knot that formed in the tendon, the tendon is weaker, and that can lead to the tendon possibly rupturing.
What does tendonitis of the foot feel like?
In tendonitis of the posterior tibial tendon, you may feel pain in the instep area and swelling along the tendon, and in more extreme cases, the tendon may rupture due to its degeneration. A ruptured tendon can lead to a deformed and flat foot. Not only that, but someone with a ruptured tendon is also unable to stand on their tip-toes.
How do health care professionals identify posterior tibial tendonitis?
Your physical therapist at Hicksville Physical Therapy will probably go through your history and administer a physical examination to diagnose posterior tibial tendonitis. They will want to know where your pain is, when it started, and what activities alleviate the pain or continue to aggravate your condition.
After the initial assessment, your physical therapist will examine your foot and lower extremity, touching around the affected area to determine the exact location of your pain. They will also check your body’s alignment in your hips, knees, feet and ankles, observing you when you stand and sit to check if anything is abnormal when you do either. Your physical therapist may also ask you to twist your body while your feet are securely planted on the ground, do a squat, or walk barefoot so they can see how your feet move and arch.
After that, your physical therapist will check on the position and mobility of your foot bones to determine if any parts of your feet or ankles are suffering from any subluxation, laxity or stiffness.
Your foot and lower leg muscles will also be assessed on their strength. Your hip muscles will also be observed, as they are involved in controlling the alignment of your leg and lifting the arch of your foot. You can feel the link between your feet and hips if you squeeze your buttock muscles together; as you perform this action, the arches of your feet will slightly lift. Control of the foot is not determined by just the muscles and joints only in the foot, but other parts of the body like the hips, making many parts dependent on each other to function properly. That is why it is important for each part of your body to be properly taken care of. The hip muscles must be assessed as well, to determine if they are adequately functioning.
Testing your muscles will help identify any areas of weakness, muscle impairment and imbalance, and will be performed in both weight-bearing and non weight-bearing positions. One test that determines insufficiency of the posterior tibial tendon is the single heel raise. Your therapist will ask you to stand on one foot and rise up on your toes. This exercise is meant to see if you can lift your heel off the ground easily, while keeping the calcaneus (heel bone) centered, inverted or inward, and having your knees stay straight. If this function is not performed normally, your posterior tibialis muscle and tendon may be diagnosed as ruptured.
Usually, a physical examination alone can determine whether you have a posterior tibial tendon problem. However, difficult cases may exhibit a need for a magnetic resonance imaging (MRI) scan. An MRI will use magnetic waves instead of X-rays to display the tissues of the body, creating images that look like slices to display the tendons and ligaments clearly and accurately. Fortunately, the test does not need any needles or special dye and won’t cause any pain.
What can be done for the condition?
Physician’s Review
If you are still suffering from the inflammation stage in your injury, your doctor may prescribe anti-inflammatory medications such as ibuprofen or aspirin.
Injections with corticosteroids (cortisone injections) are not recommended for this injury, as the tendon is more likely to rupture. Those injections are usually reserved for various forms of arthritis. One method that may be considered, however, is a cortisone treatment called iontophoresis. This treatment uses an electric current to deliver cortisone medicine through the skin and into the inflamed tendon. Risk of tendon rupture is reduced in this method, making it a viable option for tendonitis or tendonosis.
Nonsurgical Rehabilitation
Physical Therapy at Hicksville Physical Therapy is extremely beneficial in treating posterior tibial problems.
Your first few treatments at Hicksville Physical Therapy will be focused on pain relief. Your physical therapist may use heat, ice, an ultrasound or other electrical procedures on the instep of your foot or up the shin, and may also recommend for you to ice and heat the areas while you’re at home. They may also massage the bottom of your foot, calf, and muscles surrounding your shin. However, these methods provide only temporary relief, and to fully fix the problem that your posterior tibial tendon is suffering from, methods such as strengthening exercises may need to be implemented to prevent a chronic issue and a tendon rupture.
Exercises will start with activities meant to strengthen the small muscles of your foot and posterior tibialis muscle. As a refresher, these muscles support and lift the foot arch with your hip muscles that control the leg’s alignment, and also assist in lifting the foot arch. A “theraband” may be used to add resistance to your foot muscles and strengthen hip muscles. Your physical therapist will also assign stretching exercises to help your calf muscles, which, if tightened, can force the foot out of its proper alignment. While stretching, it is integral to maintain proper posture in your foot and foot arch to not further irritate an already inflamed posterior tibial tendon. Your physical therapist will watch over you as you perform your exercises, and give constructive feedback to whether or not you are performing them successfully, and whether your alignment is sufficient.
Because posterior tibial tendon problems tend to develop over time, a patient may not even notice that their alignment is off, and you may think that your feet are even normal. The term “proprioception”, also known as kinesthesia, is your body’s sense of self-movement and body position, that allows for you to walk properly without thinking about it. Re-learning to properly align your feet is crucial to pain relief, and from preventing a further foot and tendon deformity from developing. Your physical therapist will help re-teach your feet so that they will walk in the correct way, assigning exercises that challenge the proprioception of your foot, knee, ankle and arch. At first, these exercises may only be done while you are sitting, but as you progress in rehabilitation, your therapist will gradually introduce the exercises as you stand, and eventually on one foot at a time. It is imperative to work up to standing, as standing leads to many of your normal activities like walking and climbing the stairs. As you continue to improve, your therapist will then start prescribing even more difficult exercises so that you can return to daily life, especially if you play a high-level sport. They will give you exercises like squats and jumps, and you will be expected to maintain proper foot, arch and leg alignment while doing so.
If you haven’t already bought orthotics (devices that treat foot conditions, such as a shoe insert) to aid your arch support and take pressure off your posterior tibial tendon, your physical therapist will advise you on whether you need them, and where you can purchase them. Your physical therapist may also tape the bottom of your foot, as well as teach you how to do it on your own, and this can be done before purchasing an expensive orthotic. Taping may be enough in mild cases of tendon pain, but you must be able to control your foot’s alignment properly and be able to maintain it during various activities. Otherwise, a shoe insert will improve your symptoms significantly, and will be recommended to relieve your symptoms and avoid the injury from progressing further. Custom fit orthotics should be made for patients with a significant case of flat foot, and for people whose symptoms do not see relief from premade ones, but premade orthotics are enough for those with mild cases.
Excess weight can also be the cause of posterior tibial tendon problems, which we mentioned previously in this article. Losing weight may be recommended to feel relief in your foot and make it easier to maintain a proper foot alignment. Your physical therapist at Hicksville Physical Therapy can discuss weight loss strategies and possibly refer you to a Nutritionist if this is something you struggle with. It is difficult to exercise and increase energy expenditure to lose weight if your foot is in pain, but there are several safe activities that you can potentially participate in, such as stationary cycling or swimming.
Modifying activity is important to posterior tibial problems here at Hicksville Physical Therapy. Your physical therapist will advise you to avoid any activities that cause discomfort if you still have any symptoms. You should rest for a short period after any sport, or at least decrease the amount of activity you do if you still want to participate in your daily routine. Your therapist will work with you and guide you in the amount of rest you need for your individual injury. Rest may seem difficult, but without properly doing so, it is unlikely to heal, and a period of rest improves the ability of any medication you may be taking, as well as the treatment you’re receiving and thereby assisting your injury’s healing process. Your physical therapist will advise you when it’s safe to start activity again after resting.
Unfortunately, especially if you have a difficult injury, not all posterior tibial tendon problems will respond favorably to physical therapy treatment. If your injury does not seem to get better even after seeing a physical therapist at Hicksville Physical Therapy, your physical therapist will refer you to your family physician for further options, or consult an orthopaedic surgeon to discuss more aggressive forms of treatments.
If you’ve tried it all and still do not see improvement, you may have to consider getting surgery on your foot.
Tendon Debridement
If your problem is diagnosed to be tendonitis with thickened tissue around the tendon (tendon sheath), a tendon debridement operation may be necessary to remove the thickened tissue. This surgery is performed to decrease pain symptoms and prevent tendon rupture.
In tendon debridement, a small incision is cut in the instep of the foot just over the posterior tibial tendon. The surgeon identifies the tendon and the thickened tissue is removed.
If you’ve tried it all and still do not see improvement, you may have to consider getting surgery on your foot.
Tendon Debridement
If your problem is diagnosed to be tendonitis with thickened tissue around the tendon (tendon sheath), a tendon debridement operation may be necessary to remove the thickened tissue. This surgery is performed to decrease pain symptoms and prevent tendon rupture.
In tendon debridement, a small incision is cut in the instep of the foot just over the posterior tibial tendon. The surgeon identifies the tendon and the thickened tissue is removed.
Fusion
Finally, in cases where the foot has been neglected and a fixed flat foot deformity is present, fusion (or arthrodesis) may be suggested. In a fusion procedure, a joint between two of the bones is removed, and the two bones are allowed to grow together to “fuse”. This surgery is performed for joints that suffered from severe wear and tear, and can be used to realign the bones if tendons and ligaments are unable to do their jobs. Several joints must be fused together to fix a flat foot after a posterior tibial tendon rupture.
After the surgery on your posterior tibial tendon is performed, you will need to wear a bandage or dressing for a week. The stitches will be taken out after 10-14 days, but do not need to be removed if your surgeon used a dissolvable form.
It will take around eight weeks before your soft tissues are healed; however, in simple debridement, the tendon takes less time to heal. If it has been repaired or grafted, your foot will be casted or be put in a cast boot to protect the tendon while it’s healing, and you may need crutches to move around. Your physical therapist will teach you how to use the crutches on stable ground, and while climbing the stairs.
Physiotherapy at Hicksville Physical Therapy can begin when your surgeon gives you the approval, usually after 8-weeks or so. Post-surgical rehabilitation focuses on minimizing pain and swelling after surgery, using methods like ice, ultrasound or interferential current like in a non-surgical approach. Your doctor may also gently massage your foot and leg. As you recover, your physical therapist will advise you on how to increase the weight-bearing load on your surgical foot by using your crutches less. You’ll go from using two crutches to only one, or be given a cane or stick, before transitioning to having no aid and putting your full weight on your foot with surgery. Having the ability to walk without any walking aid is essential, but it is also easy to develop walking patterns trying to compensate for lack of aid if you forgo it too early.
Some of the first exercises you may receive are those of gentle range of motion, so that your foot can gradually regain movement and to decrease its swelling. Such exercises include ankle circles, and pointing and pulling your toes upward and forward. These exercises should be done in pain-free motion. However, movement is encouraged even with slight discomfort as it can assist with getting rid of swelling as well as improve pain. You should also be elevating your foot as much as you can, as it can greatly help assuage your ankle’s swelling. Try elevating it above your heart’s level while lying down to allow gravity to assist with fluid drainage.
A stationary exercise bike is a great tool that can help with rehabilitation. Exercising with the bike can aid with gaining your ankle’s mobility back and decrease its swelling. The back and forth motion on a stationary cycle is an excellent way to encourage the ankle to move normally, even if it is unable to fully rotate the pedals.
Your physical therapist may also advise you to do exercises in a pool or whirlpool once the wound heals, if you have access to such equipment. Weight bearing exercises are much easier if performed in water, and the water’s warmth can also assist with regaining your range of motion.
When you begin treatment at Hicksville Physical Therapy, your physical therapist will immediately work with you to address your proprioception of your foot, ankle and leg, and the alignment of the entire local limb. Regaining a sense of the proper alignment of your foot and foot arch is crucial to avoid relapse. Simple strengthening exercises for the bottom of your foot, posterior tibial muscle and hip muscles will also begin early into recovery. Exercises should be attempted with pain-free motions, but feeling mild discomfort is fine as your muscles start strengthening again as they regain new feelings of mobility.
As this article mentioned under non-surgical rehabilitation, it is imperative that you pay attention to the alignment of your arch, foot, ankle and lower limb while you exercise. Poor alignment can result in your posterior tibial tendon being damaged again. Your physical therapist at Hicksville Physical Therapy will repeatedly try to instill consciousness of your alignment, while you walk and stairclimb and do any other everyday activities.
You’ll start to see visual and significant improvement in your foot after surgery after around four-to-six months. During this time, your physical therapist will start increasing your exercise program’s overall intensity, but appointments at Hicksville Physical Therapy will start to decrease. However, for those who went through the fusion surgery, you may still feel stiffness and loss of motion in the foot/ankle, but this is still expected. The amount of stiffness and its location is dependent on which of your bones were fused together.
Even though you may see improvement after six-to-ten months, swelling and discomfort still aren’t uncommon. Standing on your feet for prolonged periods and walking long distances can still cause foot pain and discomfort, but these symptoms will eventually wane.
Going back to your original lifestyle will gradually start over a period of around four-to-six months. Your physical therapist will advise you on the appropriate time to add more high-intensity exercises to your rehabilitation routine. If you want to go back to exerting yourself in cardio activities, your physical therapist will work with you to implement exercises with a safe intensity and determine an appropriate duration during non-weight bearing cardio sports, such as swimming or cycling. Your physical therapist will also help determine when it will be safe to return to more aggressive forms of exercise for your foot and ankle, such as jogging and running.
At Hicksville Physical Therapy, we strive to provide the most quality care so that your recovery post-surgery and rehabilitation for your posterior tibial tendon problem goes well. However, if your pain lasts longer than it should, or your rehabilitation remains stagnant or is not progressing in a timely fashion, your physical therapist will follow up with your surgeon to examine your situation and make sure nothing is impeding your injury’s healing.
