Common running injuries
Tibialis posterior dysfunction
Tibialis posterior is a tendon controlling the medial (inside) arch of the foot. When this is weak or injured it can result in a collapse or lowering of the medial longitudinal arch of the foot, commonly called a ‘flatfoot’ deformity. Injury to the tendon can occur by trauma, for example a direct blow or following a quick, sharp movement of the foot or ankle that causes tethering or tears in the fibres of the tendon. There will be localised pain and irritation, and you may see some swelling in the area. Long standing problems with niggling pain and weakness seem to be more common presentations in the runners we often see in clinic. We call these types of injuries overuse injuries, as they are the result of repeatedly stressing and straining the tendon at sub maximal forces. These injuries typically have a gradual onset over a progressive time period and sometimes there is a ‘final straw’ incident which prompts the individual to seek treatment. Overuse injuries will facilitate early degeneration of the tendon.
Three stages of tibialis posterior tendinopathy have been described (Johnson & Strom, 1989) – stage 1 with swelling, 2 with swelling and partial tear and 3 with complete tear.
The main actions of the tendon are plantarflexion (pointing the toes), supination and inversion of the foot (turn inwards and up), in addition to supporting the arch. On examination you will feel pain usually on stretch of the tendon, when the foot is moved outwards into eversion and/or dorsiflexion (toes towards the nose), and also on resisted inversion. Coming up into a heel raise position might be quite difficult and painful as the function of the tendon is compromised. Kamiya et al (2012) found on testing cadaveric legs, that the tibialis posterior tendon was essential for maintaining the arch of the foot in dynamic weight bearing. They tested fourteen normal cadaveric legs (not injured) both with tibialis posterior activated and without it’s activation in loaded states to assess changes in the medial arch of the foot. Without the tibialis posterior tendon, other passive structures were not sufficient to maintain the lift of the arch.Symptoms of this tendinopathy usually include pain along the inside of the ankle where the tendon runs, and sometimes there will be swelling around this area and also the ankle joint itself. There may also be pain at the lateral side of the ankle where the body compensates, as the heel bone may shift over a bit following collapse of the arch.
Physiotherapy is an excellent way of treating this problem conservatively and treatment will usually include methods to relieve symptoms of pain initially. Manual therapy, such as soft tissue techniques and massage can address imbalances such as tightness in the calf muscles, and friction massage can help stimulate the healing process of the tendon itself. Joint manipulation can also be helpful in realigning and correcting any positional problems. Ultrasound, or other types of electrotherapy to can reduce pain, facilitate healing and stimulate tendon activity. Of course specific exercises and stretches are essential to get the tendon functioning normally again.
Exercises to strengthen the weak tendon and stabilise the foot are very important for recovery and also prevention of recurrence of injury to the foot. It is also important to assess the biomechanics of the lower limb and see whether any problems higher up the kinetic chain are contributing to the foot trouble. For example, often weakness around the hip or lack of stability at the pelvis allows the knee to roll inward and thereby alters stresses and loading down the entire limb through the running cycle (during which the impact on ground contact can be up to 7x body weight). Regularly stretching the main muscle groups used for running is very important to try and prevent imbalances and maintain as efficient running mechanics as possible. In addition, core work to strengthen the lower abdominals and running drills to promote good technique are very helpful in injury prevention.
Kulig et al (2009) conducted a randomised controlled trial among patients with tibialis posterior dysfunction, looking at specific types of resistance exercise and orthotics. Patients were divided into three groups, orthotics as sole treatment, orthotics and concentric exercise (shortening the muscle under load and orthotics and eccentric exercise (lengthening/stretching the muscle under controlled load). They concluded that between three groups the two groups doing exercise in addition to using orthotics improved more than the orthotics alone group. In addition, the eccentric group improved functionally significantly more than either of the other two groups. This indicates that by following functional exercise programs we will get better results in conservative management as the tendon is actively strengthened and lengthened in ranges of motions, with loading akin to that required in day to day functioning. Outcome measures used in the trial were the foot functional index, the 5-minute walk test and VAS score for subjective levels of pain.
Exercises that can be helpful include:
- Arch lifts to activate and strengthen the tendon. You can start in sitting when this injury is acute and gradually progress to standing with support and then without. Progress in standing from two legs to single leg stance (with and then without support).View video of mEdial longitudinal arch activation.
- Resisted inversion with manual resistance or theraband – one of the primary actions of the tendon is to invert the foot, so to strengthen it up we add resistance to this movement. Begin with a static pressure against the hand or a stable surface (eg the side of a table or chair leg) and then add in movement against the resistance of a theraband.View video of foot exercises inversion.
- Heel raises with ball – this encourages good positioning of the foot and activation of the tendon in it’s main movements (plantarflexion and inversion) View video of Heel raises with ball.
- Golf ball/spiky ball massage under the foot – this helps to soften the fascia (connective tissue) underneath the foot, which can become very tight and sore as commonly it becomes overloaded and overworked with this problem
Where conservative management fails, treatment will vary according to the severity of the injury and flexibility of the foot. The treatment for a more flexible foot is typically more conservative than a non-flexible foot, which potentially may need surgery. Your physiotherapist or specialist will be able to advise you of the most appropriate treatment for the severity of your injury. Surgery will only be done usually when the pain and function does not improve after several months of appropriate treatment.
In summary management of mild-moderate tibialis posterior problems includes:
- Rest/modified activity. No activity that particularly strains or overloads the tendon (or inside aspect of the ankle) should be performed. For example, running or high intensity activities such as sports involving jumping, hopping and quick changes of direction. For most people swimming and cycling will be activities that can be managed comfortably and taping the ankle/tendon can be helpful when progressing through rehabilitation so that pressure through the tendon can be offloaded to a degree and better movement patterns facilitated.
- NSAIDs (eg ibuprofen, nurofen) – can be used in the acute phase to assist with pain relief and limit inflammation, however it is not recommended that these medications be taken over any prolonged period as they interrupt the body’s natural healing process (blocking inflammatory mediators). In addition, they do have potential for known side effects which often become more pronounced when taken over a longer time period. If you are seeking pain relief for more than 7-10 days it is best to speak with your GP.
- Stretching the calf muscles and lower limb muscle groups, whilst working on strength and stability of the foot specifically.
- Address any biomechanical problems with the rest of the lower limb (nb consider hip and pelvis in particular for runners).
- Orthotics can be useful. For the milder presentations of dysfunction and acute conditions (present for a short time only) over the counter medial arch supports can often provide some welcome relief in terms of pain and also benefit the overall foot position. However, if the problem is more long standing specially measured orthotics may be required. You can discuss this with your GP, physiotherapist or podiatrist.
- Steroid injections (cortisone) – should be avoided. They can sometimes be useful for pain relief, however the substance used for the injection is known to weaken the tendon structure and can therefore predispose rupture.
- Bodill , Concannon (2012) Treatments for posterior tibial tendon dysfunction. Clinical musculoskeletal. Practice Nursing Vol 23 (8).
- Johnson KA, Strom DE (1989). Tibialis posterior tendon dysfunction. Clinical
- Kamiya et al (2012). Dynamic effect of the tibialis posterior muscle on the arch of the foot during cyclic axial loading. Clinical Biomechanics 27: 962-966
- Kulig et al (2009). Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial. Journal of the American Physical Therapy Association Vol 89 (1) pg 26