Posterior Tibial Pain Syndrome: Part 1

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  Richard Blake KRM team

  4/22/25, 4:53 AM

  

   

       Posterior Tibial Pain Syndrome refers both to the tendon and the many places pain can be located when the patient presents to you. The posterior tibial tendon works across many axes and therefore has many functions. These functions sometimes require the tendon to produce marked moments (rotational forces) that cause strain to its structure. When the function is a deceleration activity, the tendon contracts eccentrically, and in an overuse situation, this gives the tendon a disadvantage over more concentric contraction activities. The functions of the posterior tibial tendon include:

  • Deceleration of contact phase internal tibial rotation associated with subtalar joint pronation motion
  • Acceleration of contact and propulsive phase ankle plantar flexion
  • Deceleration of contact phase subtalar joint pronation
  • Deceleration of contact phase arch collapse
  • Deceleration of contact phase midfoot mobility
  • Stabilization of the arch structure in midstance and propulsive phases
  • Acceleration of midstance and propulsive phase subtalar joint supination

   

         Problems in the posterior tibial tendon complex can occur during any of these functions when its demands are overloaded by something.The problem may be simple or complex to discover in your role at helping the patient in their training as they recover. You can imagine that each one of these functions can be present in feet and legs with other weak spots. I always say that the Rule of 3 is usually present with overuse injuries. Three factors, and sometimes more, will exist besides straight overuse that sets a patient up for an injury. These factors create a permanent or  temporary weak spot in a patient’s system. Whether it is permanent or temporary depends on whether it can be reversed so repeat injuries will not keep occurring. Consider a weak posterior tibial, that gets injured, and never properly strengthened. Return to activity with flares of pain can occur over and over again. Consider a stress fracture caused by poor shock absorption, selection of shoes too rigid, and low Vitamin D. Return to activity with flares of pain can occur over and over unless one, two, or three of these factors are reversed. The posterior tibial tendon, due to its complex functions, gives plenty of excitement in trying to find a few causes that can be reduced. Try to challenge yourself at finding 3 or 4 causes of an overuse injury besides just straight overuse, with one of them possibly being over-pronation. 

   

       Here is my office handout for patients with a working or initial diagnosis of posterior tibial strain syndrome. Of course, this is generic and may include patients with tendon tears or PTTD. It is written for the patient so that they can have some information on day one about possible upcoming treatments. 

   

  The top 10 treatments for tibial tendinitis/dysfunction/tear are:

  1. Understand the biomechanics of the posterior tibial tendon to support the medial longitudinal arch and begin to support the arch as part of all phases of the rehabilitation: immobilization, re-strengthening, and return to activity.
  2. Start with OTC and advance to custom orthotic devices with maximal support (this is not an injury to have less than optimal support).
  3. Learn several different taping techniques: posterior tibial and circumferential arch.
  4. Ice the area three times daily for 15 minutes each.
  5. If possible and warranted, get a baseline MRI (may be an important comparison six months later).
  6. Most ankle braces hold the ankle pronated, which is bad for this injury. Consider an Aircast Airlift PTTD Brace for times when you are not using orthotic devices, like walking barefoot around the house. 
  7. Create an initial pain-free environment with below-knee removable boot/cam walker, and perhaps a rollabout or crutches if you are limping.
  8. If the injury is substantial (Grade 3-4 typically), have a Richie AFO or Arizona Brace made right at the start of the injury (it can take a while to get fitted).
  9. Begin strengthening the posterior tibial tendon as quickly as possible with at least active range of motion exercises. The posterior tibial tendon is strengthened by pointing the ankle first and then moving the foot towards the other foot. 
  10. Begin PT for functional activities and strength as the symptoms get consistently 0-2.

   

       With any injury, the causes and treatments of pain are 3 fold: mechanical causes and treatments, inflammatory causes and treatments, and neuropathic causes and treatment. With the large branch of the sciatic nerve, called the posterior tibial nerve, right next to the tendon, nerve pain that rarely can be ignored is a commonplace component to treatment. I will conclude today with a list of common mechanical changes that are made in the treatment of posterior tibial tendon problems in my daily Podiatry practice. I look at all posterior tibial problems as precursors to PTTD years down the line, so very seriously.

    

  Common Mechanical Changes for Posterior Tibial Tendon Syndrome 

   

  1. Cam Walker with and without Crutches for the Immobilization Phase
  2. Inverted Orthotic Devices or other Highly Supported Orthotic Devices, including Medial Kirby Skives
  3. Varus Wedges
  4. Circumferential Taping to Stabilize Navicular Attachment
  5. Taping to Stabilize Medial Arch
  6. OTC Arch Supports to Stabilize the Medial Arch
  7. J Strap with Leukotape for Pronation Control
  8. Stromgren Ankle Brace with Lateral Velcro Strap Removed
  9. Aircast Airlift PTTD Brace
  10. Progressive Posterior Tibial Strengthening Program
  11.      2 Positional Single Leg Heel Raises
  12. Metatarsal Doming and Single Leg Balancing Exercises
  13. Stability Shoes or Shoes Not Allowing Excessive Pronation
  14. High Top Boots
  15. Activity Modification Principles to Decrease Tendon Stress for Healing
  16. Understand Motions of the Sport Involved to Develop Cause a Reversal Plan

   

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