Posterior tibial tendonitis causes pain on the inside of the ankle. Generally, treatment consists of exercises, orthotics, and injections. So, how long does posterior tibial tendon pain or dysfunction take to heal, and do injections help?
Where is the posterior tibial tendon, and what does it do?
The posterior tibial tendon attaches the back muscles of the calf to the foot. It forms above the ankle and passes behind the bone inside the ankle. It connects directly to the inside of the foot, close to the medial arch.
The posterior tibial tendon supports the medial arch and the inside of the foot. Other structures that also support the arch include the spring and deltoid ligaments.
Posterior tibial tendonitis symptoms
The inside of my ankle hurts
Usually, posterior tibial tendon pain occurs at the inside ankle bone (medial malleolus) level. This area is prone to tendonitis because of tendon compression and poor blood supply.
Generally, people with tendonitis have pain on the inside of the ankle and weakness in the foot. As the tendonitis gets worse, the arch flattens, causing more pain. If this process is not stopped, the ligaments inside the ankle (such as the spring ligament) stretch and the joints become malaligned—eventually, ankle arthritis forms. We often term this malalignment posterior tibial tendon dysfunction.
Usually, there is swelling and tenderness on the inside of the ankle. Also, turning the ankle inwards is weak, and standing on the toes is difficult.
Posterior tibial tendon radiology
We often use ultrasound or MRI to detect tendon changes such as swelling and collagen disorganisation. In more severe cases, we may see posterior tibial tendon tears, which are generally more painful.
MRI can also see damage to other structures in the inner ankle, such as a spring or deltoid ligament tear.
Navicular stress fracture or posterior tibial tendonitis
Sometimes, it can be challenging to distinguish these two problems. In general, navicular stress fractures cause pain and tenderness at the front of the ankle. Nevertheless, there is a significant overlap in the presentation of both conditions. Therefore, you should consider a navicular stress fracture in any active person with mid-foot pain.
Other causes of pain in the inner part of the ankle that need to be excluded include tarsal coalition, accessory navicular syndrome or subtalar joint arthritis.
Treatment of posterior tibial tendon dysfunction
Generally, most cases of posterior tibial tendon pain can be managed with simple treatments such as:
- Activity modification, including rest from sport
- Anti-inflammatory tablets such as ibuprofen
- Physiotherapy to strengthen the posterior tibial tendon and the foot’s small muscles. Posterior tibial tendonitis exercises generally enhance the calf muscles and medial ankle flexors. Exercises include calf raises and theraband exercises to strengthen the muscles that move the ankle inwards. An example of a specific exercise is using a tennis ball between the legs while performing a double-legged heel raise.
- Orthotics support the arch and allow the tendon to heal.
- In severe inflammatory cases, a removable walking boot is helpful
Shoes for posterior tibial tendonitis
Generally, we suggest stability shoes for posterior tibial tendonitis. These shoes support the medial arch, reducing the load on the tendon and allowing it to heal.
Nitroglycerine patches for posterior tibial tendon pain
Nitroglycerine patches contain a substance called nitric oxide. Recent evidence suggests that nitric oxide patches improve pain in tendinopathy. Generally, we recommend patches for 2-3 months combined with exercise therapy.
You must be aware of potential side effects, such as headaches and skin rash. The way you use the patches is critical to their success.
Cortisone shot for posterior tibial tendonitis.
Sometimes, we use injections to help with ankle pain and weakness.
Traditionally, cortisone injections provide pain relief and reduce swelling. This pain-free effect means that people can work harder with exercise. However, we should be careful with a cortisone shot for posterior tibial tendonitis because it can cause tendon tearing and worsening weakness.
Some doctors have recently used a high-volume stripping with sterile water, hyaluronic acid or PRP injections for posterior tibial tendonitis, especially if the tendon shows a split or tear on ultrasound or MRI.
Generally, any injection into a tendon needs ultrasound-guidance to improve the injection effect.
What about posterior tibial tendon surgery?
Posterior tibial tendon surgery should only be considered if simple treatments have already been tried.
Most surgeons consider a combination of tendon clean-up, repair of a tendon tear, or reconstruction using another ankle tendon. Some surgeons perform these procedures through keyhole surgery.
In cases involving flat foot deformity, realigning the heel bone will help maintain the tendon surgery. Finally, ankle fusion is the only option in severe cases associated with a tendon tear and a flat foot.
Other Frequently Asked Questions about Posterior Tibial Tendonitis
How common are isolated acute ruptures of the posterior tibial tendon?
These injuries are rare but can occur in athletes younger than 30. Generally, a posterior tibial tendon repair is required.
Can posterior tibial tendons dislocate?
Yes, but they are much less common than peroneal tendon dislocations. The mechanism of injury is usually when the ankle is forced upwards and inwards. Sports involved in this injury include rock climbing, motorcycling, dance and martial arts.
The athlete often reports instability, swelling and intermittent snapping or popping when the acute swelling settles. Surgical treatment is almost always required.
Final word from Sportdoctorlondon
Generally, if this condition is diagnosed early, it responds well to simple treatments such as posterior tibial tendonitis exercises and orthotics. Occasionally, a cortisone injection to help rehab is reasonable if there is no tendon tear. Otherwise, we consider hyaluronic acid or PRP injections for posterior tibial tendonitis, especially if there is a partial tear.
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