Physical Therapy for Posterior Tibial Tendonitis

 Physical Therapy for Posterior Tibial Tendonitis

Physical therapy for posterior tibial tendonitis (PTT) can help you regain normal foot and ankle range of motion (ROM), strength, and mobility. This can help eliminate your foot and ankle pain and get you back to your normal work and recreational activities.

Posterior tibial tendonitis is a condition that affects your foot and the inner part of your ankle. The condition is marked by pain in your foot and ankle, and it may prevent you from walking and running properly. The symptoms can also limit your normal day-to-day activities.

Sometimes, PTT is called posterior tibial tendon dysfunction or posterior tibial tendonopathy. Regardless of the name of the condition, your physical therapist can help you regain normal pain-free mobility if you have it.
The Posterior Tibial Tendon

The posterior tibial tendon is a tendon that arises from a muscle called the tibialis posterior. This muscle resides in the inner aspect of your lower leg, just beneath your calf muscle. The tendon courses down your leg and into the inside part of your foot.1 It attaches to the bottom of your foot.

The function of the posterior tibial tendon is two-fold. The muscle acts to move your foot inward, especially when your foot and toes are pointed down. The tendon also helps to support your foot's medial arch.
Symptoms of Posterior Tibial Tendonitis

If you have posterior tibial tendonitis, you will likely experience different symptoms. These may include:1

Pain in the inner aspect of your ankle
Pain in the arch of your foot
Difficulty with walking or running
A flat foot or fallen arch

Usually, symptoms come on gradually for no apparent reason and without a specific injury or insult. For this reason, PTT dysfunction is usually thought of as a repetitive strain injury; the pain comes on due to overloading and over-stressing the posterior tibial tendon.1 The challenge with diagnosing and treating the condition is to determine the mechanical causes of this overload and to correct them. Your physical therapist is the perfect healthcare professional to do this.
Could It Be Something Else?

Sometimes, the pain you are feeling in your ankle may not be coming from your posterior tibial tendon, but rather from another nearby structure. Other possibilities that may be causing your medial ankle pain may include:

Tendonitis of the toe flexor muscles
Medial Achilles' tendinopathy
Ankle deltoid ligament sprain
Ankle stress fracture

Since so many different things can cause medial ankle pain, it is a good idea to see your healthcare professional to get an accurate diagnosis.
Diagnosis of Posterior Tibial Tendonitis

The diagnosis of PTT dysfunction is made largely by clinical examination.1 Your doctor or PT will look for specific signs. These may include:

Painful palpation of the inside aspect of your ankle, along the posterior tibial tendon
Pain when pointing your foot and toes or moving your foot inwards, especially when pushing against resistance
The presence of a flat foot or fallen arch
An altered gait and walking pattern

Your doctor may consider viewing diagnostic studies like an X-ray or an MRI to confirm the diagnosis and rule out any other condition.1 These studies are not essential or necessary when you are first diagnosed. They simply confirm the clinical diagnosis. Most people benefit from starting a course of physical therapy prior to obtaining any diagnostic studies.

There are four stages to PTT dysfunction, each with their own features.2 Stage I is simply irritation of the PTT with no obvious foot deformity. In stage II, the PTT is ruptured or elongated, and the foot is flattened but remains flexible. Stage III occurs when your PTT is damaged or ruptured and your foot is rigid, essentially stuck in its flattened position. The most severe presentation of PTT dysfunction is stage IV, where your PTT is ruptured and your ankle ligaments are overstretched to the point where there is a longstanding flat-foot deformity.
Physical Therapy Evaluation Components

When you first attend physical therapy, you will be evaluated. During this evaluation, your PT will collect information about your condition. He or she will also perform certain tests which may include:

Palpation (physical examination by touching anatomical structures)
Range of motion measurements
Strength measurements of your ankle, knee, and hip muscles
Gait analysis
Foot position analysis and footwear inspection
Balance and proprioception testing

Once all of these tests have been done, your PT should be able to determine the likely mechanical cause of your PTT dysfunction, and then treatment can begin. Be sure to ask your PT questions about your condition if you have any. The relationship you have with your therapist should feel like a therapeutic alliance; both of you should work together to properly manage your posterior tibial tendon dysfunction.
Physical Therapy Treatment for Posterior Tibial Tendonitis

Treatment for PTT may involve many different components, and these may vary based on your specific condition and needs. You can expect some common treatments from your physical therapist for posterior tibial tendonitis.

Exercise should be your main tool to treat your PTT dysfunction. Why? Because research shows that performing the right exercises—at the right time—can help you take control of your symptoms and learn to keep them away.

Your physical therapist should prescribe exercises specific to your condition and needs. He or she may have you exercise in the clinic, and you will likely be prescribed a home exercise program to perform independently. Exercises for posterior tibial tendon dysfunction may include:

Ankle stretches: Your PT may have you perform various exercises to improve your ankle ROM.1 This can help restore normal mobility to your foot and help decrease pressure on your tibial tendon.
Ankle strengthening exercises: Ankle strengthening exercises may be used to help improve the strength of various muscles that support your foot and ankle.1 That can create muscular balance in your foot, ensuring that your posterior tibial tendon is not overstressed.
Hip and knee strengthening exercises: Sometimes, weakness in your hip or knee muscles can cause your foot to turn in, placing stress on your posterior tibial tendon. Your PT may have you perform strengthening for your hips and knees to help keep those joints (and your foot and ankle) in proper alignment. This may relieve stress on your posterior tibial tendon.
Balance and proprioception exercises: Improving balance and body positional awareness can help improve the way your foot and ankle work. This may relieve stress off your tibial tendon.
Gait training: If you are having a difficult time walking or running due to PTT dysfunction, your PT may prescribe specific exercises to improve your gait.
Plyometric exercises (during the latter stages of your rehab): Once things have healed, your PT may have you start jumping and landing to improve the load tolerance of your posterior tibial tendon. Plyometric training is especially important if you are planning to return to high-level athletics.

Some exercises may be painful to do and others may be easy. If you have any questions about your rehab exercises, be sure to ask your physical therapist.

While exercises should be the main component of your PT rehab progress for PTT dysfunction, you may encounter other treatments during therapy. Other treatments and modalities for posterior tibial tendonitis may include:

Shoe insert or orthotic recommendation: An orthotic or insert can help keep your foot in optimal alignment, relieving stress and strain off your posterior tibial tendon.1
Ultrasound: Ultrasound is a deep heating modality that is thought to improve local circulation and blood flow to your tendons.
Electrical stimulation: This treatment may be used to improve local blood flow or to decrease pain that you are feeling.
Kinesiology taping: This newer treatment involves placing tape on your body on or near your foot and ankle. The tape can be used to improve muscular contractions or to inhibit muscles from contracting improperly. It may also be used to help decrease pain.
Bracing: If your foot and ankle are turned significantly, you may benefit from using an ankle brace to maintain optimal lower extremity alignment.
Iontophoresis: This form of electrical stimulation is used to administer anti-inflammatory medication to your tendon through your skin.
Massage: Your PT may use various massage techniques to help decrease pain, improve blood flow, and promote improved flexibility of muscles and tissues around your foot and ankle.

Remember, many of these treatments are passive in nature; you do nothing while the therapist performs the treatment for you. Research indicates that taking an active role in your care for PTT dysfunction is the best course of action to take. Passive treatments may feel good, but their overall effect is often deemed negligible.

Also, some treatments for PTT dysfunction like electric stimulation, kinesiology taping, and ultrasound are not supported by rigorous scientific study. These treatments may not hurt you, but research shows that they may not be a helpful component of your rehab. If your PT suggests a certain treatment for your condition, be sure to understand the goal of the treatment and if it is a necessary part of your rehab program.
First Steps to Treating Posterior Tibial Dysfunction

If you suspect you have posterior tibial tendonitis or dysfunction, there are a few things you should do right away. First, contact your doctor, just to be sure the pain isn't something more serious. You can also call your PT right away; most states in the US allow you to see a therapist without a doctor's prescription via direct access. The quicker you can get started on treatment, the quicker the pain can be abolished.

When managing PTT dysfunction, it's a good idea to avoid aggravating activities.1 If you are a runner, perhaps avoiding running for a while is a good idea. Cross training on the bicycle or in the swimming pool can help you maintain your current fitness level.
How Long Does PTT Dysfunction Last?

Most episodes of posterior tibial tendonitis last about 4 to 6 weeks. Pain may last longer than 3 months even with early treatment.1 The first few weeks are hallmarked by sharp pain, and the pain gradually subsides over the course of a month or so. Some episodes are shorter, and some are longer. Everyone heals at different rates, and everyone's condition is different, so be sure to talk to your PT about your specific prognosis with posterior tibial tendonitis.

If your symptoms persist after 8 weeks, you may need to consider other options for treatment. These may include cortisone injections to manage the inflammatory process in the tendon or a surgical procedure where the tendon is moved to a different position in your foot, taking stress off the tendon while supporting your foot's arch.1

If you do have surgery for posterior tibial tendon dysfunction, you may benefit from PT after the procedure to help you fully recover.
A Word From Verywell

If you have posterior tibial tendon dysfunction or tendonitis, it is a good idea to get started on treatment right away. Don't let little problems become chronic conditions that may be difficult to treat. Most cases are easily handled by the skilled services of a physical therapist. By doing the right things for your condition, you can quickly and safely get back on your feet and back to your normal activities.

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