When you walk or run, your foot hits the ground, you pronate to absorb impact and then you supinate to push off again. All of this is possible because of a muscle in your leg call the tibialis posterior. This muscle deep in the back of your leg forms a tendon call the posterior tibial tendon that attaches to your foot. It attaches to the navicular bone in the instep of your foot, right at the top of your arch.
In the very simplest of terms, this tendon helps to hold up the arch. It is really much more complex than that, but we won’t bore you with the details. All you really need to know about this is that when you get posterior tibial tendinitis it can quickly progress and become a surgical problem.
The good news for runners is that it one of the things that least frequently affect us. It most often affects people who are middle-aged. It also is often associated with high blood pressure, obesity and diabetes. Not exactly the picture of a runner. Interestingly though, one study showed women get it four times more often than men.
This is one thing to watch out for if you have fleet feet. It seems many who get this problem are already flat-footed long before it starts. Excess pronation (common in people with flat feet) puts tremendous stress on the tendon. Running increases the stress and strain several fold. The result is repetitive overuse that can set the condition off.
When too much stress is placed on this tendon, it can become inflamed. Continued inflammation can weaken the tendon and cause it to stretch out. This can lead to a torn or ruptured tendon with a complete collapse of the arch. Not good.
So how do I know if have posterior tibial tendonitis? One clue that you might be getting this problem is pain from the ankle bone to the arch on the inside of your leg. If it is inflamed and you stand up on your toes on that foot, it will likely hurt much worse. If you stand only on one leg and do this, it will be even more painful. You might even have some swelling around the ankle or arch.
If you notice these symptoms you need to get it checked out by an foot and ankle expert. This is not one of the ice-it-and-will-go-away kind of problems. Neglecting it can (and often does) lead to surgery. It is preventable as well as easily treatable in its early stages. Orthotics can limit the force of pronation and help to decrease the risk of injury to the tendon, especially if you over-pronate or have flat feet. And as always, make sure you are wearing the right type of running shoes for your foot type.
The day that Jessica came into the office she was worried. Not only was she worried, her mother was worried as well. Jessica is a 26-year-old healthy runner with a penchant for training and a high tolerance for pain.
She was in the middle of training for an upcoming marathon. Her mother had noticed her limping about and recommended that she go see somebody. She came in because she was worried about her Achilles’ tendon. She had heard that could be very serious.
I asked her about her training routine. She said that she typically ran 8 miles at a time on a very hilly course area. She felt that this was a good training strategy given that the upcoming marathon would contain a lot of hills. She wanted to make sure that she would be ready. But running up and down all of those hills was aggravating her condition.
She could remember exactly when her pain started. It’d been getting progressively worse. She pointed at the back of her ankle, but it wasn’t right at her Achilles’ tendon where she had the most pain. It was actually deeper in the back of the ankle.
I poked and prodded and couldn’t find any pain or tenderness anywhere around her Achilles’ tendon. However, if I squeeze the back of the ankle, away from the Achilles’ tendon, she had a great deal of pain and tenderness. Next, I put my thumb underneath her big toe. I had her try to push down with her big toe as hard as she could. And when she did, she had the same kind of pain in the back of the ankle.
We took some x-rays and noticed that she had a portion of bone that was not completely fused to the back of her talus bone. This is a condition known as os trigonum syndrome or posterior ankle impingement syndrome.
We got an MRI that reassured us that she had no issues with her Achilles’ tendon or the tendons to go to the big toe area. The flexor hallucis longus (FHL) tendon which pulls the big toe down against the ground when a runner pushes off can sometimes become torn or irritated and have the same type of presentation. But her FHL was fine.
However, not everything was fine. There was a great deal of swelling with in the talus bone (the bone that connects the foot to the ankle), as well as an accessory bone at the back of the talus called the os trigonum. These two pieces of bone in her ankle were connected with some soft tissue attachments which were very irritated.
Os trigonum syndrome is not a common injury. However one study showed that runners who to do a significant amount of downhill running have an 18% chance of acquiring posterior ankle impingement syndrome. And when it does occur, it can be debilitating.
Runners who develop this problem might have no pain at all when walking on level ground. It starts to become painful when they walk on uneven ground. It becomes much worse when they run on hills. This is because the foot needs to point further down (plantarflexion) and the soft tissues can become irritated or even get caught and pinched between the talus and the calcaneus (the heel bone). This causes a great deal of inflammation and pain.
Not only will there be pain, but many will also have swelling and stiffness in the back of the ankle that may extend all the way to the Achilles’ tendon. That is why many patients who think they have Achilles tendinitis might actually have this problem instead.
Although this is not the most common running injury we see, it is important to get it treated. Chronic inflammation can lead to pain that interferes with activities ranging from normal walking to running. Anytime you suspect an Achilles tendon injury, it is important to be evaluated.
Even though Jessica did not have an Achilles’ tendon injury she did have an injury which could be treated effectively. In most cases, immobilization and physical therapy can calm it down. In rare cases, surgery is needed to take out the accessory bone and inflamed tissue. In any event, with this type of problem it is never a good idea to stick your head in the sand and foolishly hope you’ll cross the finish line in record time.
