■ ■ ■ Description

Posterior tibial tendon tendinitis is characterized by inflammation and pain at the posterior tibial tendon (back of the inner ankle). This structure is the tendon attachment of the muscles of the leg to the inner foot and is important in standing on your toes, in the pushing-off phase of running or jumping, and in turning your foot inward. This is usually a grade 1 or 2 strain of the tendon. A grade 1 strain is a mild strain. There is a slight pull without obvious tearing (it is microscopic tendon tearing). There is no loss of strength, and the tendon is the correct length. A grade 2 strain is a moderate strain. There is tearing of fibers within the substance of the tendon or where the tendon meets the bone or muscle. The length of the muscle-tendon-bone unit is increased, and there is usually decreased strength. A grade 3 strain is a complete rupture of the tendon.

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■ ■ ■ Common Signs and Symptoms

• Pain, tenderness, swelling, warmth, or redness over the back of the inner ankle at the posterior tibial tendon or the inner part of the mid-foot

• Pain with ankle motion (especially when pushing off or pushing down with the front of the foot) or when standing on the ball of the foot

• Crepitation (a crackling sound) when the tendon is moved or touched

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■ ■ ■ Causes

• Usually a degenerative process (occurs with aging) or from overuse of the lower leg muscles

• Strain from sudden increase in amount or intensity of activity, from a direct injury, or from injury to the lower leg, foot or ankle

• A return to activity following a previous injury with incomplete rehabilitation

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■ ■ ■ Risk Increases With

• Sports that require sudden repetitive pushing off of the foot (jumping and quick starts) or kicking and running sports, especially running down hills and long distances

• Poor physical conditioning (strength and flexibility)

• Flat feet

• Previous injury to the foot, ankle, or leg

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■ ■ ■ Preventive Measures

• Appropriately warm up and stretch before practice or competition.

• Allow time for adequate rest and recovery between practices and competition.

• Maintain appropriate conditioning:

  • Ankle and leg flexibility

  • Muscle strength and endurance

• Use proper technique.

• Complete rehabilitation from a previous injury.

• Wear arch supports.

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■ ■ ■ Expected Outcome

• This condition is usually curable within 6 weeks if treated appropriately with conservative treatment and resting of

  the affected area.

• Recovery is usually quicker if the inflammation is due to a direct blow, as compared with overuse or sudden strain.

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■ ■ ■ Possible Complications

• Prolonged healing time if not appropriately treated or if not given adequate time to heal

• Recurrence of symptoms if activity is resumed too soon, with overuse, or when using poor technique

• Untreated, partial or complete tendon rupture requiring surgery

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■ ■ ■ General Treatment Considerations

Initial treatment consists of medication and ice to relieve the pain, stretching and strengthening exercises, and modification of the activity that initially caused the. These all can be carried out at home, although referral to a physical therapist or athletic trainer for further evaluation and treatment may be helpful. A cast or walking boot may be recommended to immobilize the tendon and allow the inflammation to settle down. For less severe cases or before returning to activity, those with flat feet are usually prescribed an arch support (orthotic) to reduce stress to the tendon. Others may require more extensive supports or braces. Surgery to remove the inflamed tendon lining or degenerated tendon tissue is occa- sionally necessary.

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■ ■ ■ Medication

• Nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen (do not take within 7 days before surgery), or other minor pain relievers, such as acetaminophen, are often recommended. Take these as directed by your physician. Contact your physician immediately if any bleeding, stomach upset, or signs of an allergic reaction occur.

• Pain relievers may be prescribed as necessary by your physician. Use only as directed.

• Cortisone injections are rarely, if ever, indicated. Corti- sone injections may weaken tendons, so it is better to give the condition more time to heal than to use them.

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■ ■ ■ Heat and Cold

• Cold is used to relieve pain and reduce inflammation for acute and chronic cases. Cold should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates your symptoms. Use ice packs or an ice massage.

• Heat may be used before performing stretching and strengthening activities prescribed by your physician, physical therapist, or athletic trainer. Use a heat pack or a warm soak.

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■ ■ ■ Notify Our Office If

• Symptoms get worse or do not improve in 2 to 4 weeks despite treatment

• New, unexplained symptoms develop (drugs used in treatment may produce side effects)