Physical Therapy in Lowell for Foot

Due to the fact that we use our feet continuously, tendonitis in the foot is a common problem. One of the most frequently affected tendons is the posterior tibial tendon.

This guide will help you understand:

• How posterior tendonitis develops
• How the condition causes problems
• How health care professionals diagnose the problem
• What can be done to treat it
• What Therafit Physical Therapy’s approach to rehabilitation is

Where is the posterior tibial tendon, and what does it do?

The posterior tibial tendon runs behind the inside bump on the ankle (the medial malleolus), across the instep, and into the bottom of the foot. The tendon is important in supporting the arch of the foot and helps turn the foot inward during walking.
Tendons are made up of strands of a material called collagen. Think of a tendon as similar to a nylon rope and the strands of collagen as the nylon strands. As we age, or repetitively use the tendon, some of the individual strands of the tendon can degenerate, lose normal arrangement due to the degeneration, or break, and the tendon loses strength. 

 

 
Related Document: Therafit Physical Therapy's Guide to Foot Anatomy

How do posterior tibial tendon problems of the foot develop?

Multiple factors can contribute to posterior tibial tendon problems. Patients with flat feet are at a higher risk of having a posterior tibial tendon problem because of the persistent stretch on the tendon. Having flat feet can contribute to posterior tibial tendon problems, but conversely, posterior tibial tendon problems can lead to the medial arch of the foot dropping causing a flat foot.

Injury to the nerves of the foot, bones of the foot, or having laxity (looseness) of the ligaments on the medial side of the foot can all result in deformity of the foot and/or ankle resulting in the posterior tibial tendon being more stressed.  The posterior tibial tendon can even be directly affected by systemic diseases such as diabetes, rheumatoid arthritis, and high blood pressure, or from the prolonged use of steroids. These diseases cause either increased laxity in the ligaments of the foot, which affects the foot biomechanics, or they directly affect the blood supply to the posterior tibial muscle and tendon, and contribute to the problem in that regard.  Obesity is another factor that can cause problems with the posterior tibial tendon.  The excess weight causes pressure on the foot and particularly on the posterior tibial tendon as it struggles to support the medial arch under the extra weight. Poor alignment of the lower extremities in any patient can also lead to pain in the posterior tibial tendon as the alignment forces undue stress down the medial side of the foot.

Problems with the posterior tibial tendon seem to occur in stages. Initially, irritation of the outer covering of the tendon, called the paratenon, causes paratendonitis. This means that there is inflammation between the lining of the tendon and the tendon itself where it runs through the tunnel behind the medial malleolus. This tendonitis can start a process of wear and tear on the tendon fibers.

As the tendon heals itself from wear and tear, scar tissue forms, thickening the tendon. This process can continue to the extent that a nodule, or knot, forms within the tendon. Once the painful tendon has changed in structure, the term tendonosis, rather than tendonitis, is used.  Unlike with tendonitis, recent evidence shows that inflammation is not present with tendonosis. The area of structural change in the tendon is weaker than normal tendon. The weakened tendon sets the stage for the possibility of rupture of the tendon.

What does tendonitis of the foot feel like?

The symptoms of tendonitis of the posterior tibial tendon include pain in the instep area of the foot and swelling along the course of the tendon. In some cases the tendon may rupture due to the degeneration of the tendon. Rupture of the tendon leads to a fairly pronounced flat foot deformity that is easily recognizable. In addition, a patient with a ruptured tendon is unable to rise up very high onto their toes, which also leads to the suspicion of a ruptured tendon.

How do health care professionals identify posterior tibial tendonitis?

The history and physical examination are probably the most important tools that health care professionals, including your Physical Therapist at Therafit Physical Therapy, will use to diagnose this problem. Your therapist will want to know exactly where your pain is, when it started, and what activities ease or aggravate your symptoms.

Next your Physical Therapist will physically examine your foot and entire lower extremity. They will palpate, or touch, around your area of discomfort to determine the exact location of pain. The alignment of your hips, knees, ankles and feet will be observed in both standing and sitting. You may be asked to twist your body with your feet planted on the ground, squat, or walk without shoes so your therapist can observe your feet and arches as you move.

Next your Physical Therapist will assess the position and mobility of the bones of your feet to determine if there is any subluxation, laxity, or even stiffness in any part of the ankle or foot, which may be contributing to your problem.

The strength in the muscles of the foot and lower leg will also be assessed.  In addition, your Physical Therapist will assess the strength in the muscles of your hip, as these muscles also play a part in controlling the alignment of your lower leg as well as lifting the arch of your foot. The biomechanical link between the hip and foot can be felt if you stand relaxed and squeeze both buttocks muscles together. As you do this you will feel the arches of your feet slightly lift. It is for this reason that control around the foot cannot only be left to the joints and muscles directly connected to or in the foot. The strong hip muscles will also need assessing and addressing if they are shown to be weak or inadequately functioning.

Muscle testing helps identify any areas of weakness or muscle impairment and imbalance. This will be done in both the weight bearing and non-weight bearing positions.  As briefly mentioned above, an important test that can help identify insufficiency of the posterior tibial tendon is the single heel raise. You therapist will ask you to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the heel bone (calcaneus) centered and slightly turned inward (inverted) and your knees straight.  If you cannot, your posterior tibialis muscle and tendon may be ruptured.

Posterior tibial tendon problems are usually apparent on physical examination. In some difficult cases, however, a magnetic resonance imaging (MRI) scan may be necessary to confirm whether the tendon has ruptured. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. The MRI creates images that look like slices and shows the tendons and ligaments very clearly. This test does not require any needles or special dye and is painless.

Therafit Physical Therapy provides services for Physical Therapy in Lowell.

What can be done for the condition?


It may be suggested that you take anti-inflammatory medications, such as ibuprofen or aspirin if you are in the stage of injury where inflammation is a culprit.


Rehabilitation

Physical therapy can be extremely beneficial in treating posterior tibial problems.

During your first few treatments at Therafit Physical Therapy your Physical Therapist will focus on relieving your pain. They may use ice, heat, ultrasound, or other electrical modalities on the instep of your foot or up the medial shin to provide you with relief. Icing or heating these areas at home will provide similar relief. Your therapist may also massage the bottom of your foot, calf, and muscles around your shin. Massage can be particularly useful in relieving your discomfort. Unfortunately these types of treatments only provide temporary relief; addressing the real problem of why the posterior tibial tendon is being stressed will provide more long-term relief to your injury and help to avoid an irritated tendon from developing into a chronic problem, or from rupturing.

Physical Therapy exercises will begin with strengthening exercises for the small muscles of your foot and posterior tibialis muscle. As mentioned above, these muscles work to lift and support the arch of the foot, along with the muscles of the hip, which control alignment down the lower leg chain, and also assist in lifting the arch of the foot. A Theraband may be used to provide added resistance to the muscles of the foot, and to strengthen the hip muscles. Your therapist will also prescribe stretching exercises, particularly for the muscles of your calf, which, when tight, can force the foot out of alignment. When performing all stretches it is imperative that you maintain proper alignment of your foot and arch so as not to compound the forces going through an already irritated posterior tibial tendon.  Your Physical Therapist will give you feedback on whether or not your alignment during your exercises is sufficient.

Being that posterior tibial tendon problems tend to develop over time, it is common for patients to not even notice that their feet may be flat or their alignment is off. The position of your feet becomes the ‘new normal.’ Re-learning the proper position of your arch is crucial to relieving the pain in your posterior tibial tendon as well as stopping the progression of the tendon problem and preventing a resultant deformity developing in the foot. Proprioception is the term used to describe one’s sense of joint position.  Your Physical Therapist will teach you what the correct position of your foot and arch should be and will give you exercises that challenge the proprioception of your knee, foot, ankle, and arch. Initially these exercises may be while you are simply sitting but as you progress, your Physical Therapist will advance your exercises so you are doing them in standing, and eventually just on one foot at a time. The standing position is an important position to work up to as it is much more functional in mimicking normal everyday activities such as walking or stair climbing. Eventually your Physical Therapist will prescribe exercises that are extremely challenging, especially if you are involved in a high-level sport.  Exercises such as squatting and jumping will be added and you will be required to do these activities while maintaining proper foot, arch and leg alignment.

If you have not already invested in some orthotics to assist with supporting your arch and taking some pressure off of your posterior tibial tendon your Physical Therapist will advise you on whether you should purchase some, and where to do this. Often taping the bottom of the foot, which your Physical Therapist can do, and can teach you to do on your own, can be trialed before expensive orthotics are purchased. Taping may be enough in mild cases of posterior tibial tendon pain, as long as you can learn to control the position of your foot and maintain this position during high-level activities. In most cases shoe inserts, even pre-fabricated ones, will significantly improve the symptoms of a posterior tibial tendon problem, and will be recommended to both relief symptoms and to avoid any progression of the injury. Custom fit orthotics are recommended for any individuals who have a significant flattened arch, or for whom prefabricated ones do not relieve their symptoms.

As mentioned above, excess weight can be the cause of posterior tibial tendon problems. Losing excess weight can greatly improve the pain you feel in your foot and make it easier to maintain normal foot alignment during everyday activities. Your Physical Therapist at Therafit Physical Therapy can discuss weight loss strategies with you and if need be, refer you to a Nutritionist who can also assist with this goal. Often it is difficult to exercise and increase your energy expenditure to lose weight when you have a painful foot, however, there are several safe activity options that your therapist can discuss with you, such as stationary cycling or swimming.

Activity modification is an important part of our treatment for posterior tibial problems at Therafit Physical Therapy. Your Physical Therapist will strongly advise you to avoid any activities that cause you discomfort while you still have symptoms. This may also mean resting for a short period from any sport you do, or at least decreasing your amount of activity over a period of time. Your Physical Therapist will specifically guide you regarding the needed rest for your individual injury. This rest may seem quite difficult to achieve, however it is well known that without a relative rest for a painful foot, there is little chance for it to heal.  A period of rest where the foot is not being aggravated also greatly improves the ability of any medication you may be taking, along with the Physical Therapy treatment you are receiving, to assist the healing of the injury. Your Physical Therapist will advise you when it is safe to slowly start back at your activity after your period of rest.

For the majority of patients, physical therapy can be very effective at addressing and treating posterior tibial tendon issues.

Discover how we can help you. Contact us at 978-452-9252 today to learn more.