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Monday, September 5, 2011

Plantar Fasciitis or Tibialis Posterior Tendonitis?!?

Ok, here's my dilemma.   I've been seeing more people who have what is called "Tibialis Posterior Tendonitis".  This can often present as plantar fasciitis but it does have clear cut tell tail signs and symptoms that distinguish it from plantar fasciitis.  The mechanism of injury or the cause of tibialis posterior tendonitis differ only somewhat from those of plantar fasciitis.  

Before I go on, I've got to get on my soap box and tell you what's bothering me.  In my past and recent experience, doctors are apparently having a hard time properly diagnosing the difference between tibialis posterior tendonitis and plantar fasciitis.  That being said, I'd really like to empower you to be your own diagnostician!  So, here we go!

In my experience, if people have a problem with their feet, they go to a podiatrist.  You could also go to an orthopedic doctor who specializes in the foot and ankle.  Here's the difference.
An orthopedic doctor can treat dysfunction coming from the foot, ankle, knee or anywhere above the foot.  An orthopedic doctor, if thorough, will check the joints and muscles above the ankle and will take into consideration that the problem in the foot or ankle could be coming from somewhere upstream (often times the hip is the source). 
A podiatrist looks at the foot from the ankle down.  Most often and especially in an athlete, a foot problem stems from a biomechanical or physiological dysfunction upstream; you know, like the knee or hip or even your back.  Podiatrists are often able to address the symptoms in your ankle and foot but very often they are unable to resolve the cause of the foot or ankle injury because the source of the foot and ankle dysfunction is coming from above the ankle or knee.    
The point I'm trying to make is that if you have pain in the arch of your foot and/or pain in your heel, especially for the first few steps in the morning when getting out of bed, this is not an automatic diagnosis of plantar fasciitis!  If you feel that something just isn't adding up with what you are feeling and what the doctor has diagnosed you with, I encourage you to heed that little voice that's speaking to you from your body!  Some simple problem solving can go a long way with finding the origin of your foot and ankle pain and curing your pain in the foot!  Unless the podiatrist or orthopedic doctor isn't able to discern the signs and symptoms between tibialis posterior tendonitis and plantar fasciitis along with it's origins or mechanism of injury, you may be a long time in getting rid of your pain in the foot.  This could quite possibly be at a high cost physically and monetarily!

Image 1
Notice that the Tib Posterior Tendon and the origin of the Plantar Fascia overlap

Image 2
Pain can be present along the path of the Tib Posterior muscle up to the
back of the knee.  Palpation is one way to distinguish between plantar fasciitis
& tibialis posterior tendonitis.

Before I give you a tell tale sign of tibialis posterior tendonitis, I need to review some anatomy with you.  Image 1 shows the area that is occupied by the tibialis posterior tendon on the plantar surface of the foot.  Its job is to point the foot or plantar flex the foot and invert the foot or turn it in.

Then, notice the origin of the muscle in Image 2.  It's high up in the leg and originates just below the knee.  Now, here's the important part.  Looking at Image 1, the area inside the circle is occupied by the origin of the plantar fascia on the calcaneus and the insertion of the tibialis posterior tendon that crosses over the origin of the plantar fascia and terminates deeper in the foot but running nearly parallel with the plantar fascia for a short distance.  This distance extends somewhat into the area that is the "arch of the foot".  This is the same area that the plantar fascia spans.

So, if you're trying to diagnose whether the pain in the heel and arch of your foot is plantar fasciitis or tibialis posterior tendonitis, then your going to have a hard time doing this by just palpating the arch of the foot. 

So here's how you tell what's what:  
On the inside of the ankle feel or palpate the underside and back side of the medial malleolus or ankle bone.  If your tibialis posterior tendonitis is severe or acute, then a sore or bruised sensation upon palpation will be felt.  If symptoms are not too bad at this spot, then go higher up in the leg.  Now, palpate the medial side of your calf muscle where the tendon starts to go into the muscle belly as indicated in Image 2.  If in fact you do have tibialis posterior tendonitis then this area will be quite sore.  If you keep palpating upwards toward the back of your knee on the inside of your leg/calf, the soreness may become even worse.  These symptoms are most likely those of tibialis posterior tendonitis.  Plantar fasciitis usually doesn't present with pain up into the calf muscle.  Plantar fasciitis will present with pain on the back of the heel vs. the inside of the heel and up the medial calf muscle.  
When palpating the arch of the foot near the insertion of the tibialis posterior tendon, usually only the insertion site is sore vs. the entire arch of the foot or the metatarsal heads as would be typical with plantar fasciitis.

So, now you know!  You are now empowered to be your own diagnostician!  

I'll go into much more detail about the mechanics of the foot and causes of both pathologies in a separate post.  The Plantar Fasciitis Cure goes into detail regarding the causes of plantar fasciitis and tibialis posterior tendonitis.  The treatment for tibialis posterior is similar to the treatment of plantar fasciitis.  

Something that will help resolve tibialis posterior tendonitis is wait for it...wear minimalist shoes but part time to start with.  If your new to this blog and the minimalist shoe, these would be the Vibram Five Finger Shoe, New Balance Minimus, Nike, Merrill, and many other brands now have nice minimalist shoe.  

If these are too aggressive initially, then try the latest version of the Nike Free or the Zoot racing flats.  These shoes are great for restoring the use of the tibialis posterior muscle and strength to this muscle.  But to really and permanently get rid of tibialis posterior tendonitis and plantar fasciitis, my simply written, The Plantar Fasciitis Cure will give you the resources, insight, and advice for you to take control over your feet without having to fear the recurrence of this nagging and style cramping injury.

Well, until next time...Happy Bipeding!!

Brad Senska, PT, DPT, BS, ASTYM.