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Endurance Athlete Consulting covers a broad range of topics regarding human performance in sport, sport related injuries, and rehabilitation. If there is something specific you would like to inquire about, please feel free to email me at: bradsenska@yahoo.com.

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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 to...now 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.




9 comments:

  1. the five fingers are what caused my PTT. As much as I hate to admit it because they are and have been great for my pelvic tilt which caused a limp for most of my life because of a short leg. Any running or long walks will have to be done with more support for me.

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    1. I'm sorry to hear that! You could possibly alternate with your Five Finger shoes and more supportive shoes until your tibialis posterior tendon adapts to the new length tension and force that goes through it. I'm currently working with a lady whose left tibialis posterior tendon has been stretched beyond the point at which it originally was. Unfortunately, her tib posterior tendon will remain this length now. But as she consistently works at balancing out the muscles in her legs, she's nearly completely resolved her symptoms and is back doing all of her usual recreational activities. Good Luck. Send me an email if you have any other concerns or questions.

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  2. Do the Skecher GoRuns cause PTT too? They seemed to quell some serious heel pain that felt like the calcaneous bone was going to crack at about mile 1-2 but now the tendon seems inflamed.

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    1. Hi Charles,

      The Skecher GoRuns do have a strong potential to causing tib posterior tendonitis. This is because of the contour of the sole of the shoe. The shoe limits the amount of active plantar flexion and muscle recruitment during the toe off phase of the running cycle because of the rocker type sole on the shoe. The shoe assists you too much with advancing from heel or mid foot strike to the toe off phase when running. Add this to high repetition, then you would be assisting in the onset of disuse and the eventual onset of tib posterior muscle weakness and tendonitis. If you've read a couple of the blogs regarding TPT, you'll know that the tib post tendon attaches very near to the bottom and medial aspect of the calcaneus. So this would make sense that the initial area that became symptomatic would be felt on the bottom and medial aspect of your foot. So what you've stated in the progression of your symptoms make sense. I hope this helps!

      Of one other mention, you may want to look at the details of the class action lawsuit against Skechers that occurred last year from similar injuries to the one you're describing.

      Sincerely,

      Brad Senska, PT, DPT, BS, ASTYM.
      bsenska@gmail.com

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  3. There has been pain in that foot for over a year now. It began after trail running in Nike Vomeros, feeling like a strain due to running on the uneven surface. It slowly built up, even after running in the original Nike Free's, which felt really natural. When those were discontinued I went back to the Vomeros but they felt so clunky so I searched for a new minimalist shoe. I tried the PureFlows, which weren't bad and seemed to help that mysterious calcaneal pain described above. One short run in the old Nike Frees made the bone hurt again. I tried the GoRuns and the heel bone pain was better but then the tendon acted up. I have had TPT in the past with the Vomeros but it resolved. Not sure what to run in now.

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    1. Hi Charles,

      Without seeing your foot or your running mechanics and some other things that would let me be more objective about advising on the right shoe for you, I'm unable to tell you exactly which shoe would work the best. I can say that when you're running in the Nike Free's, pay attention to your foot strike. Notice if you're landing hard on your heel or landing on the outside of your mid foot. This will make a big difference with the heel pain. The Nike Frees were the first minimalist type of shoe to come out. The minimalist shoes aren't meant for someone to strike with their heel. When using the GoRuns, this shoe will cause your tibialis posterior tendon/muscle to become painful. This shoe deletes a necessary aspect of foot mechanics when running. Of the shoes you mentioned, I would stay with the Brooks Pureflows. One recommendation that I can make is, if you have a medium to medium high arch, then use more of a cushioned shoe vs. a posted or firm soled shoe. Get a shoe that doesn't have a dual density sole. New Balance makes a nice one as does Saucony. Again, I hope this helps!

      Peace!

      Brad Senska
      aka: Packmonger

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  4. Back in the PureFlows. I definitely land flat in that shoe, maybe rising up on my toes if I'm running fast. I ran eight today with some pain in the medial/posterior arch area and it's sore with walking, particularly at toe off. I'm 5'7" and148 lbs. I have been stretching that leg by doing knee bends and wall push ups with my foot turned in, which seems to reduce the discomfort a little.

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    1. Hi Charles,

      Try reducing your mileage just a bit. Instead of 8 miles, run 6.5 with 3 - 5 30 second pick ups during the run. Also, when in the Pureflows, try to land more mid foot and lateral on your foot. Following your run, perform a self massage to your medial calf. This area may be tender at first with the massage but after several minutes, this tenderness should reduce to almost no tenderness. Follow this up with ice for 8 - 10 minutes on your medial calf. Continue the stretches but in modest. Don't go overboard with the stretching. Too much stretching can continue to irritate the tib posterior tendon. If you have access to a Bosu ball, begin doing single leg stands in sock or bare feet on the Bosu ball. Balance on the affected lower extremity for 30 seconds to 1 minute. Use a hiking pole or stick to assist with re-acquiring your balance. Don't use it to balance with though. This may be quite challenging at first. Keep your knee just slightly bent. You'll have better control this way and recruit more thigh, calf, and foot muscle activity. You'll feel the arch of your foot begin to become fatigued and tired. This is expected. A good number of repetitions to start with is 4 - 7 repetitions of 30 seconds to 1 minute duration. The massage, the stretching, reducing your mileage while symptoms resolve, icing, performing the Bosu ball exercise, and changing your foot strike just a bit more should finish off getting rid of your foot and calf pain. Just one other thing. When you're on the Bosu ball balancing and your hip begins to get tired or fatigued, the source of your foot and leg pain may actually be coming from weak hip abductors and weak hip external rotator muscles. Good luck and keep me posted!

      Peace,

      Brad Senska
      aka: Packmonger

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  5. Give your knee pain relief, apply ice to reduce swelling, wear a compressive bandage, and keep your knee elevated. Don't overlook your weight.

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