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Tuesday, April 2, 2013

Tibialis Posterior Tendonitis Case Study With Pics!

The material that I'm going to present here is an actual case study in which this patient was initially diagnosed with plantar fasciitis.

Patient demographics:
  • Female
  • 38 years old
  • Height = 5' 5"
  • Weight = 148 lbs
Abbreviated patient history:

With out too much formality, I'll summarize her limitations and significant clinical findings upon her evaluation and assessment.

This patient was a professional.  She managed a very upscale dining facility.  She was required to be on her feet for over 8 hours at a time.  The dress code required her to wear high heel shoes.  When not at work, she did go for hikes on hilly terrain that lasted up to an hour or more.  She had a mesomorphic body type with poor joint mobility and a low Beighton Index score.  Her overall general fitness level was good.  Given this information, she was found to have poor motion either actively or passively with right dorsiflexion.  Active and passive calcaneal inversion and eversion were also moderately restricted.  Her overall foot structure was semi-rigid.  Midfoot and forefoot joint mobility was also moderately restricted.  The arch of her foot was appropriately maintained in standing and in a non-weightbearing position.  She did not present with pain in the arch of her foot nor at the MTP joints with firm palpation.  Initial stepping in the morning was intermittent with pain.  As you'll see in the below images, she did have swelling present in her medial calf, her medial ankle, and slight swelling near the medial malleolus.  She also did not present with any leg length discrepancy.  Her pelvis was well aligned in the frontal and sagittal planes.  When observing her walking gait, she showed more midfoot pronation on her right during mid stance than with her left foot midstance.  With regards to her gastrocnemius/soleus strength, she demonstrated a 5/5 on the left and a 4-/5 on the right.  Right hip abduction and right hip external rotation strength were also showing weakness.  Right hip external rotation active and passive range of motion were increased compared to the left.  Single leg standing was > 45 seconds on the left. Single leg standing on the right = < 20 seconds due to onset of symptoms combined with weakness.

Other findings were present, but let's move forward from this.  Here are key findings that I immediately identified as suspect:

1.  Prolonged habitual posturing.  During the subjective part of the evaluation, she was asked to show me how she stands at her station or which posturing habits she favors.  She immediately went to posting on her right lower extremity while letting her left hip drop.  This explains the increased movement with hip external rotation and the weakness.  The weakness here was identified as a stretch weakness from overuse during habitual posturing.
2.  Pt. presented with a deficit in right ankle dorsiflexion.  This is indicating either a capsular restriction at the ankle or shortening of one or more contractile tissues in one of the posterior compartments in her right leg.
3.  Weakness was present with plantar flexion, midfoot inversion, and heel raises.  Pain symptoms also presented when performing these motions and activity.  Pain also presented with prolonged single leg standing.
4.  During weight bearing and walking, her right arch showed a moderate collapse in mid stance.  Her left foot did not show this same collapse.
5.  Her description of her pain was not consistent with plantar fasciitis in spite of the fact that she was feeling pain in the same area that plantar fasciitis would also present.

So, with the above findings, I would say that this would be plenty to move on with.  I begin with palpation of the suspected tissue.  In the first image, I'm identifying the insertion of the tibialis posterior tendon and the origin of the plantar fascia on the calcaneus.

In this series of pictures, I'm isolating the tibialis posterior tendon, muscle belly, and origin in order to help confirm what my suspected diagnosis.

Notice the space shared by the origin of the plantar fascia and the insertion of the tibialis posterior tendon.  The way to rule out that the plantar fascia is not inflamed is by examining the arch of the foot up to the MTP joints.  If indeed plantar fasciitis is present, pain will be present at the heel, through the arch, and to the MTP joints.  In Image 1, the patient was extremely tender with moderately firm palpation. 

Image 1

To help determine the severity or acuteness of her symptoms, I'm going to palpate the tibialis posterior tendon and muscle up to its' origin.  Typically, if pain already presents in the foot at the insertion site, then this is an indicator that her injury or the process of acquiring the tendonitis has been in progress for some time.  In this case, she stated that her foot had been bothering her for over 6 months.

In Image 2, I'm still over the tibialis posterior tendon just below the musculo-tendon junction.  Again, this area was extremely painful with just light to moderately firm palpation.  Fluid or swelling was also palpable in the area with a crepitus or gas exchange type of sensation and sound.

Image 2

Also, to better isolate palpation over the tibialis posterior tendon, I maintain the ankle at 90 degrees dorsiflexion.  This was enough dorsiflexion in this case to bring the tibialis posterior tendon more pronounced without exacerbating her symptoms.

Image 3

Notice in Image 3 the swelling present above the medial malleolus, posterior of the medial malleolus, and anterior of the achilles tendon.  This swelling was obvious and palpable the entire length of her medial calf along the path of the tibialis posterior tendon.  My right index and middle finger are over the musculo-tendon junction at this point.  Because of the amount of stretch receptors and nocioceptors present here, this area was again extremely painful to just light palpation.  This area felt as if it had a collagenous callus over the area.  This developed most likely from the same principle as Wolff's Law.  The body recognized a weakness and attempted to strengthen it through laying down scar tissue.

Image 4
I've now palpated the entire length of the tibialis posterior tendon and muscle.  My right index and middle finger in Image 4 are over the origin of this muscle.  Again, because of the more dense group of various nerves and blood supply here, her pain was quite elevated with light palpation.  There was also the same palpable swelling and collagenous tissue build up here.

Assessment:  Stated simply, I am positive that she has tibialis posterior tendonitis and it has been present for quite some time.  The combination of her already inherit tight connective tissue and joint capsule (as indicated by the Beighton Index), prolonged habitual posturing, and then aggressive hiking on steep and rolling terrain were all contributors to acquiring this diagnoses.  

I believe that because of her requirement to wear high heeled shoes for such long durations at work and then habitually posting on her right lower extremity caused a shortening of this muscle and tendon.  When she went hiking in much flatter shoes (she would hike in Merrell shoes which had a very close heel box and toe box height ratio), this caused a stretch weakness in the muscle and it's subsequent breakdown.  

Just to editorialize some here, when climbing a steep grade, this is going to put a very significant strain on this muscle and tendon at the origin, musculo-tendon junction, and insertion site.  This can easily explain the build up of scarring or collagenous tissue at the origin and the musculo-tendon junction.  With the lengthened position of the tibialis posterior muscle while hiking steep grades, this tendon and muscle were under a heavy and vigorous tensile load.  It was substantial enough and lasted for a long enough period of time, this muscle was not able to adapt to the loads being placed on it.  This in turn invited the onset of this injury.

Treatment:  I'll give you two components of her treatment:

1.  ASTYM or Augmented Soft Tissue Mobilization
2.  Contrast Baths
3.  You'll have to buy my book! :)

Treatment Duration & Outcome:  Patient had complete resolution of symptoms, full return of strength, normalized ankle joint active and passive range of motion, and was pain free with firm palpation the length of her tibialis posterior muscle and tendon.  Her treatment duration was 8 weeks.  

This patients symptoms were quite engrained and it took aggressive and dedicated commitment and compliancy with her treatment protocol in the clinic and outside of the clinic with her usual work and recreational activities.  She did not undergo any injections or invasive treatment.  She also did not require the use of orthotics or any kind of splinting with her treatment protocol.  Changes in body mechanics, body awareness, specific strengthening, and a change in habitual posturing made all the difference.

As usual, if you have any questions, inquires, intrigues, or other concerns regarding PT, please feel free to email me. 

Happy Bipeding!!

Brad Senska, PT, DPT, BS, ASTYM.

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