Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Posterier Tibial Tendon insertion pain?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by JohnW35, Sep 13, 2011.

  1. JohnW35

    JohnW35 Member

    Members do not see these Ads. Sign Up.
    Hi I could do with a bit of advice please.
    Initial HistoryThis chap (35 year old athletic male, runner and mountain biker) sustained an right foot inversion ankle injury in June 2010 after climbing down a ladder in poor footwear. It was no problem at the time, in fact the following day he took part in a 2.5 K running race. However the day after the race the ankle inflamed. I saw this chap in October 2010 and although he had stopped any sort of activity other than walking, the pain was getting worse as time progressed. He also has a fused distal interphalangeal joint from an injury over fifteen years ago.
    He was at that time taking NSAIDs and analgesics.
    ExaminationNo pain along the peroneal and posterior tibial tendon. No abnormal muscle power testing. No pain at the Sinus Tarsi. Negative results for Tarsal Tunnel. The right medial ankle was excessively warm and there was quite significant pitting oedema on the medial and lateral aspect of the tibiotalar joint. In RCSP both heels are everted showing mild pes planus deformity.
    Initial management PRICE and Aircast walker and booked in for MRI.
    MRI results
    Showed posterior talus impingement and degeneration of the posterior STJt with osteophyte formation. He also showed some inflammation of the flexor hallucis and posterior tibial tendons.
    Second examination
    The second examination showed him to be all but pain free with any swelling disappeared due to religious use of the aircast walker. I believe him to be hypermobile with a forefoot supinatus of both feet (correctable forefoot to rearfoot inversion). This is probably prevented complete healing of the original injury. I prescribed him a cast orthotic and for several months started to build back up to running and biking, he does admit to not always wearing the orthotics as he was pain free! However in the last few weeks a very localised pain when palpated and has reoccurred shown in the photo.

    He can perform a heel rise without much pain but looks far more unstable when doing so compared to the left side.
    Is it possible that pain could be occurring at the point the PTT inserts the navicular? What could this have to do with the original inversion injury. Although ligament damage was not noted on the MRI scan is it possible I am missing a ligament injury here. I’m at a bit of a loss as what to do next.
    thanks John

    Attached Files:

  2. hamish dow

    hamish dow Active Member

    I would deeply suspect the nature of his footwear to be less than helpfu, or at least the way he wears theml, I would suspect he might be wearing his orthotics less thatn he is telling you, I would suspect he is an impact loader and is not transitioning weight during his walking gait, and that he may be trying to "run before he can walk" outside of that suspect the spring lig and the deltoid section is not happy. All would indicate it has not recovered well enough for his activities and I would urge him back into his orthotics, get him to walk off a dynamic shortened gait to activate his calf properly and have him in good fitting well laced shoes, absolutely no slip on shoes.
  3. John:

    It is uncommon, but not rare, to have an inversion sprain lead to insertional tendinopathy of the posterior tibial tendon on the navicular tuberosity. I treat these patients with anti-pronation orthosis, icing, modified rest generally with good success. My theory of the mechanism of injury is that, during the inversion ankle sprain, the navicular tuberosity and PT tendon insertion are compressed violently against the medial osseous structures of the talus/ankle which causes the injury and pain. I don't know if this injury mechanism has been described within the literature before, but I see at least one or two of these injuries per year in my practice.
  4. efuller

    efuller MVP

    So, you've got pain at the posterior tibial insertion in someone who's had posterior tibial problems before. They are back. The question is why does he have PT dysfunction. Is it because he has a medially deviated STJ axis or does he have STJ arthritis, as shown on the MRI, and is trying to hold his STJ immobile with the PT and peroneal tendons. Does passive range of motion of the STJ hurt?

    People can do heel raises without a PT tendon and it will look funny compared to the intact side.

    Treatment of splinting may be different than excessif strain. You could have both.

  5. JohnW35

    JohnW35 Member

    Thank you for your replies,

    Do you think then that looking at the very specific location of the pain it could be insertional pain at the navicular?

    If so in addition to the management outlined by you Kevin, would you also recommend any strengthening exercises, i.e heavy load eccentric as for achilles tendinopathy? It's been over year since the first injury and although the orthotic may not have been worn religiously wouldn't you have expected healing to have occurred by now?

  6. I have seen navicular pain go on for years. Generally these are due to scarring at the insertion of the posterior tibial tendon and/or bone edema at the navicular tuberosity or accessory navicular (if present). [Has a recent MRI scan been performed?]

    I would stick with a well-made orthosis and would even suggest supplementing the orthosis with low-Dye strapping when they exercise, along with twice daily icing therapy, to see if the pain can be further alleviated.

    Hope this helps.
  7. docbourke

    docbourke Active Member

    Is it possible the injury is a red herring and he simply has grade 1 tib post tendon dysfunction. This is almost certainly a degenerate condition and can present commonly as localised pain at the insretion. I use ultrasound rather than MRI for investigation and you ask them to look for asymmetric homogeneous signal, fluid in the sheath and swelling compared to the other side. Treatment consisits of rest, orthotic support +/or taping and ultrasound guided cortisone injection around but not into the tendon. If that fails I have had good success with exploration, release and debridement/ repair of the tendo but if it develops into grade 2, a tendon transfer is required.
  8. JohnW35

    JohnW35 Member

    Thanks, I see the patient again on Monday so will followup with some suggestions.
    Sorry to ask the same question again though but once he is asymptomatic are any strengthening exercises recommended.
    Thanks again
  9. Lorcan

    Lorcan Active Member


    I have found patients in the past year with similar situations (PTTD) that didnt fully resolve that they often have a Trigger Point proximally in the Tib Post muscle which seems to weaken the muscle/tendon and refer pain to the location you show. I have been dry needling the Trigger point, PNF stretch and heat pack it and finally add an extra 3mm=4.5mm poron arch pad. If I want to see if it helps I first use a 7mm SCF arch pad to see if it helps. It usually does. I learnt the Dry needling From Shane Toohey who is on the forum.

    Hope this helps some

    best of luck with it.
  10. docbourke

    docbourke Active Member

    I have tried eccentric program and strengthening on one patient with success but that does not mean it will work for others. If he is asymptomatic a return to full activity including running gradually should strengthen the tendon. I don't think extra strengthening is required as the primary pathology is probably inflammatory/ vascular/ degenerative rather than weakness and you don't want to overstrain a healing tendon in those cases. If the pathology is akin to achilles tendinosis then over loading may be beneficial but unless you know something we don't about the initial pathophysiology I would hold back rather than risk further damage. Good luck.

  11. JohnW35

    JohnW35 Member


    The patient has been fitted with a cast orthotic. He said he has phased it in gradually but something strange has happened.
    He hasn't started running or biking just walking but the orthotic has clearly resulted in his middle toe difficult to bend and very swollen along with pain and swelling in the 5th metatarsal head.
    What can be happening? Do you think the arch support could be too much?
  12. Ian Linane

    Ian Linane Well-Known Member

    Hi John
    I've just picked this thread up. Certainly a bit of a conundrum. As well as the above advice I would give consideration that an inversion sprain can result in joint limitation of motion while the tissues are recovering.

    It would appear that such limitation can remain in some people and so, for them, a session of joint mobilisation may aid in reducing tissue stress by improving joint function.

    Even though the inversion sprain is commonly thought of as mainly lateral ankle stuff (though Kevin has helpfully described how the medial tissue can be affected) the injury can impact upon TCJ and STJ limitation range and quality of motion. A posterior/anterior drawer mobilisation to both joints may be helpful.

    Also consider the distal tibiofibular joint as stiffness can remain here post inversion sprain.
  13. JohnW35

    JohnW35 Member

    Hello all again,

    The patient has now had further complications since wearing the orthotic and I am concerned as is he that some it is associated with the orthotic itself.
    He was complaining of pain and odema in third, fourth and fifth toes since wearing the orthotic.

    I sent him for an ultrasound and they found two intermetatarsal bursae between 2nd and 3rd toe and 4th and 5th metatarsal heads. In addition the ultrasound also confirmed that the posterier tibialis tendon has a small longitudinal tear.

    The first question is do I carry on with the orthotic, high top laced shoes fpr this tear?

    In addition I think it too much of a coincidence for the bursae not to be associated with the use of the orthotic and the patient thinks so too. I do not know what to do for the best are there any other options to fix the tendon without increasing the risk of further metatarsal head issues?

    As anyone else had issues with bursae due to orthotics. The patient is loosing faith in the orthotic and I am concerned that if he stops wear it he will suffer further PTT damage.


  14. CraigT

    CraigT Well-Known Member

    Hi John
    Can we have more information on the orthosis that you have prescribed? This is something which could be related to 'overcorrection', or simply that the orthosis is pushing the foot into the upper of the shoe.
    Have a look at the foot on the orthosis out of the shoe, and look at the wear on the shoe. You may see some ballooning of the upper or other clues that this is the case.
    You have prescribed an orthosis to make a change- is it doing what you want??
  15. JohnW35

    JohnW35 Member

    Hello Craig,

    Thank you for taking the time to reply. Firstly the orthotic has been produced by the patient standing in a a foam box.

    Top Cover Blue EVA ,Shell Type - White polypropylene, Midcover 3mm Poron.

    I will have to ask the patient to bring in all the shoes he uses the orthotics in.

  16. drsarbes

    drsarbes Well-Known Member

    Just reading through all these posts from 9/13.
    That's a long time ago.
    I did not see that there were plain xrays taken; I see the MRI from the initial post.
    Are there Xrays?
    Also: My first thought when I looked at your initial photograph was that the circle you have drawn does not look as though it's over the Nav tubercle.

    I have found that most cases of insertional type post tib tendinitis (where the remaining tendon is asymptomatic) have radiographic changes at the insertion, i.e., periostitis, enthesopathy, etc...

    It is good that you are trying to get to the "root of the problem" - but it would be nice to get rid of his pain as well. Have you tried a simple cortisone injection?


Share This Page