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Tibialis Posterior Tendinopathy

Tibialis Posterior Tendinopathy (TPT)

Tibialis posterior tendinopathy (TPT) is a common overuse injury that affects the tibialis posterior tendon, a thick band of tissue that runs from the inner part of the lower leg to the inside of the foot. The tendon helps to support the arch of the foot and allows for ankle movement, specifically bringing the foot inwards (inversion).

Who is at risk for TPT?

TPT is most common in middle-aged and older adults, particularly women. It is also more common in people who participate in activities that involve repetitive movements of the ankle, such as running, hiking, or ballet and can occur as a result of a flat foot deformity. In extreme cases it can result in a flattening of the foot arch.

What are the main symptoms of TPT?

 

The main symptom of TPT is pain and swelling, most frequently seen in the inner aspect of the ankle and in towards the tendon insertion on the inner aspect of the midfoot. The pain is often worse when weight-bearing, for example, walking or running, and it may worsen with activity and improve with rest. Other symptoms may include:

Difficulty walking or running on uneven surfaces

Swelling and tenderness around the ankle

Weakness in the arch of the foot

Difficulty walking on uneven surfaces

Difficulty standing on the heel, particularly when balancing on the affected foot alone

A feeling of instability in the ankle

How is TPT diagnosed?

A doctor can diagnose TPT by taking a medical history, performing a physical examination, and ordering imaging tests. The physical examination will focus on assessing pain, tenderness, and swelling around the inner aspect of the ankle and foot, as well as looking at strength when resisting certain movements of the foot and ankle. Imaging tests that may be ordered include:

  • Ultrasound:

    Ultrasound can be used to demonstrate a thickened and disorganised appearance of the tibialis posterior tendon, as well as assessing for fluid in the tendon sheath.
  • X-ray:

    X-ray can rule out other conditions that could be causing the pain, such as a fracture or bone spur.
  • MRI:

    MRI can provide the most detailed images of the soft tissues around the ankle joint, including any areas of inflammation or damage in and around the tibialis posterior tendon.

How is TPT treated?

 

Treatment for TTP typically involves conservative measures, such as:

  • Rest:

    Avoiding activities that aggravate the symptoms.
  • Ice:

    Applying ice packs to the affected area for 10-15 minutes at a time, several times a day.
  • Compression:

    Wearing a splint or brace to support the ankle.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs):

    Taking over-the-counter NSAIDs, such as ibuprofen or naproxen, to reduce pain and inflammation.
  • Stretching and strengthening exercises:

    Once the pain has subsided, stretching and strengthening exercises can help to improve flexibility and strength in the muscles around the ankle.
  • Podiatry:

    A formal podiatric assessment will involve assessing the patient statically, when lying or standing and dynamically, when walking. The podiatrist may consider orthotics (heel inserts) to support the arch and take the stress off the damaged tibialis posterior tendon.
  • Corticosteroid injections:

    Injecting corticosteroids into the tibialis posterior tendon sheath can help to reduce inflammation and pain.

At The Joint Injection Clinic, these injections are performed after a thorough consent process, whereby the risk and benefits of the procedure are discussed in detail with your doctor. The experienced medical doctor will then place you in a lying position. The inner aspect of the ankle is cleaned using a cleaning solution to ensure that the procedure is performed under sterile conditions. Local anaesthetic is injected from the skin to the tendon sheath under ultrasound guidance. After giving the local anaesthetic a few minutes to take effect, the tendon sheath injection is performed with a small dose of steroid and local anaesthetic.

The injection itself is normally completed within 30-60 seconds, after which a plaster is applied and post-injection advice is given. The patient is advised to look out for any signs of infection, specifically to check whether the local area becomes red, hot, tender, swollen or if they develop a fever. If this occurs then the patient is asked to contact the clinic immediately at which time a formal reassessment will occur and if needed oral antibiotics can be prescribed. The patient is also warned that following any injection they may notice a short-term worsening or flare in their symptoms after the local anaesthetic has worn off (4-5 hours). This may last for 3-5 days and the patient is advised to consider icing of the area using an ice pack for 10-15 minutes every hour as required.

Surgery:

Surgery is typically only considered for severe cases of TTP that do not respond to other treatments. Surgery involves removing the damaged tissue and repairing the tendon.