Case Study – Tibialis Posterior Overuse and Ankle Pain

March 19, 2019 | By | Reply READ MORE...

– Dr Niriksha V. Khasgiwala

Dheep Vora, 30 year old female runner came to PHYSIOREHAB with complains of pain in her inner part of right ankle and foot since 2 weeks (near the medial malleolus i.e. bony prominence on the inner side of ankle).She was preparing for her first full marathon i.e. 42 km and hence had increased her mileage.There wasn’t any apparent injury but she herself felt that she has overtrained in the last 2-3 weeks.

AGGRAVATING FACTORS:

  • Running post 9-10 kms
  • Running uphill
  • Sudden increase in pace
  • Incorrect footwear

RELIEVING FACTORS:

  • Rest
  • Icing
  • Gradual increase in pace
  • Corrective insoles for the shoes

ON EXAMINATION:

  • Pronated feet both sides (collapsing arches) right more than the left
  • Single leg balance on right leg more unstable than left
  • On palpation tenderness over the right inner ankle bony area and inner part of the shin
  • Muscular trigger points (Muscular knots) over the Tibialis Posterior muscle i.e. the inner side of the shin muscle (due to overuse)

ORTHOPAEDIC CONSULTATION:

Visited a local Orthopaedic doctor who diagnosed it as calf overuse and advised to stop running for four weeks and then gradually resume running.

INVESTIGATIONS:

After doing 4 sessions of rehab the pain was better but tenderness persisted hence we advised to do a MRI

Right Ankle MRI revealed mild bony swelling over the right distal tibia and tendinopathy of the right tibialis posterior muscle.

CLINICAL DIAGNOSIS:

Biomechanical dysfunction at the ankle leading to overuse of tibialis posterior muscle. Aggravated currently due to increase in training duration and mileage.

WHAT IS TIBIALIS POSTERIOR MUSCLE AND ITS FUNCTION:

The tibialis posterior muscle originates on the inner and back of the shin bone (tibia) and fibula

The tendon of the tibialis posterior muscle (sometimes called the posterior tibial tendon) connects this muscle to the bones of the foot.So when the tendon becomes injured, as a result of trauma or overuse, the body has difficulty delivering the proper nutrients for healing.

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The muscle is mostly involved in providing stability to the lower legs and helps in the foot movements as well as provides support to the medial arch (inner arch)of the foot.

PHYSIOTHERAPY MANAGEMENT:

  • Pain management: Ultrasound therapy over tender areas
  • Kinesiology Taping: To support and offload specific muscles like calf and tibialis posterior
  • Soft tissue release: Calf muscle and Tibialis posterior
  • Cold Compression
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    with insole
  • Strengthening of muscles like Tibialis Anterior (Front ankle or shin muscles)
  • Eccentric strengthening of Tibialis Posterior muscle without causing excessive loading
  • Gluteus Medius and Gluteus Maximus strenghthening: It is important to strengthen the glut muscles since they help in maintaining stability and it’s equally important to look into the strengthening of entire biomechanical chain.
  • Core Strengthening exercises
  • Orthotics with corrective insoles given
  • Barefoot Dynamic Ankle stability work
  • Functional training and proprioceptive training
  • Agility training
  • She was advised to gradually increase her pace and to take anti- inflammatory medicine

Dheep was re-evaluated every session and every week using different physical markers like tenderness, movement etc which helped us to chart her further plan of action.

Dheep came to us twice per week for 8 weeks. She had pain for the first 3 weeks after which once her strength started picking up and with support of insoles her pain was gradually tapering in intensity. She was diligent and would continue the same exercises at home. She was finally able to run pain free and was feeling on top of the world to have completed her first full Marathon.

We at PHYSIOREHAB deal with runners from varied age groups. We cater to runners participating in Trialthons, Ultra Marathons, Ironman and Trail walks as well.

We do a one on one running evaluation and then train the runners’ specific to the evaluation and the findings which helps them to run better and without injuries.

We incorporate functional training, TRX based body weight exercises, Pilates both mat and equipment.


TESTIMONIAL

BIGGEST THANK YOU TO DR ANJANA, DR NIRIKSHA AND TEAM PHYSIOREHAB!

I suffered an ankle injury due to excessive running load. A terrible one for me at a wrong time. Something in me didn’t want to accept the statement that my ortho made that just with break from running will help me get back to running painfree and hence on my yoga teachers recommendation I turned to PHYSIO REHAB for some therapy that could help speed my recovery. This was my first physio visit and I was totally in awe of the way they examined the minutest details about my body and not just the injury portion. In that one visit, I realised there’s much more to running and fitness than what I thought. We started with my pain management and strengthening and slowly started to feel better. During this time, I was insanely impatient, restless and helpless and kept bothering my therapist Niriksha with a zillion doubts. I haven’t seen a person so confident and patient. Seeing her confidence in my progress, I couldn’t help but trust my progress myself rather than worrying.

It took me approx 2 months to get back on my feet and resume my training again, only as a much stronger runner now. Thank you for being my constant support. Niriksha is my go-to person for any fitness related stuff. Working out with her is fun too, the way she concentrates on minutest detail about your body form, muscle or posture is just commendable. She makes you do it the right way, in it’s truest sense and that’s what I love about my workouts with her. It kills you sometimes but that’s sweet pain in her language.Thank you Niriksha and Team Physio Rehab for having my back!

Lots of Love,

– Dheep Vora

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Category: Case Studies

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