The Achilles tendon is the single strongest tendon in
the human body. The primary function of the Achilles tendon is to transmit the
power of the calf to the foot enabling walking and running. If it has to do with
upright, bipedal motion, the Achilles tendon is a part of that activity. Occasionally,
the Achilles tendon can fatigue, begin to show signs of inflammatory change and
develop Achilles tendonitis. This article discusses the onset,
symptoms and treatment of Achilles tendonitis.
Acute Achilles tendonitis
Acute Achilles tendonitis (also known as Albert's Disease) typically has a abrupt
onset with moderate to severe pain found at either the insertion of the tendon
in the back of the heel (insertional tendonitis) or in a location 2-3 cm proximal to the tendons' insertion.
Many individuals who suffer from acute Achilles tendonitis can describe an injury or single
event that initiated the pain. Symptoms of acute Achilles tendonitis occur
at the beginning of an activity and are typically described as sharp pain.
As the activity continues and the Achilles tendon 'warms up', the Achilles
tendon pain begins to feel a bit better. With
excessive use, the Achilles tendon again becomes painful at the end of activity.
For example, runners with Achilles tendonitis experience pain as they begin
their run. The pain subsides during their run only to recur near the end
of their normal running distance.
Chronic Achilles tendonitis(tendonosis)
Chronic Achilles tendonitis is also called Achilles tendonosis. Chronic Achilles tendonitis can
also cause hypertrophy
(enlargement) of the posterior heel and distal Achilles tendon. When viewed on x-ray, this finding is
called an increased Phillip-Fowler angle.
In cases of chronic Achilles tendonitis it's
important to differentiate between pain strictly due to the pull of the Achilles tendon
and pain due to the enlargement of the posterior heel rubbing against the
shoe called a
bump or Haglund's deformity. The difference between Achilles tendonitis and
a pump bump can be understood by evaluating the pain while barefoot (suggestive
of Achilles tendonitis) compared to pain while wearing shoes with an enclosed
heel (pump bump).
Another way to differentiate a pump bump from insertional Achilles
tendonitis is by the location of the pain.
picture shows the back of a right heel, the outside of the ankle and a few of
the lesser toes. The red dotted line outlines the Achilles tendon.
This is the area within the tendon where we are most likely to find an
acute tear of the Achilles
tendon or tendonitis. The red circle shows the area where the Achilles
tendon inserts into the calcaneus and is the location of chronic insertional Achilles
tendonitis. This area will often become hypertrophied (enlarged) as the
result of spurring that forms on the posterior heel at the insertion of the
tendon. The red circle is also the area where we would find pain
associated with retrocalcaneal bursitis. The blue area is on the outside,
or lateral aspect of the heel. The blue area is where we would find the
symptoms of Haglund's Deformity or a pump bump. You can see that a Haglund's
Deformity is usually found on the posterior lateral heel (blue) while
insertional Achilles tendonitis is central to the Achilles tendon.
Treatment of acute and chronic
that the single greatest contributing factor to acute and chronic Achilles tendonitis is
equinus (see the biomechanics section below for more information on equinus), we know that we need to weaken the calf muscle to allow the Achilles
tendon an opportunity to heal. This can be done by elevating the heel with
heel lifts or by wearing a subtle high heeled pair of shoes. Inflammation of the tendon can be calmed by
ice, both before and after activities. Anti-inflammatory medications,
ultrasound treatment can also be used. Steroid injections are typically
not used to treat Achilles tendonitis since injecting the tendon has a tendency
to weaken the tendon resulting in a possible rupture.
In cases of chronic Achilles
tendonitis, patients who do not respond to heel lifts and
anti-inflammatory medications require a lengthening procedure of the Achilles
tendon with or without a partial resection of the posterior heel. In cases
with minimal hypertrophy of the heel, lengthening of the tendon will suffice.
Lengthening of the Achilles tendon may be performed through three 0.5cm
incisions but does require a period of casting. Full recovery may take
6-18 months. Endoscopic techniques are also available in a limited number
of cases, correcting equinus with a procedure called an
Cases of insertional Achilles tendonitis that fail to respond to
conservative care will require partial resection of the posterior heel and
lengthening of the Achilles tendon. The following images show a Z-plasty
lengthening of the Achilles tendon and resection of the posterior heel with a
mallet and osteotome. A bone anchor with attached suture is placed in the
posterior heel to affix the Achilles tendon. This procedure is performed
in a hospital or outpatient surgery center and is typically performed under a
general anesthetic. Casting for 6-8 weeks following the procedure is
A newer method of treating chronic Achilles tendonitis (tendonosis)
is called Topaz Radiofrequency Ablation. Topaz is used to stimulate an acute inflammatory reaction
within the tendon. The inflammatory reaction attracts cellular and
chemical mediators of inflammation and is assumed to jump start the natural
healing process. Topaz surgery uses a grid of small holes that are placed
in the tendon using a radiofrequency wand. The depth of the holes are
varied. The indications for Topaz surgery includes those individuals who
are interested in an ambulatory solution for Achilles tendonosis or who may have
co-morbidities that preclude them from having an Achilles tendon lengthening.
The term heel spur often conjures
up images of a sharp bony prominence on the bottom of the heel that
pokes and prods us with every step. But that image couldn't be further from the truth.
Heel spur syndrome is not a bone problem at all. Heel spur syndrome is actually a soft
tissue problem. Confused? We'll explain.
spurs, heel spur syndrome and plantar fasciitis refer
to the same condition. Although hard to pronounce, plantar fasciitis is
rapidly becoming the most commonly used term to describe this
condition. Plantar is a geographic term that refers to the bottom of
the foot (dorsal on top/plantar on bottom). Fascia is a tough, inelastic
band. And 'itis' always refers to something that's inflamed (bronchitis, arthritis,
etc.). When the root words are combined they describe is an inflammatory
condition of a fascial band on the bottom of the foot; plantar fasciitis.
Pain associated with plantar fasciitis is specific to the plantar heel as seen
in red in the accompanying image.
How do we develop plantar fasciitis?
Plantar fasciitis is an overuse syndrome that is the result of
excessive and repetitive loading of the plantar fascia. When we stand, load is applied to the
arch of the foot causing the height of the arch to drop. This drop
in the height of the arch places tension on the plantar fascia. If the
tension (load) applied to the plantar fascia is greater than what the fascia can tolerate,
the fascia will become inflamed.
Treatment of Plantar Fasciitis
Treatment of plantar fasciitis is based on four
broad categories of care; biomechanical methods, anti-inflammatories
methods, surgery and other methods. Let's take a closer look at each of these four categories and
see how they can often work together.
The leg, ankle and foot functions as a lever. This lever is
called the CT band.
Levers consist of three parts; an effort arm, a fulcrum and a
resistance arm. In the CT band, the leg is the effort arm or source of
force coming primarily from the calf muscles. The ankle is the fulcrum or
hinge of the lever. And the foot is the resistance arm of the lever.
The resistance arm of the lever is where the force creates action.
The lever action of the leg, ankle and foot is to deliver force from the
strongest muscle in our body (the calf) to the ball-of-the-foot. The
action created is what we know as walking. Plantar fasciitis is the
result of an imbalance in the lever mechanics of the leg ankle and foot.
This imbalance results in force from the effort arm (calf) that overwhelms the
resistance arm (the foot).
The first step in treating plantar fasciitis is to try and restore
the balance between the effort arm and the resistance arm of the CT band.
To do so, there are three simple steps;
Avoid going barefoot or wearing a shoe with a low heel.
Taping the arch,
heel cushions and a host of other 'devices' have been used successfully to
treat plantar fasciitis. All of these devices focus on changing the
biomechanical properties of the CT
band. Remember, the key to
treating plantar fasciitis is addressing the entire CT Band and not just the
plantar fascia. Stretches and heel lifts
are quite often all that is needed to change the biomechanical properties of the
CT band and for complete resolution of symptoms of plantar fasciitis.
Arch supports can be used on a daily basis to maintain good support of the arch
and help to decrease recurrence of plantar fasciitis.
The second category of care is the use of anti-inflammatories. Anti-inflammatories include steroid injections, oral anti-inflammatory
medications such as aspirin, prescription strength medications called NSAID's,
topical medications and a host of other methods to reduce
inflammation. When using anti-inflammatories, bear in
mind that we are treating a problem that we know is mechanical in nature.
Plantar fasciitis is caused by mechanical overuse or
overloading of the CT band. Anti-inflammatories help with the dull ache common
in cases of plantar fasciitis. Anti-inflammatories typically do not help
with the sharp tearing pain found with that first step out of bed or when
initially standing during the day. That's why it's important to combine
mechanical methods of care (above) with the use of an anti-inflammatory. The two methods
work in conjunction with each other to address the two different types of pain that are
common in cases of plantar fasciitis.
The third category of care includes surgery and what we describe
as other methods (below). Surgery becomes indicated when a course of
conservative care has failed. Endoscopic surgical
methods have become the standard of care for the treatment of plantar fasciitis.
The surgical procedure used today to treat plantar fasciitis is called an
endoscopic plantar fasciotomy. The
older methods of surgical correction included resection of the heel spur or
partial resection of the heel bone. With an endoscopic plantar fasciotomy, we
release, or make a cut through the fascia, leaving any spur in place. It's
important to recognize that we are treating a soft tissue problem (plantar
fasciitis) and not a bone problem (heel spur).
The following video shows the steps used to perform an endoscopic
plantar fasciotomy. This procedure is performed at a surgery center or hospital and is
completed with sedation and local anesthesia. The procedure takes
approximately 15 minutes to complete. Patients are able to walk the very
same day on the foot and return to most activities within 3-4 weeks.
Heel spur surgery, whether performed endoscopically or with a traditional
method, is not without problems. While 90% of EPF cases are completed without
complication, 10% do have problems that can vary in severity. One complication
specific to plantar fasciotomies, regardless of how they are performed, is later
column syndrome (LCS). LCS is sometimes a very difficult complication to
understand, diagnose and treat. The complications of LCS occur not in the first week or two after surgery but
rather 2-4 month after a plantar fasciotomy. As
a patient reaches status 4 weeks post surgery, they start to feel
more able to return to their normal activities. As they progressively
increase their activities they begin to add an increase of load to the foot.
Although the surgical site no longer is sore from the surgery, the biomechanical
impact, or change to the joint structure of the foot is not complete for 4-6
months following the surgery. Early symptoms of LCS are a dull ache of the
lateral (outside) of the foot and the top of the arch. This ache is a
stiffness that if left untreated will result in small stress fractures if the
lateral and dorsal aspects of the foot. LCS is a manageable complication
of this procedure and should be thoroughly discussed before surgery so that
patients are aware of the symptoms of LCS and can make their doctor aware should
they experience problems.
Other non-conservative methods of care include shock wave therapy, Topaz surgery
growth factor injections and neuroablation. These methods of treating plantar
fasciitis focus on the difference between the terms plantar fasciitis and
plantar fasciosis. Plantar fasciitis is an acute inflammatory condition of
the plantar fascia. But after several months, the inflammatory nature of
plantar fasciitis changes. Studies that have used tissue biopsy of long
term plantar fasciitis show that over time, there become less of an inflammatory
response by the body within the plantar fascia. So the acute inflammatory
condition of plantar fasciitis changes to a non-inflamed case of plantar
fasciosis. This finding is the basis for several other techniques used to
treat plantar fasciitis.
Extracorporeal shock wave therapy is used
as a tool to break the re-injury cycle associated with plantar fasciitis. Shock wave therapy employs an acoustic wave that
results in an explosion of energy at the point of focus. Shock waves
differ in amplitude and are 'tuned' for a specific purpose based upon the
desired amplitude and medium that is crossed to reach a target tissue. The
effect of the shock wave in cases of plantar fasciitis is not fully understood.
It is believed that the effect of the shock wave stimulates an intense focused
inflammatory reaction that promotes healing at the insertion of the plantar
fascia. Shock wave therapy can be painful to perform and
therefore requires that the procedure be performed in an outpatient setting with
deep sedation. The procedure takes about 15 minutes to complete and does
not require a local anesthetic (only sedation). Patients are able to walk
on the foot the same day. Complication are minimal. Most doctors
will require continued stretching and limited activity for 4 weeks following
shock wave therapy. The long term success or failure of shock wave therapy
is yet to be seen, but recent studies have had short term success rates of
65-95%. For additional information on shock wave therapy refer to The
International Society for Musculoskeletal Shock Wave Therapy.
Topaz surgery is used to treat plantar fasciosis. To
complete Topaz surgery, a patient is taken to surgery, sedated and anesthetized.
A Topaz wand is used to place a series of small holes or defects within the
fascia. The Topaz wan creates this defect by using radio frequency
ablation. Patients are able to bear weight and walk immediately following
Growth factor injections are also used to treat cases of plantar
fasciitis/plantar fasciosis that have failed conservative care. Growth
factor is isolated from the platelets in a patient's blood. This technique
can be completed in the doctor's office. A 50cc sample of blood is drawn
from the patient and spun down in a centrifuge. The platelets are then
re-injected into the most symptomatic area of heel pain. Patients are able
to walk immediately following this procedure.
Neuroablation is a technique used to treat heel pain that doesn't
focus on treating inflammation, but instead focuses
on deadening nerve pain in the plantar heel. Neuroablation doesn't actually treat the
mechanical component of heel spur syndrome, but instead destroys nerve that
supplies sensation to the bottom of the heel. Neuroablation can be
performed with a cold probe (cryoablation, thermoablation) with a hot probe
(radiofrequency surgery) or with injectable chemicals (alcohol, phenol).
Neuroablation is an appropriate procedure for select patients who have not
responded to conservative care.
What's the best method of care for you? That decision
should be made by you and your doctor as a team. Consider conservative measures
of care as a means to help your body heal itself. Surgery on the other hand is
the physical change. The first consideration in determining a treatment plan is
the duration of your symptoms of plantar fasciitis. How long has your plantar fasciitis been present?
If your symptoms have been present for more than a year or if you've tried 4
months of conservative care with no change in your symptoms, you are probably a
good candidate for surgery or other care.
Plantar Fascial Tears
Plantar fascial tears are a relatively uncommon injury.
There are no precipitating factors (age, weight, smoker, etc) that would tend to
one patient more susceptible to a plantar fascial tears. Plantar fascial
tears occur in men within the 20-50 year age range who are engaged in aggressive
activities such as sports or physical labor. The onset of a plantar
fascial tear is abrupt and typically secondary to a fall or sports injury.
Sharp pain with weight bearing, along with bruising specific to the plantar heel
and arch are found. Treatment include, rest, ice, compression and partial
weight bearing to tolerance. Surgical repair of a torn plantar fascia is
unnecessary. The fascia will heal over the course of 4-6 weeks to be fully
functional. Plantar fascial tears should be evaluated with an x-ray to
rule out a stress fracture of the heel.
Posterior tibial tendon
dysfunction (PTTD), also known as posterior tibial tendonitis, is one of
the leading causes of acquired flatfoot in adults. The
onset of posterior tibial tendon dysfunction may be slow or abrupt. An abrupt
onset is typically linked to some
form of trauma, whether it be simple (stepping down off a curb or
ladder) or severe (falling from a
height or automobile accident). PTTD is seldom seen in children and
increases in frequency with age.
The characteristic finding
of posterior tibial tendon dysfunction include;
medial arch height.
Edema (swelling) of the medial ankle.
Loss of the ability to resist force to abduct or push the foot out from
the midline of the body.
the medial ankle with weight bearing.
Inability to raise up on the toes without pain.
Too many toes sign.
Lateral subtalar joint (sinus tarsi) pain.
A common test to evaluate
PTTD is the 'too many toes sign'. The 'too many toes sign' is a test
used to measure abduction (deviation away from the midline of the body) of
the forefoot. With damage to the posterior tibial tendon, the
forefoot will abduct or move out in relationship to the rest of the
foot. In cases of PTTD, when the foot is viewed from behind, the
toes appear as 'too many' on the outside of the foot due to abduction of
In advanced cases of PTTD,
in addition to the pain of the tendon itself, pain will also be noted in the
subtalar joint and sinus tarsi. The sinus tarsi refers to a small tunnel or divot
on the outside of the subtalar joint that can actually be felt. This tunnel
is the entry to the subtalar joint. The subtalar joint is the
joint that controls the side to side motion of the foot, motion that
would occur with uneven surfaces or sloped hills. As PTTD
progresses and the ability of the posterior tibial tendon to support the
arch becomes diminished, the arch will collapse overloading the subtalar
joint. As a result, there is increased pressure applied to the
joint surfaces of the lateral aspect of the subtalar joint, resulting in
been many proposed explanations for PTTD over the years since this
condition was first described by Kulkowski in 1936. The most
contemporary explanation refers to an area of hypovascularity (limited
blood flow) in the tendon just below the ankle. Tendon derives
most of its' nutritional support from synovial fluid produced by the
outer lining of the tendon. Extremely small blood vessels also
permeate the tendon sheath to reach tendon. This makes all tendon
notoriously slow to heal. In the case of the posterior tibial
tendon, this problem is exacerbated by a distinct area of poor blood
flow (hypovascularity). This area is located in the posterior
tibial tendon just below or distal to the inside ankle bone (medial
Tendon is most susceptible
to fatigue and failure at an area where the tendon changes
direction. As the posterior tibial tendon descends the leg and
comes to the inside of the ankle, the tendon follows a well defined
groove in the back of the tibia (bone of the inside of the ankle).
The tendon then takes a dramatic turn towards the arch of the
foot. If the tendon is put into a situation where significant load
is applied to the foot, the tendon responds by pulling up as the load of
the body (in addition to gravity) pushes down. At the location
where the tendon changes course, the tibia acts as a wedge and may apply
enough force to actually damage or rupture the tendon.
Equinus is also a
contributing factor in cases of posterior tibial tendon dysfunction. Equinus is the term used to describe
the ability or lack of ability to dorsiflex the foot at the ankle (move
the toes towards the shin). Equinus is usually due to tightness in the
calf muscle, also known as the gastroc-soleal complex (a combination of
the gastrocnemius and soleus muscles). Equinus may also be due to
a bony block in the front of the ankle. The presence of equinus
forces the posterior tibial tendon to accept additional load during
factors that contribute to the onset of posterior tibial tendon
dysfunction may include obesity, hypertension, diabetes,
peripheral neuropathy, smoking or arthritis.
PTTD is a progressive condition, meaning to say, that if
left untreated, PTTD will become worse over time. The progression of PTTD
begins with focal tendonitis. If left untreated, tendonitis will progress
to partial and then complete tears of the posterior tibial tendon. Several classifications have been developed to describe
posterior tibial tendon dysfunction. The classification as described by Johnson and Strom is most
commonly used today.
Posterior tibial tendonitis without tendon tear
Tendon status - Attenuated
(lengthened) with tendonitis but no rupture. Clinical findings -
Palpable pain in the medial
arch. Foot is supple, flexible. Too many toes sign may be positive or
X-ray/MRI - Mild to moderate tenosynovitis on MRI, no X-ray changes
Posterior tibial tendonitis with partial tendon tear
Tendon status - Attenuated with
possible partial or complete rupture.
Clinical findings - Pain in arch. Unable to raise on toes. Too
many toes sign positive.
X-ray/MRI - MRI notes tear in tendon. X-ray noting abduction of forefoot, collapse of
Posterior tibial tendonitis with partial to complete tendon tear.
Tendon status - Severe
degeneration of the tendon with likely rupture.
Clinical findings - Rigid flatfoot with
inability to raise up on toes. Too many toes sign positive.
X-ray/MRI - MRI shows tear in tendon. X-ray noting abduction of forefoot,
collapse of talo-navicular joint
An additional consideration in diagnosing PTTD pain is the presence of an accessory bone called an
os tibiale externum. The os tibiale externum, or what is frequently called
and accessory navicular, is a small bone that resides
within the body of the PT tendon. The os tibiale externum functions to
facilitate motion around the navicular. The os tibiale externum functions much
in the same way that the knee cap (patella) works to guide the quadraceps tendon
around the knee as it bends. The os tibiale externum can undergo degenerative
wear called chondromalacia. The os tibiale externum also can fracture.
Therefore, the os tibiale externum must also be considered when diagnosing PT
Treatment of posterior
tibial tendon dysfunction
for PTTD is dependant upon the clinical stage and the health status of
the patient. It is important to recognize that PTTD is a
mechanical problem that requires a mechanical solution. This means
that treating PTTD with medication alone is fraught with failure.
Prompt introduction of some form of mechanical support is imperative.
PTTD is a condition that
increases in frequency with age and the prevalence of poor health
indicators such as diabetes and obesity. As a result, many patients
with PTTD are poor surgical candidates for correction of PTTD.
Prosthetics such as an ankle foot orthotic (AFO), Arizona
Brace or other bracing may be
very helpful to control the symptoms of PTTD.
Surgical procedures which
focus on primary repair of the posterior tibial tendon have been very unsuccessful.
This is due to the fact that tendon heals slowly following injury and
cannot be relied upon as a sole solution for PTTD cases. Surgical
success is usually achieved by stabilization of the rearfoot (subtalar
joint) which significantly reduces the work performed by the posterior
Stage I PTTD may respond to treatment that includes
variations of rest. Variations in rest include an
ankle brace,walking cast with
an elevated heel
or a hard, below the knee non-weight bearing cast. Pain and inflammation may be controlled
with anti-inflammatory medications. It is important to be sure
that Stage I patients realize that the use of shoes with additional
arch support and heel elevation is
imperative. Arch support and
should be continued
indefinitely. Arch support, whether built into the shoe or added as
helps support the posterior tibial tendon and decrease the amount of
mechanical load applied to the posterior tibial tendon.
Elevation of the heel, reduces equinus, one of the most significant
contributing factors to PTTD. If Stage I patients return to low heels
without arch support, PTTD will recur.
Stage II patients typically require surgical
correction to stabilize the subtalar joint prior to further damage to
the posterior tibial tendon. Subtalar arthroeresis is a
procedure used to stabilize the subtalar joint. Subtalar arthroeresis
may only be used in flexible feet. Arthroeresis is a
term that means the motion of the joint is blocked without fusion.
Subtalar arthroeresis can only be used in cases of Stage II posterior
tibial tendonitis where mild to moderate
deformation of the arch has occurred and MRI findings show the tendon to
be only partially ruptured. Subtalar arthroeresis is typically performed in
conjunction with an Achilles tendon lengthening procedure or endoscopic
gastrocnemius recession to correct
equinus. These procedures require casting for a period of weeks
following the procedure.
The following video shows placement of a subtalar joint implant
for control of pronation in a flexible foot with PTTD. The sinus tarsi is
dissected free of capsule and ligament and the implant is placed in the sinus
tarsi. This procedure is completed in a hospital or out-patient surgery
center using a general anesthetic. Patients can walk immediately following
subtalar arthroeresis if an Achilles tendon lengthening is not performed.
If an Achilles tendon lengthening is performed, a 6 week period of non-weight
bearing casting is required.
When an os tibiale externum is present, a modified Kidner
procedure is typically performed. The following images show
excision of the os tibiale externum and transposition of the posterior
tibial tendon. This procedure is performed in a hospital or
out-patient surgery center using a general anesthetic. Weight
bering following the surgery is dependent upon the integrity of the
tendon following excision of the os tibiale externum. Most
modified Kidner procedures do require a period of non-weight bearing.
Stage III patients require
stabilization of the rearfoot with procedures that fuse the primary
joints of the arch and foot. Rearfoot stabilization is used to correct
rigid deformities of the foot. These procedures are salvage
procedures and require prolonged casting and disability following
surgery. A common procedure for Stage III is called triple arthrodesis
which is a technique used to fuse the subtalar joint, the talo-navicular
joint and the calcaneal cuboid joint (picture at left).
Shin splints are a common cause of lower leg pain. Shin splints can be broken
into two basic categories based upon the location of the leg pain;
Anterior Shin Splints -
Anterior shin splints are the most common cause of anterior shin
pain. Anterior shin splints are also called medial tibial stress syndrome
(MTSS), exertional shin pain, medial periostalgia, medial tibial periostitis and
traction periostitis. Anterior shin splints are caused by overuse of the tibialis anterior
muscle and tendon. The function of the tibialis anterior is to
decelerate the foot at heel strike during the gait cycle.
The symptoms of anterior shin splints
occur at the origin of the tibialis anterior muscle and tendon on the
leading edge of the tibia. Anterior shin splint pain is the result of the tibialis anterior muscle
pulling the periosteum (surface lining of the bone) from the bone.
of anterior shin splints is usually based upon the location and
character of the symptoms. Diagnostic testing may include x-rays,
bone scans or MRI studies to rule out tibial stress fractures.
Treatment of anterior shin splints
The key to treating
anterior shin splints is to change the functional length of the tibialis
anterior muscle and tendon, thereby weakening the pull of the muscle on
the tibia. Pain and inflammation may also be treated concurrently, but
mechanical component of anterior shin splints is not treated, recurrence
of symptoms are likely with any increase in activities.
Biomechanical changes and changes in your training that may effect
the tibialis anterior muscle are simple and include the following;
1. Decrease the length
of stride - Taking shorter steps decreases the functional
length of the tibialis anterior and subsequently reduces the pull of
the muscle on the tibia.
2. Avoid running downhill - Running downhill will increase
stride length. Also, the excursion of the tibialis anterior increases with
3. Modified arch
support to decrease the functional length of the tibialis anterior -
This can be accomplished by extending the arch of an arch support or
orthotic distally to reach under the first metatarsal and big toe
joint. This modification is often called a Morton's extension. Changes should be made slowly and incrementally. As
you build up and extend the arch, you are decreasing the functional
length of the tibialis anterior.
4. Calf stretches - The tibialis anterior is the antagonist
muscle to the calf (gastroc-soleal complex). A tight calf will increase
the work load applied to the tibialis anterior.
is a simple and effective way to regain balance between the tibialis anterior
muscle (anterior leg) and calf (posterior leg).
5. Cross train - Vary your activities to decrease load
applied to the tibialis anterior. Alternate running with biking or
6. Range of motion exercise - Warming the tibialis anterior
with range of motion exercise helps to improve strength and flexibility.
Use the ankle as the pivot point and write the alphabet with the foot, tracing
an A, B, C, etc.
In addition to treating the
mechanical aspects of anterior shin splints, inflammation of the tibia
and tibialis anterior muscle can be address with these simple steps.
Ice before and after activity helps to reduce the
swelling of the muscle.
Physical therapy to include range of motion exercises, deep tissue
massage and ultrasound.
As a last resort, rest is helpful but never a
final solution. Rest can be as simple as a decrease in activity,
walking cast or even a cast with crutches.
Posterior Shin Splints -
Posterior shin splints describes the less
common form of shin splints of the lower leg. Posterior shin splints describes
pain in the tibialis posterior tendon. The role of
the tibialis posterior is to support the arch as the body moves over the
foot during the gait cycle. Posterior shin splint pain is
specific to the medial ankle, just behind the medial malleolus.
Interestingly, in non-athletic circles, posterior shin splints
is known as
posterior tibial tendon dysfunction or PTTD. PTTD describes a
progressive weakening of the tibialis posterior tendon. Severe cases
of PTTD may result in a rupture of the tibialis posterior tendon.
Knowing that the two conditions are synonymous, we can consider posterior
shin splints stage 1 PTTD.
Treatment of posterior tibial shin splints
One of the keys to treating any form of tendonitis is to
recognize that tendonitis is an overuse syndrome. Therefore, effective
treatment lies either in modifying the way the tendon functions
(biomechanical changes) or changing the activity that contributes to
overuse. We know that the function of the tibialis poster tendon
is to support the arch. Subsequently we can support the function
of the tibialis posterior tendon by supporting the arch with a
arch support. The tibialis posterior can also be helped by
elevating the heel with a
firm heel lift
and by performing calf stretches to weaken the calf muscle.
Ice before and after activity helps to reduce swelling of
Subluxation is the medical term used to describe the action of one or more
anatomical parts slipping or moving out of its' normal position. Peroneal
tendon subluxation refers to a recurrent snap or popping sensation of the
peroneal tendons on the lateral (outside) aspect of the ankle.
Peroneal tendon subluxation occurs during gait while the tendon is loaded.
Subluxation of the peroneal tendons occurs as the tendons jump from the peroneal
groove behind the fibula (outside ankle bone)
to the side of the fibula and back into the groove.
retinaculum is a small fibrous band that acts to restrain the peroneal tendons in a deep groove on the back
of the fibula. Peroneal tendon subluxation occurs when the peroneal retinaculum
is damaged or injured.
The peroneal retinaculum is often injured in a
lateral ankle sprain. Other causes of subluxation include anatomical variations of the fibular groove that may make the groove shallow and less able to
inhibit the peroneal tendons from subluxation during ankle motion.
Another interesting injury in the region of the fibular groove is a compression injury to the peroneus brevis tendon
resulting in a
longitudinal peroneal tendon tear. Several authors have described a mechanism by which the peroneus longus tendon actually cuts into the brevis tendon, effectively splitting the brevis tendon. There appears to be a statistical relationship between
peroneal tendon ruptures and recurrent peroneal tendon subluxation.
Treatment of recurrent subluxating peroneal tendons
A period of conservative care should be observed following an acute injury to
the peroneal tendons. A
a compression wrap
may help to enable healing of the peroneal retinaculum. A lateral sole wedge
can be used to limit load to the peroneal tendons by inhibiting supination of
the foot (rolling out).
sole wedges can be placed
in the shoe, on
orthotics or applied to the outer sole of the shoe by a shoe repair shop or
O&P facility. In cases of chronic
peroneal tendon subluxation, surgical repair will be
required to prevent subluxation and long term damage to the peroneal tendons. Treatment of peroneal tendon subluxation involves deepening the peroneal groove of the fibula
and retinacular repair. A number of different methods have been described in the surgical literature to add depth to the
peroneal groove, thereby limiting peroneal tendon subluxation. Those methods include drilling, tamping and creating rotating osseous (bone) shelves. Repair of the peroneal retinaculum may be accomplished by direct suture repair or by a supplemental graft from the Achilles tendon.
When surgically treating peroneal tendon subluxation, it's important to
remember to treat any biomechanical factors that may contribute to lateral
instability and ankle sprains. It's important to recognize that these
biomechanical factors may be the contributing causes of what caused the peroneal
tendon subluxation in the first place. If these biomechanical
co-morbidities are not addressed, surgical repair of peroneal subluxation may be
doomed to failure. Two common biomechanical faults found in conjunction
with peroneal tendon subluxation include lateral ankle ligament instability and
uncompensated rearfoot varus.
Lateral ankle ligament instability and ligament tears contribute to
ankle instability and recurrent
ankle sprains. If ligament laxity is not addresses and lateral ankle
sprains continue, surgery to correct peroneal tendon subluxation is likely to
fail. It is not unusual to perform a Brostrom lateral ankle stabilization in
conjunction with a repair of peroneal tendon subluxation.
rearfoot varus is a structural deformity of the heel. Rearfoot varus is an
often overlooked contributing factor in recurrent
lateral ankle sprains.
Uncompensated rearfoot varus is another biomechanical issue that is often
corrected in conjunction with correction of peroneal tendon subluxation.
Correction of uncompensated rearfoot varus is accomplished by a
Dwyer osteotomy of the heel.