INJURY TIBIALIS POSTERIOR DYSFUNCTION

should also be painful. As the condition progresses, the pain on palpation will become less localised and may spread up the muscle, towards the knee. Lake and colleagues report that as the pain progresses, the patient may experience lateral foot pain due to impingement between the calcaneum and fibula (4). Also, patients may start to report knee, hip or lumbar pain. Pain in these areas will be due to the biomechanical changes occurring. It should be noted that as the injury progresses, the inflammatory signs will diminish. At this stage the biomechanical issues rather than the reported area of pain are the most important to address.

TREATMENT

Within the first 48 hours following a direct contact injury, ice should be applied to decrease the swelling and reduce the inflammation. Another useful treatment at this point may be the use of low-dye taping to take the load off the tibialis posterior by holding the foot in supination. After 48 hours, deep transverse frictions may be used to help re-align any damaged muscle fibres and to stimulate the healing process. Once the pain levels have reduced, the patient needs to begin an eccentric strengthening programme of the tibialis posterior; in addition, exercises to correct any biomechanical factors need to be addressed. It is thought that orthotics may

help most patients by maintaining the medial arch and therefore reducing the stress on the tibialis posterior. However, in certain sports, such as football, getting an orthotic to fit inside the boot is very difficult. Therefore, each patient still needs to follow a re-strengthening programme.

EXERCISES Not every patient needs to complete every exercise. The rehabilitation programme needs to focus on the patient’s level of dysfunction and level of activity. Some examples of exercises are listed here: n Concentric strength: use a Theraband initially to strengthen plantar flexion and inversion separately and then eventually by combining the two movements. n Eccentric strength: stand on a step with the medial arch off the side. Slowly lower the arch off the end of the step

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An overview of the anatomy of tibialis posterior

THE AUTHOR

Karen Hankey, Bsc (Hons) is a graduate sports rehabilitator from Salford University. She has worked with numerous football clubs, including Liverpool Ladies FC and Bolton

Wanderers academy. She is currently working with the first team squad at Scarborough Athletic FC. She also works within a number of private clinics in Cheshire and within the occupational health department of a large blue-chip company.

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and rise back up. n Walk on heels: walk on the heels into eversion to control the foot at heel-strike. n Wobble board: bilateral and unilateral. n Toe-grasps: use the toes to grasp an imaginary object on the floor.

CONCLUSION Due to tibialis posterior dysfunction being, in most cases, a progressive disorder, diagnosing and treating this condition quickly and effectively is very important. The low-dye taping technique is of

great value to this condition because it can act as a diagnostic and a treatment technique.

References

1. Norris CM. Sports Injuries: Diagnosis and Management, 2nd edn. Butterworth Heinemann 1998. ISBN 9780750628730 2. Kohls-Gatzoulis J, Angel JC, Singh D, Haddad F, et al. Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot. British Medical Journal 2004;329:1328–1333 3. Kohls-Gatzoulis J, Angel JC, Singh D. Tibialis posterior dysfunction as a cause of flat feet in elderly patients. Foot 2004;14:207–209 4. Lake C, Trexler GS, Barringer WJ. Posterior tibial tendon dysfunction: a review of pain and activity levels of twenty one patients. Journal of Prosthetics and Orthotics 1999;11:2–7 5. Trnka H-J. Dysfunction of the tendon of tibialis posterior. Journal of Bone and Joint Surgery 2004;86B:939–946

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Video showing use of theraband to strengthen tibialis posterior (thanks to Primal Pictures)

Video showing PNF on tibialis posterior (thanks to Primal Pictures)

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