Adventures In Massage Therapy: Posterior Tibial Tendon Dysfunction
“The human foot is a masterpiece of engineering and a work of art.”
- Leonardo da Vinci
The Posterior Tibialis is one bad ass muscle. I can’t imagine a structure more tied into foot mechanics and overall foot health than this crazy connected, sneaky strong and often overlooked tissue. How’s that for alliteration?
I had a woman come into my office this week on referral from another therapist. The woman is in her 70’s, extremely active, in excellent health and had recently received a diagnosis of Posterior Tibial Tendon Dysfunction from her doctor. She’s hungry for information and excited to do the work. An ideal client that really got me thinking about how much potential we massage therapists have to help people, and how few massage therapists actually receive sufficient training to provide quality care.
My goal with this blog post isn’t so much to discuss the particulars of my sessions with this woman, but instead I want to take the opportunity to both introduce this under appreciated muscle to folks who may be unaware, and also to provide a framework for the budding massage therapist to assess and treat common orthopedic issues your clients will present with.
You see, I was wildly underprepared for these situations 6 years ago coming out of massage school. There is just no way a newly minted massage therapist in the state of Texas having received 500 hours (500 hours?!) of education can be adequately prepared for the deluge of orthopedic issues they are guaranteed to encounter when working with the general public. It’s a recipe for disaster and any therapist who strives to provide the best care possible within their scope of practice will have to take massive amounts of continuing education to get anywhere near the competency I feel is required to elevate this profession. I’m speaking to myself as much as anyone. We all have to up our game.
So what exactly is my assessment, treatment and exercise strategy to get this Tibialis Posterior muscle back online and my client back to doing the things she loves? Glad you asked! In part 1 of this 2 part series we will explore the Tibialis Posterior through the lens of the HOPRS (History / Observation / Palpation / Range of motion and Resistive Testing / Special Tests) assessment paradigm. Then in part 2 we will look at some useful manual therapy techniques and home exercises that could help this woman get where she wants to be.
Where is it and what does it do?!
First things first we have to know where it is and what it is responsible for when it is healthy and functioning well. Here is a picture from the Complete Anatomy 2020 App to get us oriented:
The first thing to notice about this muscle is that it is super long and super connected. It has attachment to the tibia (shinbone) and fibula just below the knee then proceeds down to the ankle to attach to literally every bone in the midfoot. All of them! It even grabs onto the base of the 2nd - 4th metatarsal (long toe bones) for good measure. You have to imagine that a strong Tib Post is essential for healthy arches.
The second thing to notice is that the muscle makes a very sharp turn as it crosses the ankle and flows into its tendinous attachment onto the base of the foot. When we see sharp turns we have to generally consider the fact that the tissue will experience more friction. The body does what it can to reduce this friction with synovial sheaths, retinaculae and all that good stuff, but the years and use of these structures are well known to develop problems over time. This knowledge helps us palpate and identify Tib Post as the possible irritated structure relative to other tissues in the area.
When functioning properly the Tibialis Posterior has the distinction of being the primary muscle of foot supination. This means that it must eccentrically decelerate (slow down) the normal foot motion of pronation at the beginning of the stance phase of gait. It must then dynamically stabilize the inside arch of the foot and participate in ankle plantarflexion for propulsion and push off so you can take another step. Simply put, this muscle does it all! It is the only muscle that is actively involved throughout the entire stance phase of gait.
Client Assessment
So let's talk assessment. Here are a few simple ways to either confirm or deny the Tibialis Posterior as the possible tissue of interest.
History:
A person will most likely feel discomfort along the medial longitudinal arch and around the medial malleolus. Any pain in this area will likely receive a self diagnosis from the client as Plantar Fasciitis. But we know that the famous fascia of the plantar surface of the foot is but one of many tissues that can become irritated in this area. A key thing that a client may say in their history that could shift your focus to the tibialis posterior rather than the plantar fascia is that the presenting pain either gets better with movement or worse with movement. With plantar fascia issues it is common for the pain to get better as the day goes along and it experiences load. On the other hand with posterior tibialis tendon issues it is common for the pain to get worse as the day goes along and it experiences loading.
Observation:
Visually, you are likely to see what is referred to as the “Too Many Toes Sign” in someone with medial longitudinal arch issues. Now this doesn’t tell you specifically whether tibialis posterior is the dysfunctional tissue or even if there is any dysfunction at all, but when accompanied with a description of pain by the client, it does let you know that some adaptability has likely been lost in the area. The “too many toes sign” is generally described as a flattening of the arch combined with calcaneal valgus and abduction of the forefoot. Here is a picture to get a visual:
Palpation:
Since we know that the tibialis posterior tendon is experiencing increased stress as it makes the sharp turn around the malleolus, we can reliably reproduce the characteristic pain pattern by palpating the tendon in this area and up into the deep posterior compartment of the leg. This will once again help to differentiate the tib post tendon from what the client will most likely describe as plantar fascia pain.
Range of motion:
Range of motion testing is difficult to directly apply to the tibialis posterior as end range eversion is hindered by the fibula. You can however simply assess the basic ankle motions of Inversion / Eversion / Plantarflexion / Dorsiflexion. If you find the joint ROM is insufficient for whatever activities the person would like to use their body for, then you have at the very least a useful course of action in restoring that range of motion that could possibly remove stress from the tendon either directly or indirectly.
Resistive testing:
By placing the foot in a position of end range plantarflexion + inversion and then asking the person to maintain this position while you exert a force in the opposite direction is an excellent way to test baseline strength of this muscle. If they are unable to hold the position easily, curl their toes under to try and support the position, or it reproduces pain in the characteristic area, then you have some indication of dysfunction with the tissue.
Special tests:
My favorite test to attempt to implicate the tibialis posterior is to simply perform a heel raise on one foot. A client with an issue to the muscle will usually be able to do this on the unaffected side but will have significant difficulty on the affected side and will characteristically have the heel flare out laterally. This gives a solid indication of muscle weakness and functionally indicates the client has difficulty controlling eversion.
What Else Can It Be?
The next logical question you have to ask is, “Could it be something else?!” It absolutely could! And to make things even more complicated, it is most likely a combination of things. But before I go off listing a few of the possible things that irritation in this area could possibly indicate, it is worth noting that regardless of the tissue that is deemed to be causing a person’s issue, having a functional and strong tibialis posterior will elevate the functioning of the entire system. That is one reason I think getting to know this tissue well is useful for not only massage therapists, but all people with feet. You can’t go wrong with a stable and adaptive arch and will most likely improve whatever named condition is ailing you.
So that being said, here are a few other things to consider when looking at foot pain:
Nerve irritation: Tarsal Tunnel Syndrome / Mortons Neuroma
Systemic disorders: Ehlers Danos, Lupus, Rheumatoid Arthritis
Previous Traumatic Injury to the area
Edema
Obesity
Sedentary
Improper footwear
Overuse or recent changes in activity
Did I Keep It Simple?
It’s possible that I failed to keep it simple. For sure I made it more complicated than I initially intended when setting out to write this post. I guess the truth is that it isn’t that simple at all. Pain is weird just like feet! Hopefully though, a few useful nuggets were gleaned by anyone who made it this far. I’ll make extra effort to do better in part 2 when we discuss a few manual therapy and exercise interventions that can get that Tib Post back to being the bad ass it was always meant to be.
If your interest has been piqued for more, here are a few of the excellent resources that the information in this article is derived from:
1. Whitney Lowe: https://www.abmp.com/textonlymags/article.php?article=2001
2. Courtney Conley: https://youtu.be/mdlC5Dk2KYo
3. Donald Neumann: https://www.amazon.com/Kinesiology-Musculoskeletal-System-Foundations-Rehabilitation-dp-0323287530/dp/0323287530/ref=dp_ob_title_bk
4. Andreo Spina: https://functionalanatomyblog.com/2010/01/11/case-of-chronic-tibialis-posterior-dysfunction-with-a-partial-tear/
5. Joe Muscolino: https://learnmuscles.com/
