Tibialis Posterior Dysfunction (TPD)
Posterior tibial tendon dysfunction is the most common cause of adult acquired flatfoot. Patients will complain of medial foot pain, weakness, and a slowly progressive foot deformity. A “too many toes” sign may be present and patients will be unable to perform a single heel raise test. The optimal treatment may change based on the progression of deformity and stage of disease. Early identification and prompt initiation of treatment can halt progression of the disease and help avoid surgery.
The tibias posterior muscle originates in the deep legs and its tendon runs behind the ankle and inserts onto the midfoot. It stabilises and raises the arch of the foot and is essential in preparing the foot for forward progression. Damage to the tendon is usually due to repetitive microtrauma. With poor blood supply to the area, the trauma results in progressive degeneration leading to a rigid flatfoot deformity.
Risk Factors for TPD:
- Diabetes – Hypertension
- Obesity – Cortisone use/ local steroid injection
- Previous Surgery – Foot and ankle trauma
- Arthritic conditions
Stages of TPD:
Stage 1: Tendon intact with inflammation but no deformity
Stage 2: Tendon is ruptured or nonfunctional with flatfoot that is passively correctable
Stage 3: non correctable and arthritis evident of the rear foot
Stage 4: Stage 3 with ankle degeneration and gross malalignment
Management of posterior tibial tendon dysfunction relies upon accurate staging of the disease, as both nonoperative and operative treatment options change with each disease stage. Aims of treatment are to relieve pain, improve function, restore alignment by correction of any deformity, and to halt or slow progression of the disease.
A CAM boot can be used to immobilise the foot. If this brings relief, the patient can have shoe inserts or modifications, orthotics or an ankle-foot orthosis (AFO) fitted. Orthotics aims to provide arch support and correct the flexible component of the deformity. Physiotherapy for achilles tendon stretching and tibialis posterior strengthening can also help. In cases that do not respond to conservative therapy or cannot be managed with bracing, surgery may be considered. Surgery involves complex procedures with very long recovery periods.
Medial Tibial Stress Syndrome (MTSS) (Shin Splints)
Medial tibial stress syndrome is the most common form of exercise-induced leg pain. It represents a bone stress reaction of the tibia, the major weightbearing bone of the leg. It often results from a rapid increase in level of weight bearing exercise. The pain from MTSS is usually expressed as a dull ache following exercise that may last hours to days, and may even persist during normal activities of daily living. In the early stages of MTSS, pain resolves with rest. However, without rest, pain may transcend previous levels into severe, sharp and persistent symptoms. People affected by MTSS often undertake periods of rest only for pain to recur with resumption of exercise.
The majority of patients suffering from MTSS can be treated conservatively. The mainstay of conservative management of MTSS involves rest from weightbearing activities followed by a gradual return to activity. Proposed adjunctive treatment for MTSS includes heat/ice, massage and extracorporeal shockwave therapy.
Biochemical examination is essential for those with MTSS. It has been shown that those with pronated (flat feet) foot postures are up to three times more likely to experience MTSS. Orthoses are advocated for those exhibiting excessively pronated feet. Treatment of MTSS also include proper footwear and elimination of training errors (see gradual resumption to exercise handout).
More recent evidence suggests that those with MTSS have deficiencies in calf muscle endurance. Consult with your Clinician to assess your level of endurance.
Forefoot overload is a broad term used to define a group of pathologies of similar origin. Individually the conditions may include:
- Bone stress- where bone is broken down and is at risk of stress response/ stress fracture. This normally occurs at the head of the metatarsal bone.
- Inter metatarsal pathology- including neuromatoma (pathological thickening of the nerve sheath) and bursitis. Clinically these two problems are difficult to distinguish as bursitis may apply pressure to the nerve resulting in symptoms, (shooting pain, burning, numbness and a “full” feeling) similar to a neuroma.
- Synovitis- inflammation of the fluid in the metatarsophalangeal joint.
- Plantar plate pathology- where the plantar ligament attaching the toe to the metatarsal is ruptured or partially severed resulting in subluxation of the toe (and possibly a hammer toe).
- Transverse ligament damage- resulting in splaying of the toes.
From a mechanical perspective, these group of disorders result from mechanical overload. That is, too much repetitive pressure has been applied to this area and the body has not been able to withstand the force. During walking the body is subject to one and a half times your body weight. This increases to up to three times for running and five to six times for sports involving jumping and twisting.
The aim of mechanical treatment is to deflect load from this area. This may be done with footwear alteration and foot orthoses.
It is also important to improve your body’s ability to withstand load. Often those with forefoot overload are exceptionally restricted through the ankle joint. The ankle joint is essentially a hinge joint which allows the extension of the body over feet. When the ankle is restricted in motion, the heel may unweight quickly during gait resulting in weight bearing load to the forefoot. Range of motion can be improved through tissue massage and stretching. As passive stretching can result in a deficit of muscle power, it is suggested that once range of motion is achieved, strength over range of motion is the aim. Strengthening programs or progressive load programs are essential in improving the body’s ability to withstand repetitive weight bearing forces.
Most cases of forefoot overload improve with mechanical measures. In some cases whereby specific tissue is extremely damaged, other treatments may be required. For example neuromatoma may require injection or ablation therapy or in some cases, even surgery. Metatarsal stress may require a period of weight bearing rest in a below knee splint.
Recently Performance Podiatry Geelong spoke to an elite group of young footballers participating at the V-Line Cup in Geelong. Following are the strength and mobility exercises suggested:
- Table Top
- Decline board ankle mobility and lower limb strength
NB. This exercise is to be performed using body weight only to start with.
4. Nordic Hamstring curls
For specific information regarding repetitions/ sets please do not hesitate the clinic.
Selecting the best running shoe for you can be a daunting process. The following relates to technical guidelines that may help the process. However, there is not a “one size fits all approach.” Some people may well follow the complete opposite to what is proposed here. For those individuals, they may well be adaptive to their footwear and quite resilient to loading forces (pressure from the ground when running) and injury in general.
- Comfort: Above all factors, footwear must be comfortable. Research suggests that if an individual picks a shoe based on their perceived comfort, they are less likely to get injured. There are many factors (some of which will be discussed in further detail) that can impact comfort. One of the most important factors is “fit.” A good running shoe store can help you to ensure your heel is held firmly in the shoe and your forefoot is not too compressed. Ensuring adequate depth, width and length of your footwear is vital. If your runners are too tight, you may lose the ability to properly move your toes and contract the associated musculature. This can have a detrimental effect on your load capacity (your ability to withstand running forces) and running efficiency in general. When your toes have space and can move without impediment, deep musculature of your legs and feet are able to work more efficiently than if your toes are constricted.
- Alternating footwearAlternating footwear has been shown to decrease injury rates. By using footwear with different features, weight bearing load is varied to the body. For example, increasing the pitch of footwear (higher heel), you may decrease loading through the forefoot and distal leg. Conversely, a lower pitch runner (flatter pitch) may increase the loading of the forefoot. An example of alternating footwear could be: An experienced runner of around 80-100km mileage per week alternates three different types of athletic footwear:
1. Standard 10-12 mm pitch runner chosen based on comfort to perform easy runs on a daily basis
2. Refined footwear of lower pitch and bulk in general- used for key speed sessions
3. Maximalist footwear- cushioned footwear (e.g., Hoka) used for recovery sessions
3. Footwear selection based on age
All things being equal, the older you are (very generally speaking!), the less resilient you may be from weight bearing exercise. Good training may counter advancing years.
For older athletes, they are more likely to have adapted to wearing positive heeled (heel elevated in relation to the forefoot) footwear over their lifetime. Additionally, older individuals are more likely to experience stiffness of all components of the musculoskeletal system (calf muscles, achilles tendon etc). This is further exacerbated by a lifetime spent excessively in a flexed position (sitting at work, working on computers).
With these factors in mind, it will generally be safer for older athletes to wear footwear with higher pitch (or maximalist footwear). Stiffness and footwear adaption is not set in concrete. Mobility can be improved and footwear options may change based on an individual’s range of motion and resilience to loading.
Younger athletes generally have less history of injury and better mobility. As a result, their musculoskeletal system is able to cope with a greater variation of footwear features. From a personal perspective, I like the concept of more minimalistic footwear to prevent footwear from generating contracture in soft tissue. However, I am very aware of the natural fallacy (the concept that natural technique like barefoot running or minimalistic footwear is best). This approach is flawed as there is not a one size fits all approach.
4. Footwear selection based on mobility
Leg stiffness- If someone has excessive leg stiffness, it is generally excepted (but not necessarily supported by research…. yet!) to wear footwear with higher pitch.
5. Footwear selection based on History of injury
Achilles injury- use higher pitch footwear or footwear with forefoot rocker (e.g. Hoka)
Plantar fascial injury- higher pitch footwear
Forefoot pain-higher pitch or maximalist footwear
knee pain- minimalistic footwear. Minimalistic can help a runner strike beneath their centre of mass which can decrease loading forces through the knee. However, in this case, running assessment is key. It is vital to ensure running cadence and sagittal biomechanics are assessed to ensure decreased knee forces. Low pitch, minimalistic footwear can help but guidance may be required. For example, a runner with degenerative knee issues may also have history of Achilles pain. In this case, the individual may have to choose footwear features which are not entirely assistive of one of the pathologies. Reverting back to perceived comfort may help decide what footwear features the runner ultimately decides on.
6. Footwear selection based on history
Footwear history is an important consideration in deciding what shoe is best for an individual. For instance, if someone has been wearing a shoe with a particular feature like rearfoot support`** for a prolonged period of time (e.g., 10 years) without any injury, it may be unwise to change the type of shoe.
7. Footwear selection based features such as support
Medial support is footwear feature often used to control foot pronation (“rolling in”). Most research does not support the notion of such features reducing injury risk. However, in certain cases, it is accepted that shoes stronger on the medial ( midline side) are vital. For example, in those with tibialis posterior dysfunction, a serious foot and leg pathology, it would be recommended to wear footwear with such supportive features.
One final note. Good footwear alone will not prevent injury. Good training principles focussing on gradual overload, strength and resilience and optimal health are vital.
** Footwear features such as medial support do not always equate to changes in body biomechanics (kinematic and kinetic changes).
Knee pain is an all too common complaint in runners. There are many causes for this knee pain but one of the most common injuries is called Anterior Knee Pain (AKP) or patellofemoral pain syndrome (PFPS). This makes up to around 25% of all identified knee injuries in runners. The interesting problem with AKP is that it is a diagnosis made from its only symptom of pain which is usually located around or under the knee cap. This condition is rarely associated with any structural damage.
Historically we used to think that one of the primary causes of AKP was due to the misalignment of the patella during running. Clearly there is an association between tight and overactive structures around the knee that can influence the position of the patella through its movement. Addressing these through a structured stretching program and a course of manual therapy can help. However, more recent research is shedding new light on the most common cause of AKP. Hip weakness and early fatigue during the stance phase of running leads to a valgus or ‘knock knee’ posture and this has shown to be a leading cause of AKP. Simply put, as your foot comes in to contact with the ground the muscles on the outside of your hip must become active to stabilise the pelvis girdle and to stop it tipping forward on the opposite side. If the muscles do not do this then your knee will turn in slightly (genu valgum) to compensate causing a change in the biomechanics and probable pain around your patellar! Studies have shown that by incorporating specific hip abductor strengthening exercises in to a rehabilitation program, not only does the peak hip abduction strength improve but stride-to-stride knee joint variability improves, a reduction in genu valgum is observed during stance phase and most importantly pain is reduced!!!
So what is a good exercise to improve your lateral hip muscles? Well my 2 favourites include the resistance band walk and the lateral shuffle. All you will need to do these exercises is a loop of resistance band and a bit of space. Loop the band around your lower leg or ankles and stand in a half squat position with your feet wide enough apart to feel some strong tension in the band.
- To do the resistance band walk all you do now is walk forward in the half squat position keeping the tension in the band by making sure your feet stay wide apart. Take around 20 steps forward and then 20 steps backwards.
- To do the lateral shuffle, instead of walking forward in the half squat you take a step to the right keeping the half squat and after planting your right foot you move your left foot equal distance to the right. Take around 20 steps in each direction.
There are many more exercises that can help improve your function and running form and so if you would like a comprehensive assessment and rehabilitation program developed using the latest in evidenced based research then please do not hesitate to contact us for an appointment.