Posterior tibial tendonitis

I have had problems with my left foor for 8 months now. It started as pain in my middle calf muscle whihc resulted in teh outside of my ankle swelling. The physio initally thought in was achilles tendonitis. This calmed dowm with a couple of months but I then developed plantar faciaitis. Just as this seemed to be healing my arch started to get very score adn a bit swollen on the inside of my ankle and along the posterior tibial tendon. Eventually my podiatist decided I really did need special orthotics adn the off the shelf ones were not doing that much good. He is gradually building up the arch support in them with cushioning but it is still really sore adn is starting to be sore in the right foot too.
FOr some reason ultrasound and laser seemd to make it worse.
The wear Soloman trainers but I got these at the exact pooint of my first injury. Although they seem good shoes they are quite narrow at the toe region for me.
I am getting reall y worried adn was wondering if:
1) could my shoes be causing this as I have not had arch pain in the past although I have had plantar faciaitis?
2) could the arch on my othotics be built up too much ?
3) will this injury go away with time?
4) is there anything else I should do?
Sorry but am just so worried about it as I like to be a very active person.

Any help will be much appreciated,
Anna

Hi Anna. A couple thoughts for you...
1. Are you still seeing your physiotherapist. It MAY be important to address more than just your foot. For example, hip strength and / or your back can play a role. Basically a thorough assessment should be done.
2. Orthotics are a very valuable addition to a rehab program. An arch CAN be built up too much however I am sure that your podiatrist assesses specific things with your foot and general alignment to ensure that is not the case. But...don't be afraid to ask questions and have him/her describe what they are changing and why with the orthotics.
3. I LOVE Soloman shoes and yes they are good shoes. However....I do have a narrow foot. There are lots of good shoes out there but the most important part when choosing them is to ensure they fit YOUR foot. Also ensure that they fit well with your orthotics. If you are in an area with a good specialty running store, the sales people are very knowlegable about feet and which shoes would best suit your needs. (This is the case in Canada anyway....I would think it would be the same in Scotland as running is a pretty universal activity)

Thanks so much for your reply. I have stopped seeing the physio at the moment as my podiatrist advied that I lay off the deep massage, ultrasound and laser for a while to see if it calms down. He think that continual aggrevation of it is not helping. I have followed his advise hoping so much that he is right. I have also just gone to a good running store and got a pait of good trainers that take orthotics well adn are quite stiff in the middle - the shoe they recomended.
I am not sure why my other foot is not flairing up as well or infact why the firt one flaired up at all.
Do you see people with this type of injurying getting better? I so hope so.
Anna

Yes, they definitely get better.
If ultrasound and laser were irritating your symptoms then likely the condition was fairly acute...i.e. fairly inflamed. In which case, it makes sense that deep massage would continue to irritate it.
In the case that the affected structures are inflamed, they need to calm down before moving on in the rehab process. Unloading these structures is important which is basically what you are doing with orthotics (and activity modification which your podiatrist should be able to help you with as well).
It really sounds like you're on the right track. Try to be patient but also stay active with this rehab process (keep asking questions; make progressions as possible based on what you're advised to do)
I would encourage you to consult a physio again as things settle down. Not necessarily for deep massage as you mentioned but for a full assessment of your back, hips, feet etc. It's important to know how to prevent it from recurring and quite often the answer is not actually just in the feet.
Good luck!!

Thanks so much for your reply. My podiatrist has envouraged me to do some walking as I have been using my bike to get around as much as possible and so he said he doesnt really know how it will react to the orthotics adn I need to build up the muscles needed. I followed his advise this week and although I wouldnt say it has got any worse so far the other foot which never hurt before has started to hurt. I actually feel quite confused as I dont what is causing it and why it is not getting better. I guess I am more anxious at the momnet as I have trip for my PhD to Poland next week where I will have to do a fair bit of walking in the forest.

A couple things you may want to try that could help with increased walking on your trip...
1. hiking boots. Good running shoes allow you to roll over your foot which takes pressure off the healing plantar fascia better than unsupportive shoes. Hiking boots have a stiff sole that doesn't allow the foot to flex as much which is valuable for hiking (when on uneven ground / under the weight of a heavy backpack etc.). They are valuable when it comes to healing plantar fascia (even when not hiking) because they may allow you to walk longer when necessary without putting much increased stress on the foot. Although all tissue needs some stress to heal well (which is why your podiatrist is trying to get you to increase your walking a bit), the tissue needs to be supported well when increased activity is necessary (like your trip to Poland). Continue to wear your orthotics in your hiking boots as well.
2. Hiking poles allow you to take a little pressure off the lower extremities. The alternative is a cane....I just said hiking poles because I am used to dealing with a clientele that shudders at using a cane but feel they still look athletic / outdoorsy with hiking poles instead. If you opt for a cane, talk to you podiatrist or local physiotherapist to ensure you are walking with it correctly.

Unfortunately needs for life don't always jive with rehab needs. So these are just two ways that may allow you to do what you need to do while decreasing stress to those healing feet.

As for the other foot...it's hard to say from here but it is not uncommon to end up with some issues on the other side due to compensatory reasons. Basically, the body is not stupid! If something hurts, it tries to find ways to move that feels a little better. Unfortunately those compensations can lead to other issues. If you are actively dealing with the one foot, the other one will inadvertently be addressed so you don't have to fear that you are "falling apart"!

On a side note....what's your PhD....why are you walking in a forest in Poland? Sounds interesting!

I just wanted to thank you so so much for all your supportive replies. It really makes such a difference when you are feeling really anxiuos about variuos injuries. I have good hiking boots are am trying out my new asics trainers tonight. My podiatist advised me to get a pair and these are the ones the people in the runnig shop said too. They wont be so good for hiking but I have my boots for that. At least they are quite stiff across the middle and should support my arch (is that correct?). I also wanted to say that my foot doesnt hurt to point of flex, turn in or out or stand on my tip toes - all the normal symptoms on the web???
I see my podiatrist tomorrow so I will see what he says about my other foot.
Thanks so so so much again - if I lived near you I would def. come to your clinic!
Anna
P.S. I study ecology and my PhD is looking into ecological processes (predation and parasitism) in agroecosystems. I am going to Bialowieza in Poland on a week long field techniques course where we will be learning how to radiotrack animals, identify and survey bats, birds, small mammals etc. Also visit a bison reserve and if my foot is good a hike around the Bialowieza Forest. Sounds fun so hope foot behaves.

Good luck in Poland...very cool! (Although I'm glad I'm a physio...don't think I'd want to purposely find bats!!!)

I have just seen the podiatrist and he thinks that it is the posterior tibial nerve which is causing the pain on my right foot. It is a very localised acute pain that is sure when pressed. I was a bit worried that it was the orthotics that were causing it but he is pretty sure it is not adn said that it would have come on when I first got them - two weeks ago. I have increased the amount fo walking recently and it coincided with this so there are various possibilities it could be. He recommended I just carry on wearing the orthotics ans keep walking and see him when I get back from Poland. Do you think that is sound advice? Is there any damage I could be doing to the nerve by wearing the orthotics?

Where is the pain in your right foot? Heel pain?? Just want to clarify because when I hear "posterior tibial nerve", I'm thinking medial plantar nerve (branch of the tibial nerve) but just want to make sure i'm not assuming things here...

Before I respond I'm going to offer a "disclaimer" to help explain where I'm coming from.....
I started using this forum to discuss specific cases with other physios and totally avoided the "Patient Corner" except to have just a quick read to see if there was anything really interesting including what kind of responses were coming from other physios. The main reason I avoided it, was because other than basic info, I don't feel comfortable giving specific answers when I can't actually assess that client in person. Also, I don't like second guessing the professionals that the client has actually seen. I needed to tell you this so you know why my response may seem a little "fluffy".....

What I'm saying is that I don't want to second guess your podiatrist because he actually assessed your foot and has seen the progression since first getting your orthotics etc.

So, can a branch of the tibial nerve be irritated with foot injuries, changes in footwear etc. - YES.
Should you stop wearing your orthotics - NOT NECESSARILY. The nerve COULD be mildly irritated from biomechanical changes from the orthotics or a change in gait. I really wouldn't think that the nerve would be irritated MORE by the orthotics however it's really hard to say from here what irritated it in the first place and what to change to get the pressure off that nerve.

Basically, what I'm saying is trust the person that has been working with you (your podiatrist). BUT if your gut is saying, "this doesn't make sense" (based on your symptoms, the sequence of events etc.) then ask him to explain more thoroughly what you should do to make your rehab a little smoother (because that right foot is going to influence the left and your success and compliance with the orthotics). I can't imagine there are many health care professionals out there (physios or podiatrists or whatever) that wouldn't get it if you said, "Holy crap! I'm going to be chasing bats in a forest in Poland soon and I need to know what to do!!". (i.e. I can't imagine he's going to think you're over-anxious for asking questions...so ask questions.) If that doesn't work, have an assessment of your situation by a physiotherapist (again). If you do that, just make sure you let them know everything that you have already done and that your other foot has flared with some past physiotherapy treatment.

Whew!! That was a long-winded answer!! What I'm trying to say is that the physios that access this forum can all help to a certain extent because of our training and interest in the puzzle that is the human body. And although we can assess injuries to an extent via a computer, it's not as good as seeing you in person!!

Sorry...don't know if that helped at all....

Thanks so much for your reply. I fully appreciate that it is not possible to give a full medical diagnosises over the internet but I guess when I am anxious I just look for a bit or reassurance!
I am not sure if it is def tarsal nerve or tendon and he said that if it hasnt cleared up after Poland he would like to doctor to assess to see if it is the nerve or not.
When I first got the orthotic it felt strange and then after a couple of days it was fine. The it flaired up after the physio, then he took them away to increase the arch (which was always the plan as the actual orthotic is a low arch as he wanted me to get used to increasing the arch gradually) and the pain got really bad and both feet felt really sore all over, THEN (!) i got them back and they felt strange but at least I could walk, then I increased my walking as he said and theey still felt strange but could tolerate them although left foot didnt feel much better, then increased walking and right foot got bit sore in Post tibial tendon area. Now recommendation is to wear my new trainers but walking boots when out walking but carry on with insoles. I questioned whether I shoul take out the additional padding to increase the arch but he wants me to carry on for a bit (had them in for 10 days now). The additional padding is about 3-4mm on my right and may 6-7 on the left. It is quite soft. HE said that when I get back from Poland he will put a proper top on them but hadnt done that previosuly as it cant be taken off and on adn wanted to build up the arch gradually.
An additional think which I have not mentioned is that I have suffered from very severe anorexia for 20 years adn thus my weight has been dangerously low for an exceedingly long time. HOWEVER I have managed to gain quite a significant amount recently and my aim is to get to a healthy BMI. The podiatrist thinks that that may be contributing to the problem (weak bones adn perhaps degenerated fibres in the tendon, low fatty paddiing on foot, increased healing time).
Historically I have had many foor problems, i.e plantar faciatis, stress fractures etc adn so he thinks that this is also reason to keep going with orthotic.
Anyway, after that long story I think you have a better picture but not sure if you can say any more or give me any more help from Canada!
MANY MANY MANY thanks,
Anna

As you said, I don't think I can say much more either. Sounds like you guys are trying to figure things out....that's the important part is that you are still working actively to find a solution.
Tib.post. can be a real "trouble-maker" when there are changes to footwear ( or not wearing any) but it should improve. It is a muscle that is actively involved in supporting your arch so as it strengthens up and gets used to its new role with the orthotics it SHOULD improve. Since the orthotic is soft, the pressure from it shouldn't be further irritating the nerves in the area (I wouldn't think so anyway).
All I can say is... it sounds like you're on the right track... but it's a process. Your requirement for increased walking in Poland makes it a wee bit more difficult but not impossible. Boots will help; although your feet are getting used to the orthotics, they will help; hiking poles may help if you are able to use them.
Just want to add one more thing... my cousin has a history of anorexia which is when I learned a little about it...I don't pretend to know alot. All I can say is you are to be commended for your goal and I wish you the best of luck with that goal as well as the issue with your feet. Take care!!

One last question before Poland!
My right foot has started to really hurt on the inside ankle. I can feel exactly were the orthotic is putting pressure on and it seem to radiate up my ankle. I took the orthotic out last night as I basically could not walk anywhere with it in and out my normal padded in sole in which has a paadded arch in it anyway.
My left foot seems to have accommodated the orthotic better adn gets sore with out it!
Typical no clear answer so I was wondering if:
a) I could wear one orthotic and one just with padded insole (they are just Prothotics which I have wore for a couple of years and have been really good)?
b) my left orthotic is build up bigger than my right - may than have caused me to put more pressure on my right as it has not been sore before adn was fine with the orthotic for the first week?
Thanks heaps from the tres worried Anna!

If you wear a different orthotic on the right foot you just have to ensure that one doesn't lift you up higher...ultimately giving you a leg length discrepancy. Maybe have your podiatrist have a peak at your old orthotics to make sure that it will be okay for comfort measures.
Speaking less from the "medical" side and more from the "common sense" side....I personally would take both pairs with me to Poland. Your feet (and the rest of your body for that matter) are getting used to their new biomechanics due to the orthotics. If it's so much of an adjustment that your feet are sore and your old orthotics make it feel better....wear the old ones for a little while.
BUT...as I said before, don't mix and match your old right with the new left unless you know one doesn't lift you up more than the other.