Tibialis Posterior Syndrome

[karen.hankey]

Ok, full history as much as I know.

24 year old semi-pro footballer. No previous ankle injuries. On new years day got a kick on the ankle whilst playing. Continued to play for rest of the match and pain steadily increased. Saw a physio who didn't really diagnose, but they loosely said he had possibly pulled the deltoid ligament off the posterior aspect of the medial malleolus. He had ultrasound,interferential and told to rest. This he did for 6 weeks until i saw him.

On my assessment he had no pain on passive/resisted ankle movements. He said it only hurt on heel strike when running. He did have a limp when walking so presume this also hurt a bit as well. He had pain on palpation over the tib post tendon extending up the leg, so not localised to the posterior ankle. I treated him that day with DTFs and massage and he iced it after. Tried a strapping but to no advantage. Saw him 5 days later, pain had localised to posterior ankle. Treated the same way as above, but had looked up strappings and used the low dye technique. he went to training that night and managed to warm-up and a few sprints without pain. Was on the bench that weekend, more to make up numbers as not really fit enough to play. The following week using the strapping he trained fully and played 90 mins at the weekend. Felt sore after, but iced it and better. However, last week he didn't train with the squad, but trained on his own and didn't strap it up, so pain had increased when I saw him Saturday. Strapped it up for the match that day and he played 90 mins - visably struggled though and admitted that after. Playing tonight (Tues) as well, not sure a good idea but decision out of my hands.

The problem I have is lack of contact with the player. Due to our work committments it is hard to fit in some treatment. Obviously can't treat him on match day so we are struggling a bit.

Basically what is happening with him a the moment is we are sorting him out to be able to play for the the rest of the season, then in the summer I am hoping to do the strengthening programme when his work committments drop.

I was going to strengthen the entire ankle through theraband work, also improve balance and then specifically target the tibialios posterior. I think the key is the eccentric tib post stuff as its only really sore when increased load is placed onto it.

Any advice appreciated.

[physiobob]

I will offer some more advice on this soon but as a general comment: If this guys had no prior issue then there is not a justification that he should be considered 'weak' in an overall sense in this area. His pain might just because he is reintroducing some load on a damaged bit of tissue that is still healing, or even has healed but is still sending afferent information up to the brain due to it's non-use.

I agree that eccentric training, especially to soleus, initially both legs at the same time, later on single leg (to add in Tibialis Post. and Peroneal balance) would be useful in desensitizing the area. One must be able to prove weakness if prescribing strengthening. In this case it might not be weak and might just need a graded return to activity levels. Think of how sore things are the first day after skiing for the season, or after that first aerobics class... pretty sore.

[alophysio]

Ok, Thanks for that.

How long has the season got to go? Can he take 3 weeks off?

Theraband is going to do nothing considering the amount of forces he is putting his ankle thru in 90mins of football (and i think you mean soccer right). I would do the eccentric loading exercises now and back his training off and teach him how to strap himself for game day.

Another alternative if taping helps is to use a small orthotic for his boots. You could probably get away with a "ladies" slimtech soft interpod orthotic as they go well in soccer boots. They are small, narrow and flexible to be in those shoes yet supportive enough for this purpose.

An alternative for treatment might be just to see him on a "strapping" treatment where he only comes in for 5 mins but pays half price. You can run 5 mins late for your next patient but get the extra income...The ground rules would have to be established that he is only there for strapping and a full appointment is required for advice, treatment etc. If he doesn't like the fees, he can learn himself when he pays you for a full session.

The eccentric exercise is outlined in Clinical Sports Medicine but essentially it is the lateral edge of the foot over the edge of the step. The eccentrically lower the foot into eversion. Then return to position - can use other foot to take the load off on the return so exercise is eccentric only.

See how you go with that!

[karen.hankey]

Thanks for the replies.

With the weakness, I should have pointed out that it is not my diagnosis. The player feels weak in general in the ankle, probably from lack of use.

The season ends end of April and then he can rest until pre-season. He can strap himself for the game if needed but I am there for most games.

Will try the exercise on the step with him.