Tibialis Posterior Tendinopathy

In this video, I will demonstrate the assessment and treatment protocol for medial tibial stress syndrome or shin splint, also known as tibialis posterior tendinopathy.

Modalities demonstrated in this video:

  • Myofascial Dry Needling (MDN) applied to the Soleus muscle
  • Isometric Conditioning
  • Kinesio Taping (KT)

The tibialis posterior is located in the deep posterior compartment of the leg.

It has a tendon that runs inferiorly on the inside of the lower leg and behind the medial malleolus and attaches to the midfoot.

This stabilising muscle maintains the arch of the foot and supports the ankle.

Muscle Origin Insertion Action Innervation
Tibialis Posterior Posterior aspect of interosseous membrane, superior ⅔ of medial posterior surface of fibula, superior aspect of posterior surface of tibia, and from intermuscular septum between muscles of posterior compartment and deep transverse septum Splits into two slips after passing inferior to plantar calcaneonavicular ligament; superficial slip inserts on the tuberosity of the navicular bone and sometimes medial cuneiform; deeper slip divides again into slips inserting on plantar surfaces of metatarsals 2–4 and second cuneiform Adduction & Inversion of Foot; Assists in Plantar Flexion of Ankle Tibial Nerve

Tendinopathy contributes to pain and weakness.

  • Weakness is synonymous with neuromuscular inhibition, which is indicated by the impairment or deficit in motor control.
  • Pain represents the response of muscle nociceptors to noxious mechanical stimuli, as a result of overuse, ischemia or inflammation.

The treatment protocol for the first two phases of tendinopathy includes:

  • the application of trigger point therapy at and surrounding the site of pain;
  • corrective exercise to accommodate the kinetic chain deficit.
Differential Diagnoses
Medial tibial stress syndrome or shin splint Pain felt anywhere from along the shinbone from knee to ankle, due to chronic overuse or overload stress.
Posterior tibial compartment syndrome Often confused with medial tibial stress syndrome, compartment syndrome occurs when an osseofascial compartment pressure rises to a level that decreases perfusion of the arterial supply, resulting in ischemia to the muscles and nerves of the compartment. The symptoms include tightness, burning, pressure, cramping and/or pain in the lower leg during exercise, around the calf and shin region. The pain is difficult to assess in a polytrauma patient, and impossible to assess in a sedated patient.
Tendon rupture The tendon separates in whole, or in part, from tissue to which it is attached when stretched beyond its capacity. See a doctor.
Tenosynovitis and tenovaginitis Tenovaginitis refers to inflammation of the sheath around the tendon, whereas tenosynovitis refers to inflammation of the synovium (lining of the sheath) around the tendon. Treatment consists of complete rest and possibly applying a splint to support the tendon.
Achilles tendinopathy Achilles tendinopathy is a common overuse injury caused by repetitive energy storage and release with excessive compression. Research has found that this type of injury does not involve inflammation and is most likely due to a series of microtears (tendinosis) that weaken the tendon. Morning pain is a hallmark symptom because the Achilles tendon must tolerate full range of movement including stretch immediately after getting up in the morning. Symptoms are typically localized to the tendon and the immediate surrounding area. Physical examinations of the Achilles tendon often reveal palpable structural thickening.
Deep vein thrombosis (DVT) A blood clot in the deep veins is a concern because it can cause life-threatening complications. A blood clot (thrombus) in the deep venous system of the leg or arm, in itself, is not dangerous. It becomes potentially life threatening when a piece of the blood clot breaks off and embolizes, travels through the circulation system through the heart, and enters into one of the pulmonary arteries and becomes lodged. This can prevent blood from flowing properly through the lung and decreasing the amount of oxygen absorbed and distributed back to the body. Symptoms include: pain; swelling; warmth; redness; leg cramps, often starting in the calf; leg pain that worsens when bending the foot; bluish or whitish skin discoloration.
Tarsal tunnel syndrome Tibial nerve compression within the tarsal tunnel could come from fibrosis, ganglion cysts, osteochondromas, trauma, ankle sprains, obesity, tight shoes, or other causes. Symptoms include: burning, numbness, tingling and weakness of the plantar muscle of the foot and toes. The pain is worse with prolonged use such as standing, activity, and motion. Tinel’s sign can be elicited with percussion on the tibial nerve, and a positive sign is pain or numbness or tingling along the distribution of the nerve. Treatment can include noninvasive modifications such as weight loss, changing daily habits, changing shoes to orthotics, NSAIDs, and osteopathic manipulative medicine.
Posterior tibial tendon insufficiency (PTTI) or Posterior tibial tendon dysfunction (PTTD) Progressive loss of the medial longitudinal arch, compromising its ability for dynamic stabilization of the foot. Observation of the foot highlights a spectrum from flexible (early) to rigid (end-stage, degenerative) deformities. Too many toes sign refers to the lateral deviation of the toes relative to the hindfoot. The spectrum of PTTI foot deformity and characteristic posturing categorizes into: pes planus; hindfoot valgus; forefoot varus; forefoot abduction.