Conway McLean, DPM, Journal columnist

The subject of our discussion today is a gentleman we’ll call Sam. He was an average guy, 3 kids and a wife, employed in physical labor, difficult, demanding work. It was exhausting, and every day after work, he would go home and collapse onto the couch. Even as a young man, work would tire him out. But he experienced no pain.

Over time, this changed. Sam began noticing an aching sensation on the inner side of his foot, just below the ankle bone. The pain was subtle at first, occurring only after a more demanding day, and usually when he used his oldest work boots. Some ice, a topical cooling gel, and a cold beer were sufficient.

As with most orthopedic issues, and life in general, things don’t stay the same. Sam began noticing some pain traveling up his ankle, sometimes into the side of his calf. The discomfort became significantly sharper. More important, he began having not-so-subtle symptoms most of the day. Naturally, he tried some simple methods to get relief, including reduced use of those older boots. He even picked up some arch supports at the grocery store. And Sam hated to rely on anti-inflammatories, but without them, he was miserable.

Pain is a great motivator, and had spurred his use of all manner of home remedies. From various pads to strange smelly topical preparations, Sam was becoming tremendously frustrated. Ankle braces, new boots, his efforts were for naught. Some of these techniques reduced his pain levels, but only slightly. But when he began to experience pain just getting out of bed in the morning, he knew things were serious.

Sam came in to see me desperate for answers. What was the problem and why wasn’t it getting better? Although this was an easy diagnosis based on his history, a detailed physical exam revealed pain when pressure was applied to the area over the bump of bone found below and just in front of the inner ankle bone. This bone is the attachment site for an important tendon that runs up to the lower leg. The tendon-muscle group is the Posterior Tibial, which helps to support the arch of the foot and also serves to slow the falling of the arch when the foot lands on the ground in gait.

Tendonitis of this structure is one of the more common problems seen by lower extremity medicine specialists. Because of the architecture of the arch, the functioning of the Posterior Tibial tendon is crucial to our ability to stand and walk. When someone’s arch falls too much while walking or standing, the P.T. tendon has to over-work. Any tendon-muscle unit will become inflamed and painful if it is subjected to excessive, repeated stress over time, even becoming diseased with these on-going physical stresses. And because modern humans walk on perfectly flat surfaces most of the time, any deviation from efficient, correct alignment is going to stress some structure.

An ultrasound exam of our protagonist’s foot and lower leg revealed inflammatory changes of the Posterior Tibial tendon, but, thankfully, no structural changes. This was good news since he had experienced the pain for years. Chronic inflammation often leads to scarring and thickening of the tendon, changes which can precede a rupture. Weight bearing x-rays gave me insight into his pathologic biomechanics (a benefit of taking radiographic images with the patient always positioned the same) and, as expected, his foot alignment was placing abnormal force on his PT tendon.

The treatments that are available for an inflamed tendon are numerous. Some are more effective than others, some carry more risk. I no longer prescribe over-the-counter anti-inflammatories since they have been shown to alter the normal pathways to healing, which is acute inflammation. Steroid injections are tremendously effective for acute pain but don’t enhance the healing process. Still, as a covered service by most insurances, and as a means for fast relief, they have their place.

Although older technologies like therapeutic ultrasound and electric stimulation can help, they are rarely applied due to a lack of reimbursement. More effective at encouraging healing are the new cold lasers, which are without side effects or complications. Immobilization has been utilized for thousands of years; we just do it better. This does not necessarily require the use of those giant, ungainly cast boots, although they can beneficial. A soft cast allows use of normal shoe gear and can provide excellent support.

Once we had made Sam comfortable and relatively pain-free, we discussed the high likelihood the pain would return if he went back to his old ways. To prevent recurrence, Sam’s biomechanics had to be improved, reducing the forces placed on his PT tendon. Without question, the most efficient and effective way to do that is with prescription orthotics, which were prescribed for him. I’m happy to say these were successful in preventing recurrence of his Posterior Tibial tendonitis to date.

More severe cases sometimes require the use of a specialized leg brace, or various reconstructive surgical procedures can be performed where the deformity is sufficiently advanced. A cutting edge technique involves the recruitment of stem cells to the region to grow a new, stronger tendon. This can be realized via the regenerative medicine techniques (some of which I have found hugely beneficial).

Certainly the Posterior Tibial tendon can be acutely injured, requiring only the traditional R.I.C.E. formula (rest, icing, compression, and elevation). But more commonly it’s a chronic condition due to the individual’s foot type. Altering a person’s biomechanics is a complex, challenging task. When achieved, the rewards may extend beyond simple pain relief to reduced back pain, faster walking speed, lessened fatigue,…….an improved quality of life.

Your foot, ankle, or lower leg pain may be due to Posterior Tibial tendonitis. If so, it is probably the result of poor biomechanical function. The same applies to plantar fasciitis, the most common cause of heel pain. Today’s message? Get a thorough biomechanical assessment, get better support, and get walking. But don’t wait years to seek care: time changes many things including, maybe, your P.T. tendon.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula. Dr. McLean’s practice, Superior Foot and Ankle Centers, has offices in Marquette and Escanaba, and now the Keweenaw following the recent addition of an office in L’Anse. McLean has lectured internationally, and written dozens of articles on wound care, surgery, and diabetic foot medicine. He is board certified in surgery, wound care, and lower extremity biomechanics.