Dr. Conway McLean, Journal columnist

People are all different, unique in some fashion. This fact certainly applies to our bone structure, something which is primarily genetically determined. But your bony architecture, how all the bones line up together, goes a long way to determining what kind of problems you have as an adult. This is especially true of the feet, which must function as a unit, moving in harmony with each and every step.

One of the more common variations in foot shape is a foot type in which the arch rolls down or in excessively. This can result in repetitive strain on many soft tissue structures, primarily tendons and ligaments, that keep the foot lined up, underneath the leg and moving efficiently, allowing us to stand and walk.

One of the most commonly affected tendons with this foot type is the one attaching to the inner side of the arch of the foot, the posterior tibial. From its attachment site, the tendon courses back towards the inner ankle, running behind the inside ankle bone. Some call this the “arch tendon” because of its importance in maintaining the shape of the arch, necessary for many of the critical functions of the foot. The posterior tibial muscle-tendon unit functions to slow the falling of the arch when the foot contacts the ground.

Excessive physical stress to this type of tissue, whether sudden or over time, leads to the chemical and structural changes of inflammation, either chronic or acute. As most of us are aware, pain is one of the cardinal signs of this process. But inflammation can arise from many different situations. Sufferers of posterior tibial tendinitis often have no obvious cause for their pain. And there may be no outward sign there is a problem…other than pain, often sharp or burning in nature.

Inflammation of this particular tendon can result from numerous and varied factors, many functional and structural abnormalities. Really, any sufficient variation from the ideal will cause stress to something. Critical to this discussion are the differences between chronic inflammation versus acute. Healing of a suddenly strained P.T. tendon, which is acutely inflamed, is handled by the body in a very different manner.

It is well recognized that a chronically inflamed tendon is a weakened structure. When the posterior tibial tendon has been chronically inflamed for long enough, it thickens, almost a scarring process. Adding to this situation is the physical tension on this tendon: consequently ruptures are not a rarity.

Often, the P.T. tendon will experience excessive stress for years before the level of inflammation reaches levels sufficient to produce pain. Without alterations in activity levels, shoe gear, or other identifiable change, pain may arise one day, suddenly, without an inciting event. This is typical of a biomechanically induced problem. One day, quite abruptly, pain is experienced from some region, without any injury.

As is generally the case, treatments for posterior tibial tendonitis vary, depending partially on whether it’s acute or chronic. The latter is the subject of today’s treatise. The most effective approach will address the biomechanical problem leading to recurrent excessive stress to the tendon. Excessively used or aged shoe gear can be a factor and is a common occurrence. Strengthening exercises for the muscles can be performed, whether at home or by a physical therapist. But make no mistake, soft tissue enhancements can’t overcome skeletal alignment pathologies in the long run.

Many structures must be evaluated to determine what is leading to increased PT tendon stress. For example, a tight Achilles tendon can pull up too strongly on the heel, forcing the arch down more. Predictably, this will exert more force on the posterior tibial tendon, which is why Achilles stretches can be helpful for P.T. tendonitis.

The most effective long term approach is to reduce the day-to-day forces on the tendon, best achieved by maintaining proper alignment of the foot, leg, and pelvis, throughout the gait cycle. This is possible with properly prescribed custom foot orthotics, but these are challenging to fabricate, requiring an intimate understanding of biomechanics. When correctly prescribed, significant improvements in a variety of musculoskeletal aches and pains may be seen. And simply by putting on your shoes.

Tremendously rewarding has been the use of various regenerative techniques. These nonpharmacologic therapies have the goal of creating a stronger and healthier tendon, and therefore less prone to becoming inflamed. Shockwave therapy has been in use for decades and has been the subject of numerous studies demonstrating its effectiveness and lack of complications.

There are those individuals whose skeletal structure is too far from the norm, in which case more involved and more restrictive bracing may be needed. Also possible is surgical reconstruction of the foot, a complex task with obviously many opportunities for complications. When there’s only a slight deviation from proper alignment, a good OTC device may be enough to limit tension on the posterior tibial. But most of these products are minimally effective, providing inadequate support and scant pain relief.

Chronic and recurrent pain, that which recurs whenever there’s greater weight bearing, too often leads to a reduction in activity, meaning they do less walking. The obvious conclusion is they become less physically fit. When it causes pain to walk more, generally people won’t. And now we’re delving into the realm of weight gain, cardiovascular disease and overall quality of life issues. All from a sore arch tendon. Go figure!

EDITORS NOTE: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.