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Thursday, August 19, 2010

Advice for a suspected case of tibialis posterior tendinosis

I've been suffering from medial ankle pain for about 2 to 3 months (since early May). I initially though it was a grade I deltoid ligament sprain (in both ankles) because the pain was delayed and pretty minor. The pain came a few hours after performing lower body exercises (squats, lunges, single-leg balancing) while trying to force my feet into a neutral position, because I am an overpronator. It responded well to ice and compression at first, and after 3 weeks the pain had subsided. I was walking normally and going up and down stairs as if I was never injured, and about 2 weeks later, the pain returned. What also aggravated it probably were the exercises that I attempted to do to rehab it (single leg balancing and directional movements with theraband resistance). I think I was too aggressive with the exercises. Heat and ice both assist in pain management, but now walking will just bring pain back immediately. I have no visible signs of inflammation - no swelling or heat - and stretching seems to help for the short-term. Exercise also isn't that bad (theraband directional movements and calf raises with the knees bent) but a bit after some discomfort will arise. About a week or two ago, I found out that the pain had to be from either my tibialis posterior or another muscle in the shin/ankle (the flexor hallucis longus? I'm not sure) Since the pain usually comes about with standing and walking, and the fact that I overpronate, led me to believe it is more likely my tibialis posterior, since this has a direct link over overpronating and such
The mucous sheaths of the tendons around the a...Image via Wikipedia
I finally got otc orthotics, and put some cloth and rubber material under the arch in my shoe for added support, and the pain is minimal with walking now. To me it is visible that the arch support of the orthotics and materials help realign my lower body and prevent overpronation. What should I do now though? I believe that I'm in the tendinosis stage now because I have no signs of inflammation, and because ice does so little at this point and ibuprofen does nothing (except for giving me diarrhea -_-). What do you think? Could you give me a rehab regimen of some sort, because I heard that eccentric exercise is needed to reconstruct the collagen of a tendon that failed to already heal properly. Any info or support is greatly appreciated :-].

PS - Your website and articles are amazing, and I saw your videos on tendinosis and diet, and the tibialis posterior strengthening, but anything specific for tibialis posterior tendinosis would be helpful. Thank you!. 
I do not think you have tendinosis.  From the history you have given, there is undoubtedly an overuse injury of the muscles and tendons that stabilise the ankle and foot.

Once you have some swelling about the inside of the ankle those tendons you can see in the illustration are easily impinged and irritated.  Further repetitive movement will tend to make matters worse, hence the vicious cycle you are in.

The big mistake you appear to have made was doing too much of a group of unfamiliar exercises at once and not allowing sufficient recovery time before repeating the same or similar exercises.  The rehab exercises you are describing appear more akin to trying to beat your ankles into submission instead of loving them into recovery.  With any injury, recovery requires love and lot of patience.  Work carefully within your current limits and always err on the gentle side.  Do the exercises conservatively then rest for 2-3 days.  There must be a rest period during which the stressed areas settle and then grow a little stronger - then you repeat the exercise.  If there is insufficient rest then there will be no healing.  The injury may actually worsen.

As you found, icing the area is a waste of time and it may in fact make matters worse because excessive cooling can cause further swelling.  I never use ice on juries nowadays by the way.

The over pronation issue is, in my opinion, a popularist red herring as is the tendinosis.  Many, many people overpronate, including most of the people of the Third World who can not afford a decent pair of shoes.  The problem for you is you have overdone the lunges and other quite violent leg exercises and then not let up with the Therabands and other exercise afterwards.

Here is what I suggest:
  • Get a firm massage of the muscles of the calf and foot once a week.  Do both legs.  Include the tender points inside the ankle.  You will need an hour.  Repeat once a week until there is no pain.  You will need about four sessions.
  • Just stick to walking between massages.  But go to the gym and concentrate on building your strength and endurance, working your thighs and upper body.  Cycling is fine but use gearing that allows spinning rather than stomping.  Take up swimming.
  • Get some ICL Reparen and take 2 capsules in the morning and two at night daily until there is no pain.
  • Once recovered, gradually introduce your lower leg workouts.  If you are not fully recovered within three to four days of a workout then you are doing too much and need to back off the intensity and/or repetitions/and or loading.

Back off if not fully recovered within 3-4 days

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