This blogpost captures my experience to overcome the Posterior Tibial Tendon pain. I am not by any means a qualified person to share medical advice. I have built only a theory for the root cause in my specific case for this pain and what I ended up doing in order to overcome it. The Posterior Tibial tendon pain is quite common in novice to intermediate experienced runners. The pain comes gradually and is quite uncomfortable and prevents runners from continuing their training plans hindering the dreams of reaching their goals.
I am software engineer which I pass most of my time sat at a desk. I had run for a couple of years in my early twenties, but not any structured training plan. Fast forward to mid thirties after spending most of this time doing almost no physical activity. I was not overweight, just weak from the muscle and joint point of view and fat percentage I guess was higher than 18% of my body weight. I decided to start running regularly after I was diagnosed with mild osteopenia because of the gluten intolerance. After my first few months I got this annoying pain in the medial part of my shin in my dominant leg(right). After some googling about anatomy it was almost clear to me that the pain was posterior tibial muscle. I stopped running for a week and started again with lower intensity. This situation did repeat a couple of times. No matter how slowly I ramped up my training at a certain point I would meet the pain again and again.
This is when I met the Posterior Tibial Muscle ☺️.
Tibialis posterior is the most central and deepest muscle located in the posterior aspect of the leg. The muscle consists of two parts close to its origin one of which is attached to the tibia and the other one at the fibule. The two parts become one muscle, which travels towards the foot. At the ankle, the tendon of tibialis posterior passes posteriorly to the medial malleolus of the tibia. Tibialis posterior is involved in movements at two different joints: plantar flexion of the foot at the ankle joint and inversion of the foot at the subtalar joint. This second function allows the tibialis posterior to resist the tendency of the body to sway laterally in a one leg stance, thus facilitating balance. This muscle also plays a support role by elevating, tensing and reinforcing the medial longitudinal arch of the foot. which helps distribute the body weight when the foot is planted on the ground. Since running is basically jumping from one leg to the other, this muscle plays an important role in this activity.
I watched countless youtube videos and read online articles that talked about how to get rid of the pain. Almost every single one of them advices single leg balance as and exercise to strengthen the muscle. Additional exercises comprise the usage of elastic bands to perform inversion and eversion of the foot as well as plantarflexion and doxiflexion. After I bought the elastic bands, I started doing all these exercises but the pain was not improving considerably. Time after time I would feel it again and come back to square one. I was somehow convinced that something was wrong in my running biomechanics.
I was so committed with my running goal, so I decided to see a physio therapist. I chose a particular clinic as they offered a gait analysis as well. At the first visit, the physio therapist checked my running shoes and performed a gait analysis. He was quite surprised with the gait analysis. He said that he had never seen such a high arch in all the previous analysis he had done. I did not know how to interpret that, on one end I was happy that he could notice something was off, but on the other hand him being surprised did not give much confidence. To a big surprise for myself the therapist did not advice exercises for the foot itself. He did not even mention any issue related to wrong mechanics that could damage the painful tendon. The remedy from him was start doing hip strengthening exercises: bridge with both legs, and some machine for leg calf and hip strength. I did one session and abandoned that as I thought it was not directly impacting the painful area.
Fast forward a couple of months, I experienced the pain again and this time I decided to see another physio. The clinic has the most and highest reviews in my local area. Based on the reviews the clinic had solved issues for many runners. On the first day, the therapist assessed my leg strength, my balance (and lack of thereof), and the way I ran by recording me running in slow motion. My foot would collapse internally on each contact with the ground. He told me I had to somehow change my stride by trying to land on my forefoot when running and have a distribute the weight of my body mostly in the ball of my foot in order to not collapse the ankle. This required a lot of strength in my calves, glutes, and leg in general. He gave a complete set of strength exercises to do at home. The approach followed here was brute force: strengthening of the entire leg chain. I started doing these exercises a couple of times per week. They involved hip deadlifts raises with single leg, first only with body weight than adding dumbbells after some time. Bulgarian split squats, back lounges, jumping on a step with 2 legs and single leg, nordic quad extensions and core strength. I have to say my single leg balance was pretty poor when I started these exercises. The best advice I got from this physio therapist is how to rate the pain in a scale from 1 to 10. If the pain is rated between 1 and 3 out of 10 it is probably ok to run “carefully”. At 4 is the critical point I could run but at very low effort.
In the meantime I was maintaining a relatively low running mileage per week at around 20-25 miles. The ptt pain started to fade away and I was increasing my mileage. At some point I started experiencing a tightness in the inner thigh which I thought it was related to the adductor muscles of the leg. I would feel this tightness in almost all long runs. At some point, a new pain developed in my buttocks which was of very low intensity, but I would feel in a wide area behind my leg. All these different pains were clues that were bringing me closer to understanding what my issue really was.
I came across this article in Runner’s World Pain in the Butt
The article mentions:
Why Me?
Why did you develop this problem? A common finding is tight hip adductor muscles (these are the muscles along the inner aspect of the thigh that pull the leg inward), which override the hip abductors (muscles along the outside of the thigh that pull the leg outward); the piriformis acts as a hip abductor. If your foot excessively pronates when pushing off, your leg rotates inward; the piriformis acts as an external rotator of the hip (turns outward) and contracts in reaction to each push-off.
At this point it became very clear to me what my issue really was: My leg abductor muscles were weak while the adductors were quite tight. This caused an imbalance in the entire leg, which the Posterior Tibial muscle was trying to compensate and got over used. I had to focus into strengthening my leg abductors. I scheduled another session with my second physio clinic and asked the therapist there to assess my abductors. After the assessment, his words were “Your balance is shit”. He gave me a set of new exercises that did work on the abductors of the leg. This was similar to the Myrt Routine which I discovered later. This was on top of my strength routine for major leg muscles continuing the theme of brute-force approach. doing just the single leg balance exercise would not directly strengthen the hip muscles and the leg abductor muscle, it would just put more strain on my Posterior Tibial muscle.
I have done a sketch of the hip muscles involves in order to maintain single leg balance:
As you can see from the picture in order to balance on a single foot (right one) the psoas muscle need to be engaged in the same side (ipsilateral) to bend the body slightly and maintain erect position. Gluteus minimus and medius of the same leg are engaged together with other smaller muscles which act as abductors of the leg such as piriformis, obturator (internus, externus) and gemellus (inferior, superior). Other deep muscles that are involved are the contra-lateral (of the opposite side - left in this case) External Abdominal Oblique and Quadratus Lumborum. These two muscles make sure to balance the torque that incurs in the pelvis as a result of a single joint point on the other leg.
Since I started these exercises, I have not experienced the Posterior Tibial Muscle/Tendon pain anymore despite raising the weekly mileage to 50 miles. I successfully finished two marathons, but this pain has not bothered me ever since. Can I tell for sure that this was the root cause? No. I like to believe it was, as it just makes sense to me with the limited knowledge I have gained by reading anatomy content online. Maybe just running for an extended period of time strengthened the tendon, or maybe the majro leg muscle strength exercises helped my running form.
I have learned about new muscles as I have experienced other minor injuries but Posterior Tibial is gone for good.
This paper https://bmcsportsscimedrehabil.biomedcentral.com/articles/10.1186/s13102-021-00392-z mentions that there are four major muscle synergies, two ankle-dominant synergies, one knee-dominant synergy, and one hip/back-dominant in order to maintain single leg balance. They do not mention any involment of the deeper muscles I have depicted in my diagram and not sure why.