Deltoid Ligament Sprain? No! It's the Tibialis Posterior

R tibilais posterior

A patient who came in to see me yesterday was diagnosed with a deltoid ligament sprain in his left ankle. He had seen a doctor who referred him to a surgeon. An MRI was ordered, but all came back normal. The surgeon referred him for physiotherapy to treat his deltoid ligament.

L deltoid ligament from Dr R LaPrade JBJS

Here's what the patient told me. He was training for the Ironman 70.3 triathlon in Cebu, Philippines on August 7th, 2022. He had done a lot of  *'brick' training prior to the pain in his left ankle. Triathletes will know that *'brick' workouts are cycling followed by running straight after dismounting to simulate race conditions. One day before the race he felt a sharp left calf pain. As a result, he had to walk the whole run (21.1 km) during his race. Thereafter, after returning to Singapore, the inside part of his left ankle started hurting.

I assessed his ankle joint and his ankle proproception and both were good. No tenderness over the deltoid (inner) and outer ankle ligaments. There was however some tenderness behind his left medial malleolus (that bone sticking out at the inside ankle region) and definitely along his tibalis posterior muscle. Much more than his right ride. 

Single-leg heel raise (SLHR) test ability on the left elicited pain too. Bingo! For the physiotherapists and clinicians reading this, you may already know what is wrong with my patient. He had a problem with his left tibialis posterior. Yes, the same tibialis posterior muscle that can cause the dreaded shin splints and your arches to "collapse". Definitely not a deltoid ligament sprain in his case.

The SLHR test was described by a study (Ross et al, 2021) as one of 4 clinical tests to find out if a patient has tibialis posterior tendinopathy. The other 3 are; pain on tendon palpation, swelling around the tendon and pain and/or weakness with tibialis posterior muscle contraction.

My patient was happy to know that he can resume running after I treated him. 

Reference

Ross, MH, Smith MD, Mellor R  et al (2021). Clinical Tests Of Tibilailis Posterior Tendinopathy: Are They Reliable, And How Are They Reflected In Structural Changes On Imaging? J Orthop Sports Phys Ther. 51(5): 253-260. DOI: 10.2519/jospt.2019.9707

Picture by Ezisports.com.au

*Brick training- short form for bike-run-in-combination. Perhaps also because it was name after a world champion duathlete and surgeon Dr Matt Brick who came up with the term whem he described his bike-run and run-bike training sessions while training for a duathlon race

"Collapsed" Arches And Tibialis Posterior Muscle Pain

I had a really interesting case involving a triathlete/ runner recently. She had terrible pain in her arches and couldn't even walk around barefoot at home. It had started after she increased her run training recently. The orthopaedic surgeon she consulted had prescribed two pairs (yes two, you read correctly) of orthotics. And he said if they failed she would require surgery. A soft pair for her training and a hard pair while she was wearing her work shoes for her "collapsed arches".

She was advised not to run but was given the green light to bike and swim. Unfortunately, both times she wore her soft orthotics for cycling (and not evening running) her arches hurt after only fifteen minutes and she had stop riding. Even after icing her foot after the ride, her foot still felt sore the next day.

Pretty high eh?

Upon further questioning, she told me she didn't use the orthotic  and was able to walk pain free for 2-3 hours a few days ago in her Havaianas flip flops (or slippers).

However, after she biked again yesterday morning for only ten minutes, the pain came straight back with a vengeance.

When I examined her, her foot was was fairly flat and she had no arches. Her pain was mostly on her navicular bone and it was very tender to touch. I took a quick look at her soft pair of orthotics and noticed that the medial (inner) side of the orthotic was highly built up.

I told my patient I thought it was probably the orthotic irritating her navicular bone since it flared up within such a short time of using it while riding her bike.

Here's how the Tibialis posterior irritates the navicular bone

Other than her navicular bone tenderness, her tibialis posterior muscle was sore upon palpation all the way up her shin. Yes, the tibialis posterior muscle is the very same muscle that causes the much dreaded shin splints in runners.

L tibialis posterior

To make the long story short, I treated her and she's back running happily with no pain. What did I do? I treated her lateral, spiral and superficial back line.

Spiral Line

Accessory Navicular Bone

See the "bump" on the left foot?

A patient messaged me recently regarding pain in the left foot. This patient guessed that it might be due to an accessory navicular bone there. The patient had been doing a little more running and weight training in the gym recently and the left foot started hurting. A medial heel wedge recommended by a podiatrist didn't help. Neither did anti inflammatory medication provided by the doctor.

Our feet sometimes give even the most careful athlete/ runner problems. The so called accessory navicular  or "extra foot bone" can sometimes cause a lot of pain and discomfort.

All of us have a navicular bone on the inner part of our foot, near to the center of the arch. Not everyone has an accessory navicular though. I've actually had quite a number of patients complain of pain there. These patients tend to be more active and athletic, although some are not active at all. They often tend to have a little bump in this part of the arch.

Actually I, too have an accessory navicular bone in just my left foot, which so far thankfully hasn't given me any problems. 

This extra bone is usually not noticed until adolescence as the accessory navicular bone starts to calcify. It is then that the bump in the inner aspect of the arch gets noticed. For most people, it never gives any problems. For some, after an injury which often involves a twist, a stumble or fall, the accessory navicular bone becomes painful.

The accessory navicular bone is often attached to the posterior tibial muscle tendon. This muscle is involved when you push off your foot while walking or running. The same muscle that causes the dreaded shin splints. It helps keep the foot aligned and lifts up your arch. Hence you get pain when the tibialis posterior gets irritated from too much contact in the arch area.

My patient had the accessory navicular bone in the right foot surgically removed 30 years ago. Strangely enough, the foot only started hurting after a twisted ankle. My patient wasn't keen on surgery this time as the patient felt that after removing that extra bone, weight bearing on that side seemed altered and was never the same again.

The patient felt that removing the accessory navicular bone threw "the balance" off in the entire right side thereafter. (Surgical intervention requires the accessory navicular bone to be excised and reattachment of the posterior tibial tendon to the navicular).

I asked my patient to come in to our clinic to let me assess it. It was the accessory navicular bone causing her pain.

After treating my patient, the pain subsided . My patient then sent me a picture of the left foot the next day.

Have a look when I put both pictures together. Of course I didn't managed to "get rid" of the accessory navicular bone. The bump just doesn't look as obvious. But I definitely made my patient able to run again.