Like any tendon problem in the lower extremity, you can successfully treat posterior tibial tendon problems with the mnemonic BRISS. The letters stand for:
- B Biomechanics affecting
- R Rest or Activity Modification
- I Ice or Anti-Inflammatory
- S Stretch
- S Strengthen
In Part 1 of Posterior Tibial Tendon Syndrome, we talked about the biomechanics involved in this overuse syndrome. Therefore, we can summarize “B” by summarizing the various treatments of these biomechanical factors. They include:
- Arch support variations
- Heel valgus corrections
- Medial Column stability improvements
We normally accomplish these by progressively moving our treatment from simple methods to more complex. This progression includes:
- Various forms of arch taping
- Various forms of OTC arch supports
- Taping to prevent heel eversion
- Taping to immobilize the 1st MPJ
- Custom made orthotic devices
- Custom made orthotic devices for more heel valgus correction
- Shoe selection
- Shoe Lacing techniques including Power Lacing
How is “R” realized? Most patients don’t want to be couch potatoes while they wait to feel better. They lead busy lives. I try to focus on Relative Rest or Activity Modification instead of straight rest. I try to get them to understand the pain scale, and that 0-2 pain is okay for healing. This is minor discomfort-type pain, or aching pain. The patient has to learn what increases pain over 2, during or after activity. These situations have to be avoided typically for 2 weeks, when that activity is tested again. This learning is important for healing, and avoidance of setbacks or flares. It helps me know what phase of rehab to place them in: Immobilization, Re-Strengthening, or Return to Activity. Most injuries require some decrease or elimination of the main activity, while cross training with other activities that do not produce pain are allowed and encouraged.
What about the “I”? Ice is the symbol of anti-inflammatory, but NSAIDs and anti-inflammatory diets, and naturopathic lotions like Traumeel or Zflamend help in this category. There are also situations where you may want inflammation, typically changing a chronic condition into an acute one with Shockwave or PRP. Ice is typically done for 4 days following an acute injury three times a day, and then after activities that increase the pain over 2.
The first “S” is Stretch. Stretching is a vital part of tendon injuries. Tendon stretching is typically done for 20 seconds 3 times daily including before and after a main activity of the day. Stretching should never hurt. 5 deep breaths are encouraged over a 20 second count.
The second “S” is Strengthen. The Posterior Tibial Tendon when strengthened can hurt due to the presence of the Posterior Tibial Nerve nearby. Therefore, it is one of the only tendons to be strengthened through pain, as long as the pain is not worse afterwards. Last week's blog post had a video showing the tendon strengthening regime from AROM, to isometric, to progressive resistive, to functional strengthening.
Next week I will talk about Medial Tibial Shin Splints, a presentation of posterior tibial syndrome.
