Posterior Tibialis and Peroneal Tendinopathy

Tendinopathy may occur on the inside of the foot/ankle at the posterior tibial tendon or on the outside at the peroneal tendon. Diagnosis is typically made with palpating along the tendon as it goes around either malleolus to where it inserts at the arch and midfoot. Pain is provoked with plantarflexion (gas pedal) and inversion to the inside (for post tib) or eversion to the outside (for peroneal). The clinician should rule out, among others, anterior ankle impingement, tarsal tunnel syndrome, plantar fasciitis for the inside and sinus tarsi syndrome, peroneal or sural nerve irritation for the outside.

As we've discussed with tendinopathy, progressive loading is the most appropriate treatment, typically completed with a resistance band - plantarflexion with inversion for post tib and with eversion for peroneals. Add a tennis ball between the heels to increase post tib activation with heel raises. Single leg balance is another good way to strengthen these muscle groups, with perturbations to create instability with arm or leg reaches and with changes in the surface or completing the exercise with eyes closed. Both of these tendons are part of the active support system for the midfoot and arch, so reducing stress to this area is important. This is done with intrinsic, calf, and gluteal strengthening as well as with arch support taping, over-the-counter orthotics/insoles and more supportive shoewear.

Laser may be appropriate to speed up healing. In persistent cases, shockwave treatment may be beneficial. If there is severe collapse of the arch, surgical consultation may be warranted. Activity modification and nutritional/weight loss counseling may be helpful.