I was returning today from ‘Earth Treks,’ an indoor wall-climbing facility in Timonium with my 12-year,-old
daughter, Carleigh, when she mentioned to me that she had hyperlinked her website at Cockeysville Middle School to
mine. (For you non-tech geeks out there, it is possible, via computer magic, to type a little here, cut-and-paste a
little there and end up with a link in a website that , when clicked upon, directly routes you to another site. In this
case, it is to my website). She suggested that I do this month’s corner on the troubles of her left foot. You see,
today is a very special day for her. For the past two and a half years, the most exercise she has gotten has been by
pushing a computer mouse. The reason for her infirmary is today’s topic. Her problem began with pain on the
inside of her left foot, primarily when she ran. Being the concerned father and physician that I am, after a cursory
exam, I concluded that it was probably more related to school stressors with some possible secondary gain rewards
to avoid some unwanted activities. (Two quotes come to mind. First, ‘A physician who cares for a family member
has a fool for a patient, and an ass for a physician.’ Second, ‘Families of physicians often get the worst care’).
Sometime later, my wife Lynn the school teacher now moonlighting as a physician asked me to re-look at Carleigh’s
foot since my previous medical advice was worthless. The damage had been done. What followed has been
two years of pain, missed gym and sports opportunities, two surgeries, many weeks of casts and umpteen visits to
physical therapy, not to mention the assault on a young girl’s self esteem from being chronically impaired. She still
loves me, thought sometimes I wonder why. Today she easily climbed a 65 foot wall TWICE without any
problems. She really is quite an athlete.
So what has been the source of her misery?
The posterior tibialis tendon is located on the inside of the ankle, just behind the prominent ankle bone. Besides
supplying stability to the inside of the ankle, it helps support the arch of the foot. In fact, in cases of rupture of
this tendon, the foot becomes acutely flat, the so-called ‘acquired flat foot.’ It allows you to invert your ankles as if
you are trying to put the bottoms of your feet together. Perhaps its most important function, it allows you to stand
on your tiptoes. If your posterior tibial tendon is inflamed, it can be virtually impossible for you to stand on the
tiptoes of the affected foot. When it is functioning properly, it is painless. The pain has been Carleigh’s biggest
cross to bear.
After reading this, if you think you have the problem, what can you do? You will find that the treatment for
many musculoskeletal problems is very similar, at least in the early stages.
Here are some suggestions.
1. Stop activities until the pain subsides. Pain, as big of a pain as it is, is your friend. It tells you when your
system is overloaded and needs some relief. A great piece of advice that I give to patient’s everyday is ‘if it hurts,
don’t do it’! People HATE hearing this. They are paying money for a professional opinion and I tell something
that their mothers would tell them.
2. Massage the area with ice. Once again, our friend ice has resurfaced. The same principles apply here. Take
some Dixie Cups, fill them with water and throw them into your freezer. Once or twice a day, pull one out, tear off
some of the paper exposing the ice and massage the sore area for 10 minutes AND NO MORE!!! There are very
important structures that travel with this tendon and you do not want to freeze them. This is one of those times
where more is not better.
3. Take a non-steroidal anti-inflammatory medication. Ibuprofen or naproxen work well. They treat the
real problem — the tendon inflammation. As the inflammation improves, the pain should improve as well.
Remember though that not everyone should take these types of medications. If you are not sure, ask your health
care provider.
4. Seek out professional assistance. This is one of those problems where limping around for a long period of
time in pain could have a potentially serious complication. The posterior tibialis tendon is prone to stretching and
even rupturing. If this happens, the arch of your foot suddenly flattens, the so-called ‘acquired flat-foot.’ At this
point, the only hope to fix this is surgery to clean up the mess and reattach the tendon. So when I see someone
with this problem that isn’t getting better, I will put the them in a walking boot, or even apply a cast if I feel they
might not be compliant with wearing a removable boot. This would be for around four weeks. Once the foot had
improved, a temporary lace-up ankle support would be applied and the patient would be sent for physical therapy to
strengthen all the muscles of the foot and ankle. Permanent orthotics would most liking be in the offing as well.
I hope this month’s Corner has been of interest to you. It is not one of your everyday musculoskeletal problem,
and because of it’s potential complication, it is nice to have some knowledge of it.
