From the Guidelines
Recent research on treating medial ankle pain, particularly posterior tibialis tendinitis following an ankle sprain, suggests a comprehensive approach combining rest, physical therapy, and anti-inflammatory measures, with a focus on functional treatment and exercise therapy as the primary treatment strategy, as recommended by the British Journal of Sports Medicine 1.
Treatment Approach
The initial treatment should focus on the RICE protocol (Rest, Ice, Compression, Elevation) for 48-72 hours post-injury, followed by a gradual rehabilitation program.
- Non-steroidal anti-inflammatory drugs like ibuprofen (400-600mg three times daily with food) or naproxen (500mg twice daily) can help manage pain and inflammation for 1-2 weeks, as supported by studies showing their effectiveness in reducing pain in the short term without significantly increasing the risk of adverse events 1.
- Physical therapy is crucial, emphasizing eccentric strengthening exercises of the posterior tibialis muscle, such as heel raises and foot inversion against resistance, performed 3 sets of 15 repetitions daily.
- Orthotic devices providing medial arch support can reduce stress on the tendon during recovery.
Prognostic Factors and Prevention
Following an acute LAS, pain decreases rapidly within the first two weeks after injury, but a substantial proportion of patients report long-term unresolved injury-associated symptoms, highlighting the importance of addressing prognostic factors early in the treatment process, including the patient’s current level of pain, their workload, and level of sports participation 1.
- The use of ankle support, such as a semirigid brace, may be indicated to facilitate return to work and daily life activities, and is suggested to be the most cost-effective option compared with taping 1.
Persistent Cases and Surgery
For persistent cases, corticosteroid injections are generally avoided as they may weaken the tendon structure, but platelet-rich plasma (PRP) injections show promising results in accelerating healing.
- Surgery is rarely needed but may be considered if symptoms persist beyond 6 months despite appropriate conservative management, and should be reserved for patients that require quick recovery, such as professional athletes, or whose complaints are not resolved by conservative treatment 1.
From the Research
Treatment Options for Medial Ankle Pain
- Nonoperative treatment options for posterior tibial tendinopathy include support for the medial longitudinal arch and physical therapy focusing on eccentric exercises 2
- Surgical treatment is considered for patients who do not respond to nonoperative treatments after three to six months and is based on the specific stage of tendinopathy 2
- Immobilization, laterally posted orthotics, and physical therapy for progressive tendon loading are treatment options for peroneal tendon disorders 2
- Initial treatment for tibialis anterior tendinopathy includes immobilization followed by physical therapy, and surgical debridement can be considered if nonoperative treatment is ineffective 2
Diagnosis and Assessment
- Medial ankle pain must be carefully investigated, and the presence of instability assessed with dynamic maneuvers (forced inversion, or dorsiflexion) of the foot 3
- Sonography plays an important role in the investigation of disorders involving the posterior tibial tendon 3
- MRI findings can be subtle in cases of posterior tibial tendon tears, and associated pathology is very common and likely confounds the diagnosis and outcomes 4
- Abnormalities of the medial ligaments and posterior tibial tendon can occur because of acute injury or chronic instability or malalignment 5
Specific Considerations for Posterior Tibialis Tendinitis
- Posterior tibial tendon tears following an ankle sprain are rare, with an incidence of 1.04% 4
- Patients with posterior tibial tendinopathy present with medial ankle pain, pes planovalgus deformity, and a positive too many toes sign 2
- The most common concomitant pathology in cases of posterior tibial tendon tears is a talar osteochondral defect and ligament instability 4
- Patients should be counseled on the possibility of poor outcomes and long-term pain in cases of posterior tibial tendon tears 4