Dr. Stephen M. Pribut's Sport Pages

Sports Medicine Home   |  Chess  |   Shoes   |  Comprehensive Site Listing   |  Home Page

Sports Injuries:


Posterior Tibial Tendon Problems

Anatomy

The tibialis posterior originates from the posterior medial aspect of the tibia and the interosseus membrane. It commences at the proximal third of the tibia The tendon of the posterior tibial muscle runs behind the medial malleolus and inserts into the navicular bone, with additional tendonous slips inserting into the second, third, and fourth metatarsal bases, the cuneiform bones and the cuboid. The primary function is to slow pronation after heel contact in gait. From the anatomical origin and insertion the nonweight bearing function of this muscle would be to invert and plantarflex the foot. The plantar flexion of the foot comes about because of its posterior relationship to the axis of the ankle joint. During gait it slows the forward motion of the tibia on the foot and slows internal rotation of the leg, concomitantly slowing the rate of pronation. In a foot that excessively pronates or one which is put to use on a soft surface this tendon will be under excessive stress. A tear of this muscle will result in the unopposed action of the peroneal muscles and the gastrosoleus complex causing a progressive and severe loss of the medial arch of the foot.

The posterior tibial muscle is invested within a synovial lined tendon sheath. Inflammation occurring here may result in a true tenosyovitis (as opposed to tendinitis, occurring at the achilles tendon). Inflammation that occurs at the origin of this muscle may result in medial shin splints. Examination will reveal the posterior medial aspect of the tibia to be tender. The flexor hallucis longus is also frequently involved. This is the muscle that originates in the lower third of the tibia and the tendon also runs behind the medial malleolus to the bones of the great toe. Its functions at the ankle and subtalar joint are similar to that of the posterior tibial tendon.

Treatment of problems of the posterior tibial muscle and tendon

Since the cause of many problems occurring in this area is pronation of the foot at the subtalar joint the remedy is control of pronation at this area. Make sure that your shoes are not excessively worn. Check the heel counter to make sure that it is not caveing in medially (towards the inside of your foot and leg). Avoid overtraining and cut back on your current mileage. Calf or Achilles stretches should also be done. If excessive pronation can not be controlled by a supportive shoe than orthotics will probably be necessary. Over the counter orthotics may be tried, but in resistant cases, custom orthotics will be necessary. To control the immediate effects of the inflammation iceing may be used, anti-inflammatory medicines such as advil or alev may be helpful, and physical therapy - ultrasound and possibly galvanic (electrical stimulation) will help.


Achilles Tendonitis


Achilles tendonitis is the bane of many runners. You should not allow this to turn into a chronic and troubling malady leading to moans about how it will never end, contributing to roadsides strewn with air cushioned clad runners all with ice packs attached to their heels. First, we will review some basic information about the achilles tendon.

The achilles tendon is the connection between the heel and the most powerful muscle group in the body. This has long been known as a site prone to disabling injury. It is named after Achilles, who according to myth was protected from wounds by being dipped in a magical pond by his mother. She held him by the heel, which was not immersed, and later died by an arrow wound in his heel. Although obviously, injuries to this area must have been known for more than 2,000 years, it was first reported in the medical literature by Ambroise Paré only 400 years ago.

The achilles tendon joins three muscles: the two heads of the gastrocnemius and the soleus. The gastrocnemius heads arise from the posterior portions of the femoral condyles. The soleus arises from the posterior aspect of the tibia and fibula.

The gastrocnemius is a muscle that crosses three joints: the knee, the ankle, and the subtalar joint. The functioning of these joints and influence of other muscles on these joints has a significant effect on the tension that occurs within the achilles tendon. As an example tight hamstrings impact the functioning of the ankle joint, the subtalar joint, and increase tension in the achilles tendon. The soleus does not cross the knee and is a biarticualar muscle.

The plantaris is a nearby muscle that has its separate tendon. It arises from the lateral condyle of the femur. It has a thin tendon that passes between the gastrocnemius and soleus and inserts into the calcaneus. When this musclculotendinous structure is injured it is frequently felt as a "pellet shot" in the back of the leg. The tear is usually about eight inches below the knee joint.

The bulk of the achilles tendon inserts into the posterior superior third of the calcaneus. Some fibers course distally and continue to where portions of the plantar fascia insert into the plantar aspect of the calcaneus.

The achilles tendon does not have a rich blood supply. It is not invested within a true tendon sheath. A paratenon composed of other soft tissue surround it. The outer layer is a portion of the deep fascia, the middle layer is called the mesotenon and the inner layer is a thin layer. The blood supply to the proximal portion of the tendon comes from the branches of the muscles themselves. The distal portion is supplied by branches from the tendon-bone interface. The mesotenon supplies the major blood supply to the Achilles tendon.

Contributing Factors

There are several factors that can contribute to achilles tendonitis. First, you should know that the biggest contributor to chronic achilles tendonitis is ignoring pain in your achillles tendon and runing through the pain of early achilles tendonitis. If your achilles tendon is getting sore it is time to pay attention to it, immediately.

Sudden increases in training can contribute to achilles tendonitis. Excessive hill running or a sudden addition of hills and speedwork can also contribute to this problem. Two sole construction flaws can also aggravate achilles tendonitis. The first is a sole that is too stiff, especially at the ball of the foot. (In case you are having difficulty locating the "ball" of your foot, I mean the part where the toes join the foot and at which the foot bends) If this area is stiff than the "lever arm" of the foot is longer and the achilles tendon will be under increased tension and the calf muscles must work harder to lift the heel off the ground.

The second contributing shoe design factor which may lead to continuuing achilles tendon problem is excessive heel cushioning. Air filled heels, while supposedly are now more resistant to deformation and leaks are not good for a sore achilles tendon. The reason for this is quite simple. If you are wearing a shoe that is designed to give great heel shock absorption what frequently happens is that after heel contact, the heel continues to sink lower while the shoe is absorbing the shock. This further stretches the achilles tendon, at a time when the leg and body are moving forward over the foot. Change your shoes to one without this "feature".

Of course another major factor is excessive tightness of the posterior leg muscles, the calf muscles and the hamstrings may contribute to prolonged achilles tendonitis. Gentle calf stretching should be performed preventatively. During a bout of acute achilles tendonitis, however, overly exuberant stretching should not be performed.

Treatment

The first thing to do is to cut back your training. If you are working out twice a day, change to once a day and take one or two days off per week. If you are working out every day cut back to every other day and decrease your mileage. Training modification is essential to treatment of this potentially long lasting problem. You should also cut back on hill work and speed work. Post running ice may also help. Be sure to avoid excessive stretching. The first phase of healing should be accompanied by relative rest, which doesn't necessarily mean stopping running, but as I am emphasizing, a cut back in training. If this does not help quickly, consider the use of a 1/4 inch heel lift can also help. Do not start worrying if you will become dependent on this, concentrate on getting rid of the pain. Don't walk barefoot around your house, avoid excessively flat shoes, such as "sneakers", tennis shoes, cross trainers, etc.

In office treatment would initially consist of the use of the physical therapy modalities of electrical stimulation, (HVGS, high voltage galvanic stimulation), and ultrasound. Your sports medicine physician should also carefully check your shoes. A heel lift can also be used and control of excessive pronation by taping can also be incorporated into a program of achilles tendonitis rehabilitation therapy. Orthotics with a small heel lift are often helpful.

Exercises to Avoid

Excessive stretching is not good for your achilles tendon. The stretch that I most often recommend is the "wall stretch". I do not recommend the "stair stretch", the "incline stretch", or the "put a towel around your feet and pull up until it hurts stretch". If any of these are working for you, that's great, you don't need any advice. In most cases, for the patients I see, these stretches put too much tension on the already tender achilles tendon. Contracting the muscle when it is in a stretched position, as initial therapy of an injured achilles tendon is not a good thing.

Achilles Tendon Ruptures

The achilles tendon is the connection between the heel and the most powerful muscle group in the body. This has long been known as a site prone to disabling injury. It is named after Achilles, who according to myth was protected from wounds by being dipped in a magical pond by his mother. She held him by the heel, which was not immersed, and later died by an arrow wound in his heel. Although obviously, injuries to this area must have been known for more than 2,000 years, it was first reported in the medical literature by Ambroise Paré only 400 years ago.

The achilles tendon joins three muscles: the two heads of the gastrocnemius and the soleus. The gastrocnemius heads arise from the posterior portions of the femoral condyles. The soleus arises from the posterior aspect of the tibia and fibula.

The gastrocnemius is a muscle that crosses three joints: the knee, the ankle, and the subtalar joint. The functioning of these joints and influence of other muscles on these joints has a significant effect on the tension that occurs within the achilles tendon. As anexample tight hamstrings impact the functioning of the ankle joint, the subtalar joint, and increase tension in the achilles tendon. The soleus does not cross the knee and is a biarticualar muscle.

The plantaris is a nearby muscle that has its separate tendon. It arises from the lateral condyle of the femur. It has a thin tendon that passes between the gastrocnemius and soleus and inserts into the calcaneus. When this musclculotendinous structure is injured it is frequently felt as a "pellet shot" in the back of the leg. The tear is usually about eight inches below the knee joint.

The bulk of the achilles tendon inserts into the posterior superior third of the calcaneus. Some fibers course distally and continue to where portions of the plantar fascia insert into the plantar aspect of the calcaneus.

The achilles tendon does not have a rich blood supply. It is not invested within a true tendon sheath. A paratenon composed of other soft tissue surround it. The outer layer is a portion of the deep fascia, the middle layer is called the mesotenon and the inner layer is a thin layer. The blood supply to the proximal portion of the tendon comes from the branches of the muscles themselves. The distal portion is supplied by branches from the tendon-bone interface. The mesotenon supplies the major blood supply to the Achilles tendon.

The actual cause of rupture of the Achilles tendon is not known. The mechanism of injury is a force that increases the tensile force in the tendon beyond its tensile strenght. This may be visualized as a dorsiflexion force at the foot or concommitantly a forward motion of the tibia over the foot while the calf muscles are contracting. As stated the force must exceed the tensile strength of the tendon. A forceful stretch of the tendon or a contraction of the muscles may create this force. Most often it is a combination of the two forces. Many researchers feel that some degeneration is present in the tendon prior to rupture. The usual site of rupture is approximately 2 to 6 centimeters proximal to the insertion in the calcaneus. This is also the portion of the tendon that has the poorest blood supply. Occasionally ruptures occur at the tendon-bone interface or musculo-tendonous junction. Since vascularity decreases with age, this frequently occurs in the ageing athlete. A weakening of the Achilles tendon has been observed following intra- tendinous steroid injection. Therefore, injections of steroids are not recommended at this location. Diseases associated with a possibly increased incidence of tendon rupture include gout, systemic lupus erythematosis, rheumatoid arthritis and tuberculosis.

Diagnosis

Physical examination of the site of a recent rupture may reveal a palpable gap at the site of the rupture. Swelling will be seen. The most frequently described clinical test is called the Thompson test. With the patient lying prone (on his stomach) the calf is squeezed. The foot will plantarflex in a patient who does not have a completely torn Achilles tendon. The foot will not plantar flex when the Achilles tendon is completely torn. An MRI will accurately reveal the extent of the tear. Diagnositic ultrasound is also used to assist in the diagnosis of a torn Achilles tendon.

An MRI image of a partially torn Achilles Tendon is available on line at the site of The Graduate Hospital Imaging Center.

Treatment

Complete tears of the Achilles tendon, in the athlete, are usually treated with surgical repair followed with up to 12 weeks in a series of casts. Partial tears are sometimes treated with casting for up to 12 weeks alone, and sometimes are treated as are the complete tears, with surgery and casting. A heel lift is usually used for 6 months to one year following removal of the cast. Rehabilitation to regain flexibility and then to regain muscle strength are also instituted following removal of the cast.


Runner's Knee (Chondromalacia of the Patella)

The knee is a complex joint. It includes the articulation between the tibia and femur (leg and thigh) and the patella (knee cap). The most common knee problems in running relate to what is called the "patello-femoral complex". This is the quadriceps, knee cap and patellar tendon. What is called runner's knee is a condition known to the medical community as chondromalacia of the patella. This essentially means softening of the cartilage of the knee cap. Cartilage does not have the same blood supply that bone does. It relys on intermittent compression to squeeze out waste products and then allow nutrients to enter the cartilage from the synovial fluid of the joint. During running certain mechanical conditions may predispose you to a mistracking knee cap. Portions of the cartilage may then be under either too much or too little pressure and the appropriate intermittent compression that is needed for waste removal and nutrition supply may not be present. This may result in cartilage deterioration, which at the knee usually occurs on the medial aspect or inner part of the knee cap.

The symptoms of runners knee include pain near the knee cap usually at the medial (inner) portion and below it. Pain is usually also felt after sitting for a long period of time with the knees bent. Running downhill and sometimes even walking down stairs can be followed by pain. The condition is caused by the kneecap not tracking smoothly in its femoral groove. When the knee is bent there is increased pressure between the joint surface of the knee cap and the femur (thigh bone). This stresses the injured area and leads to pain.

Factors that increase what is known as the "Q" (Quadriceps) angle increases the chance of having runners knee. The Q angle is an estimate of the effective angle at which the quadriceps averages its pull. It is determined by drawing a line from the Anterior Superior Iliac Spine (bump above and in front of your hip joint) to the center of your knee cap and a second line from the center of your knee cap to the insertion of the patellar tendon (where the tendon below your knee cap inserts). Normal is below 12 degrees, definitely abnormal is above 15 degrees. Many times adding to the strong lateral pull of the bulk of the quadriceps is a weak vastus medialis. This is the portion of the quadriceps that helps medially stabilize the patella. It runs along the inside portion of the thigh bone to join at the knee cap with the other three muscles making up the quadriceps. Some of the mechanical conditions that may contribute to this include:

Treatment of Runners Knee (Chondromalacia of the Patella)

At an early stage running should be decreased to lessen stress to this area and allow healing to begin. It is important to avoid downhill running which stresses the patello-femoral complex. Exercises performed with the knee bent should be avoided. When the knee is bent the forces uner the knee cap are increased. Many people feel that the vastus medialis muscle works only during the final thirty degees of extension of the knee. This is the muscle that helps stabilize the knee cap medially and prevents it from shifting laterally and tracking improperly at the patello-femoral joint. Straight leg lifts strengthen the vastus medialis and do not significantly stress the undersurface of the knee cap. They should be done 10 times on each side. Start with 5 sets of 10 and work your way up to 10 sets of 10. Straight leg lifts are best performed lying on a cushioned but firm surface, with the exercising leg held straight and the non-exercising leg somewhat bent to take pressure off of the back.

Tight posterior muscles should be stretched. In many cases tight calf muscles or hamstrings lead to a "functional equinous" and make the foot pronate while running or walking. This pronation is accompanied by an internal rotation of the leg which increases the Q angle and contributes to the lateral subluxation of the knee cap. Running shoes that offer extra support should be used. If further control of pronation is needed orthotics should be considered. The late George Sheehan, M.D., sports medicine physician and philosoper, was the first to popularize the notion that it was important to look at the foot when runner's knee occurs. It is also important to rule out other knee problems when knee pain occurs in runners and not just lump every pain as "runner's knee".


Iliotibial Band Syndrome

Symptoms of the iliotibial band syndrome are pain or aching on the outer side of the knee. This usually happens in the middle or at the end of a run. A concomitant problem may occur at the hip called greater trochanteric bursitis. During flexion and extension of the knee the iliotibial band rubs over the femoral condlyle which leads to irritation. Factors contributing to this syndrome are genu varum (bow legs), pronation of the foot (subtalar joint pronation), leg length discrepancy, and running on a crowned surface. Circular track running may also contribute to this problem, since it stresses the body in a manner similar to that of crowned surfaces and leg length differences. All of these factors are aggravated by a tight iliotibial band. Changes in training frequently contribute to this problem. It is always important to examine your training regimen and see what alterations have recently occurred.

Anatomy The iliotibial band is a thickening of the lateral (outer) soft tissue that envelopes the leg, which is called the fascia. In this area it is called the fascia lata. The thickened band is called the ilio-tibial band. The muscles that insert into the proximal (upper) portion of this band are the tensor fascia lata and a portion of the gluteus maximus. At its insertion into the tibia it blends with the Biceps femoris and the Vastus lateralis.

Self-Treatment:

Self treatment for this problem should include:

The side stretching is well illustrated in Runners World, February, 1995. It is performed while standing as follows: Place the injured leg behind the good one. If the left side is the sore side, cross your left leg behind your right one. Then lean away from the injured side towards your right side. There should be a table or chair that you can hold onto for balance on that side. This stretch is the best of several that exist for this area. Be careful not to overstretch. Hold for 7 to 10 seconds and repeat on each side 7 to 10 times.

If your self-treatment has not been completely successful than a trip to a sports medicine specialist may include the additional treatment of either a steroid injection below the IT band and possible orthotics. Treatment is usually succesful for this problem.


Pace and Calories

It has been estimated that about 120 calories are burned per mile. This appears to be fairly constant and independent of running speed. Although there is a slight increase of rate of calorie burning with an increase in speed, it is considered negligible. One of the obvious advantages of running, when it comes to burning calories is the shorter time it takes to burn the same number of calories, when compared to walking bicycling, swimming and most other aerobic exercises. Many physiologists also feel that the metabolic rate seems to be going at a faster pace for several hours after exercise. A decrease in appetite is often noticed by many runners, following running. On the other hand, with all this increase in burning of calories - more food can safely be enjoyed!

Pace		1 Mile		1/2 Mile  	1/4 Mile
Calories


Slow		12:00		6:00		3:00
10 cal/min
120cal/mile

Still Slow	10:00		5:00		2:30
12 cal/min
120 cal/mile

Running 	8:00		4:00		2:00
15 cal/min
120 cal/mile

Faster Run	6:00		3:00		1:30
20 cal/min
120 cal/mile

Swimming - Crawl: 25-50  yds/min
6.0 - 12.5 cal/min

Swimming - Butterfly: 50  yds/min
14 cal/min

Swimming - Backstroke: 25-50  yds/min
6.0 - 12.5 cal/min

Mountain Climbing
 10 cal/min

Cycling  5-15 mph
5.0 - 12. cal/min


source: Brian J. Sharkey, Physiology of Fitness, Human Kinetics Press, 1979.


12 Minute Fitness Test

Several protocals exist to gauge your fitness or maximum oxygen uptake (MVO2).  Dr. Kenneth Cooper devised a 12 minute test that correlated well with testing performed in a laboratory.  To use the 12 minute test run or walk as far as you comfortably can in 12 minutes.  This is best done at a track, where you can easily measure the distance you cover. The following is a table based on Dr. Cooper's research.

Correlation between 12 minute run and maximum oxygen consumption


Distance(miles)		Maximum Oxygen Consumption	Fitness Level
			ml/kg/min

Less than 1		Less than 25		Very Poor
1 - 1.25		26-33			Poor
1.26-1.5		34-42			Fair
1.6-1.75		43-51			Good
More than 1.75	52+			Excellent


Sports Medicine Home  |  Chess  |  Shoes  |  Comprehensive Site Listing   |  Home Page


Copyright © 1995-2006 Stephen M. Pribut