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Possible TTS vs. Posterior Tibialis Tendonitis

Posted by Ryan G. on 7/07/03 at 08:55 (123700)

Questions more for a Doc or PT that reads here but input from a patient is more than welcome. I have a 33 year old female with post tib tendonits which developed afert a mild ankle sprain 10 mos ago. Active and Passive ROM is normal. Inversion strength testing is positive for marked pain behind the medial malleolus. Positive Tinnels sign more for pain but no reports of parasthesia through the sole of the foot. Patient has custom orthotics (for past treatment of heel spurs a few years back and has begun wearing in the past few months which has helped some). Patient works at a computer most of the day. Left foot involvement only so I'm thinking less about a true mechanical problem since it is not bilateral. Compounding things is that the patient is trying to get pregnant so no injections or anti inflammatorys as well as no diagnostic tests. Most of the first line of treatment has been covered ie footwear, orthotics etc. I suggested she really try icing every 3 hours for 10-15 minutes religously over the next few weeks. I'll be seeing her and will try ultrasound and gentle cross friction and mobilize the area as long as I don't aggrevate her symptoms. I had considered using iontophoresis with dexamethasone but am concerned that would be contraindicated because of the chance of pregnancy. For the most part it is a local treatment altough the drug has to be absorbed and will end up in the blood stream at some point. Basically I told her we would try the conservative things for 3 weeks and if no relief, then she would most likely have to wait until after having the baby for further work up to rule out some spur or compromise at the tarsal tunnel. Any suggestions would be welcome.

Thanks much,

Ryan Gephart, PT, CSCS

Re: Possible TTS vs. Posterior Tibialis Tendonitis

Ed Davis, DPM on 7/07/03 at 14:25 (123708)


It is possible that if there is effusion about the post. tib. tendon, that effusion can place pressure on the post. tib. nerve causing entrapement like symptoms. A 'mild' ankle sprain (most sprains being inversion sprains) would be unlikely to cause post. tib. symptomatology of such a long duration. Perhaps tibialis posterior insufficiency is a factor and it was 'lit up' at the time of the sprain. How effectively are the orthotics in controlling her biomechanics?


Re: Possible TTS -tried compression socks

lara on 7/07/03 at 15:53 (123711)

What a great doctor you are, to go find people (publicly even) who might have information you don't know - including patients! I can't tell you how many times I got told the pain was 'in my head' when they couldn't explain it! Took three years to get a diagnosis that I figured out might have some kind of nerve involvement fairly early on.

I didn't follow all the technical language, but if it's TTS, some people are helped by compression socks. They are magic for me, but others have varying results. It would be a non-invasive and relatively inexpensive treatment to try - don't see how it would hurt a pregnancy. My doctor started with Rx 'milds' - but I doubled them (for a few hours at a time) cuz I could tell they were helping almost immediately, but I wanted things to go faster (at the time I was sometimes crawling around on the floor my feet burned so badly). Some people experience pain with them, but my impression from their posts is that if so, they just take them off and any pain is reversed and no lasting damage is done.

I was given orthotics by a doctor prior to finding the doctor that recognized it as TTS, and the orthotics slowed the progression of the TTS symptoms, but they didn't stop or reverse it and I eventually found my way to another doctor. Once the compression socks got me a life back, the orthotics didn't add anything additional.

Re: Possible TTS vs. Posterior Tibialis Tendonitis

Ryan G. on 7/08/03 at 09:37 (123745)

Dr. Davis,

Thanks for your reply...I didn't spend alot of time analyzing the gait and I think the orthotics are doing what they need to. They are custom made by a local DPM. I think part of the problem was the patient stopped wearing them after her heel spur symptoms resolved last year. Her symptoms improved after resuming the use of the orthotics. The sprain was an inversion sprain but with it being 10 months ago, no major effusion an no pain with active motion but with manual resistance and the Tinnels sign, I was thinking something alittle more than just tendonitis. A few of my collegues stated they thought the use of dexamethasone via iontophoresis was not contraindicated due to the patient trying to get pregnant. I know it would be nice to have some type of scan either xray or MRI but the patient has opted not to go that route because of the pregnancy. My other thought would be tenosynovitis. At least from my end of things, I'll treat it with the standard treatments. Any input on the use of dexamethasone with the possibility of pregnancy??

Thanks again.

Ryan Gephart, PT, CSCS

Re: Some suggestions for your patient.

marie on 7/08/03 at 11:18 (123747)


Consider using some vitamins. Vitamin C is helpful for tendon pain. I take glucosamine, msm, magnesium and vitamin c....daily. Perhaps it will be an option considering her desire to become pregnant. Several posters here use vitamins in conjunction with their other perscribed medications. I have noticed some difference. Other things used by patients here include: compression socks, Birkenstock shoes, night splints, icing, physical theropy, massage(it is extremely important that there is no vigorous massage directly over the tarsal area), chiropractors can re-align the foot, yoga, acupuncture and light stretching. These are all of the non perscription things I can think of. I am sure others can add to the list. Check out Scott's heel pain book on this site.

Best wishes to you and your patient...it sounds like she is in good hands.


Re: Possible TTS vs. Posterior Tibialis Tendonitis

Ed Davis, DPM on 7/09/03 at 08:29 (123821)


The application of dexamethasone via iontophoresis to the area may be effective and is not likely to raise blood levels sufficiently to cause harm. It may be advisable to get clearance on that from her ob-gyn doc though to be on the safe side.

Re: Possible TTS -tried compression socks

Ed Davis, DPM on 7/09/03 at 08:32 (123822)


Thank you for your comments. Varicose veins in the tarsal tunnel are a culprit in about 25% of tarsal tunnel cases. I would speculate that that may be your situation since you are getting results from the compression hose.


Re: Possible TTS vs. Posterior Tibialis Tendonitis

Ed Davis, DPM on 7/09/03 at 08:33 (123823)

PS If the patient had a need for orthotics previously, it may be a good idea to re-try the devices.

Re: compression socks, varicose veins, thyroid?

lara on 7/09/03 at 09:12 (123834)

I asked the doctor about this (varicose veins being cause of my TTS) and she said it could be, they often find varicose veins when they go in that they didn't see before, but she still didn't recommend surgery given the reasonable life I have without surgery.

However, I'm now pursuing another avenue that I think might be more likely (although I would love comments from you). My first appointment is next week - I've sent articles ahead of time to the doctor (with the encouragement of her office).

There is very little history (actually none that I know of) of varicose veins in the family. This doesn't rule it out, but does make it less likely. I can't picture even one VV on the legs of my mother, either grandmother, sister, or cousins. However, I have a STRONG family history of thyroid problems (mom on thyroid since adolescence - she doesn't remember the particulars of presenting symptoms or treatments, it was over 60 years ago - and sister with thyroid symptoms traceable to childhood but not diagnosed and treated (as Graves) until about 35, and continuing problems as her blood work and symptoms jsut don't fit any textbook (but clearly thyroid-related issues are continuing to plague her).

My very limited knowledge is that thyroid may have to do with water retention, and that would also explain why compression socks would work? I think? Not sure where to go with this or whether there are treatments (worth the side effects) even if it's determined thyroid is behind all this.