I just sent my DPM of the past 3 years your information on diagnosing, and early treatment of PTT. She is the only DPM in a statewide DE orthopaedic practice. I wish I'd had your information a year ago. I'm a Nationally Certified Rehab Counselor who performed my own gait assessment 9 months after foot surgery with a compound FX of the Lt Big Toe with bones refusing to fuse after surgery was delayed 3 months when the surgical centers were closed March 2020 due to COVID-19. I have anemias of Vit D, and B12 Deficiencies. I wore a surgical boot with lift for 7 months post-op, then resumed walking 1/2021 then developed PTT with multiple neuromas, arch pain, ball of foot pain, and tibia, fibula, with navicular problems the Chiropractor tried to adjust. All this information was given to the DPM who did not diagnose the condition until I informed her it had to be PTT on 8/23/21. She wrote a new order for PT that day, and I commenced treatment on 8/23/21 which ended 12/10/21. The MPT worked with me on treatment. I joined a gym 12/31/21 to continue working with sports trainers while doing home rehab. Your video sums up a year's worth of my frustration, and learning. I am 67 having stopped running at age 30. I believe my PTT issues arose from not being able to walk due to foot surgery with intense lower extremity pain, poor posture with hip, back, knee pain with poor balance, instabilty in gait in addition to poor ankle mobility, etc., and a sedentary lifestyle for 2 years. I hope everyone understands this is "a tough tendon to rehab." From what I've read people report frequent relapse if they neglect to exercise, and maintain caution without activity modifications. I was never a candidate for another surgery. Thank you for designing FO's, and providing care with recommendations for this condition especially on RU-vid, and your blog. Connie
HEY RICHARD BLAKE! THANK FUCKING GOD FOR YOUR HELP DUDE I've spent 600$ and 1.5YEARS of rehab and now i know why i got more problems than i started with, the Anterior Tibialis was doing all the work and it lead to a whole load of other problems. THANK YOU
The instructions about the anterior not supposed to help are priceless!!! So I do not do exercises from each segment right from the get go , but start with range of motion only, then go through the variations and then move up to isometric and functional?
I’m 2 years into PTT. Just starting to get into strengthening exercises. How fast does the foot progress from stages 1-4 any rough number? I can still heel raise on occasion. Been wearing a orthotic for a year and a brace for 2 months. Learning more on RU-vid about this then my podiatrist and surgeon have told me about it.
Carlos, glad to hear and so sorry for my tardiness. The progression can be over several years if untreated, and slow if you are getting some good treatment. Rich
I hope this works. My podiatrist just gave me orthodics and told me to get new shoes. Told me to come back in two months. No exercises at all. So I am trying to search online for something to strengthen my posterior tibial tendon.
I have a TIbialis posterior tendinopathy since 5 months. My tendon was overloaded. 2 weeks ago I start with strengthing exercises by myself, because my physio or doctor don't know anything about this exercises. Another doctor did'nt diagnostic my TPTN. My knowledge about this problem is connected with youtube and such important videos like your's. Thank you so much. Can I also try to make walks about 20 minutes? Thank for your answer dear Dr.Blake. Best regards Elizabeth, Austria
I liked the thoroughness on the video of how to strengthen the Posterior Tibialis Tendon. When I did the windshield movements and had my foot Taped, I was unable to see if my Anterior Tibialis lTendon was engaged. It's helpful to see the tendon to know if I was pointing my foot enough. Tonight I went through the Video without the Tape on my foot and it was easier to see if I was doing the Windshield Movement Correctly. The Isometric segment was new to me. I just began Theraband Level 4, but had never done the Isometric segment. I will add that. When it comes to Heel Lifts & Balancing on one leg: Since I was diagnosed with Naviculars and wore a boot fo 3 1/2 weeks and have been Rehabbing, I rarely go Barefoot anymore. I need to do the 2 Leg Heel Lifts, the Single Leg Heel Lifts, and Balancing on 1 leg with my Ankle Supports and Shoes.
Great video thanks for sharing! I am.assuming if in pain when doing any of this exercises then I should stop doing? I have pain only when walking none when resting. My podiatrist informed me ice will help only temporarily to reduce current pain. But will not really help my pttd. What is your opinion on this please? Thanks again from Vancouver BC. ❤
Posterior Tibial shown here, the intrinsic foot muscles, and the achilles complex are the most important foot muscles to exercise. You also have to work on the lateral hamstrings and the gluts and piriformis. They are help the pronation motion when excessive. Rich
Dear Dr. Blake. I have pttd. I had a first TMT fusion six months ago that is 80% fused. My pttd did not resolve from being in a cast and boot for 8 weeks. I went to get a second opinion on the midfoot fusion and the xray report said “likely surgical alteration of the calcaneous.” I was shocked because the surgeon said nothing about my heel. Admittedly, he did not take measurements. I’m not wearing a brace because the first surgeon says bracing makes the tendon weak. Everything I’ve read online says bracing is effective for pttd. I do not want a calcaneal osteotomy. Could the xray report be wrong? Any advice would be appreciated. Im doing your exercises for pttd. Thank you for helping so many of us.
Do you have a scar on the inside or outside of the heel? You brace to walk and strengthen the rest of your body. You do the rest of your exercises to strengthen the PT. The goal is 0-2 pain, so if you need a brace you wear a brace to achieve that. Rich
Five months after ankle surgery, I am having difficulty walking properly without pain in my thighs and hips. I was told that I need orthotics to help strengthen this tendon.....with the help as well of these exercises, how long do you think it will take for me to walk without hip pain?
Helen, if we assume that the hip pain is from favoring, you should do everything to get the ankle bearing it’s share of the load. These exercises, taping, orthotics and stable shoes will help. You should feel better each month. Three months from now you should a lot better
Hi doc,, my orthopaedic surgeon diagnosed with me pttd stage 2,, is it possible that I strength my tendon with you exercises and my condition does not prolong to stage 4 of pttd??
All we can guarantee is with great orthotics to support your arch and getting the tendon very strong you have a good chance of delaying (and possibly preventing surgery). Good luck. Rich
Is it recommended that strengthening exercised be done after inflammation settles? MY pttd is an overuse injury from moderate overpronation. I was told walking can hinder healing. I am getting a hinged custom made AFO to help calm the tendon. down.
Beginning to strengthen an injured area as soon as possible is important. Begin easy, if there are tears in the tendon that need to heal, you may have to wait! Rich
@@drblakeshealingsole My MRI reveals Type 1 Navicular Accessory with fraying and tenosynovitis of the post tib. I will require a risky surgery where there's possibility of non union of the post tib. I was active before and feel myself atroohying from not walking to keep load bearing of the post tib to a minimum. My barn days are over and is walking my beautiful standard poodle. An emotionally challenging diagnosis with despair.
@@sahfora3388 removal of accessory navicular has great success. The post Tib can get cleaned out and then rehabbed. You can end up with a good strong ankle. Please don’t despair!
I'm pretty sure I hurt my posterior tibial tendon!! I have pain all around my accessory navicular and it goes down under my foot and up my leg. I've also noticed that my balance in that foot is completely gone!! I've been doing yoga for a few years and I can no longer do any one legged balance poses. Thank you for these exercises, I'm going to give them a try!!
سيدي لقد اجريت عمليه جراحيه وقمت بأزالة العضمه الزورقيه اجراء كيدنر والوتر متورم لحد الان ولم يشفى علما ان العمليه مضى عليها خمس شهور ماهو السبب بعدم شفاء الوتر الضنبوبي
Hello Doc ! On the first exercise I cannot figure out if you can rest your heel on the ground or if you have to kind of levitate your whole foot ? Thank you for the video, I've been given isometric exercises but it's triggered too much pain so I'm going to try those first very gentle exercise you gave at the start of the video.
Thank you for your comment. Certainly, you can rest your heel on the ground to stabilize the foot first. This will be less jerky on the tendon, so should hurt less. Due to the proximity of the posterior tibial nerve, it can be hard to avoid all pain, but it is how it feels after that tells you if it is too much. You can also shorten the overall excursion of your foot (less motion) to see if that helps. Rich
I just started suffering with this. Right foot in moonboot now for 4 weeks already. MRO showed tendosynovitis post tibialis and mild sprain spring ligament. My left foot started hurting too after being immobilised in the right. I like your exercises and explanation of anterior tibialis, which feels very sore too. When can you start this exercises after inmobilization? Do you recommend streches and massage, tens?
With all injuries motion like walking is preferred. But you have to keep pain level between 0-2. This is how you decide on distance, speed, shoes, bracing, taping, etc
@@hannahmayo6582 yeah these exercises helped a lot back when I had shin splits, especially the standing on one foot and shin raises/toe raises. I did these exerices for a few weeks and built up strength back in the posterior tib as well as anterior tib. I also iced where the pain is. And then the shin splits issue was fixed. Also stop all running until the pain is gone as it will make it worse
@@HtheKing Wow thanks for the response! Didn’t expect that after so long haha. But thank you! My issue is that I haven’t run or done anything really intense for almost 2 years and to this day I still have tenderness along my shin and PTT. I just started a PTT physical therapy program last week and really hope it helps!! How long did it take you to see results? You said only a few weeks, or was that just the first part of the program?
Thanks for the video. I was just diagnosed with PTT 3 weeks ago (thought it was plantar fasciitis for 4 months!). A PT gave me a very similar series of exercises, however, he directed me to do them twice a day. I feel that these exercises "light" the tendon back up. How do I know if I'm overdoing it and causing a setback instead of strengthening the tendon? Thank you!
Sam, thanks for your comment, the posterior tibial tendon and nerve run right next to each other, so it is one of the hardest tendons to rehab. It is a balancing act, since you do not know if you are hurting yourself if it is "lighting up". Stick to once a day in the evening, ice afterwards, go gradual, see my video on taping to take stress off the posterior tibial tendon when you walk. I have had some patients have to do 1/2 of the originally recommend exercise dose, and go to every other day. The tape will take the place of the tendon so you can strengthen it slower. Rich
@@drblakeshealingsole Thank you for sharing your knowledge, Dr. Blake. As a runner, teacher, cross-country and track coach, this a disruptive condition to say the least.
Thanks for all videos. I hurt my posterior tib this week. This is an injury that comes and goes for me. Last summer it kept me out 3 weeks. On sunday I was fine I ran 7 miles uptempo but well slower than race pace. My calfs were sore after and I went home and really stretched well. Sunday I was sore but I was able to run an easy recovery pace 5 miles. Monday was my normal off day and Tuesday morning I ran an easy 4 miles. Suddenly Wednesday morning I woke up and I felt a knot in my lower achillies whiile I was in the shower. By the time I left for work I could barely walk because of the pain in my Posterior Tib. At the moment I am using a cam walking boot until the swelling goes down and I can walk without pain. I iced a few times that first day but honestly I felt like the ice made it worse. At what point should I try and use the KT tape and implement the exercises? Thanks
Stage 2 can be improved in 6 months, but then you have to be diligent in a maintenance program of strengthening, shoe selection, occasional taping, etc
Hi doctor. Thank you so much for this video. The secondary bone under the be ankle. Can that be directly under the ankle? As I'm feeling allot of pain directly under that bone. It's very tender there also the actual bone looks more visible then then the other foot
@Ahmed Chandab I have accessory navicular which shows as an extra piece of bone where you are mentioning on the X-ray. This condition aggravates pain and issues with posterior tibial.
I recently had the same experience where the tendons under the navicular was tender and sore. Basically I went to a podiatrist for orthotics, and weekly physiotherapist sessions massaging under my foot and putting tape to support the arch. Hope that helps
Typically daily with the simpler exercises as you are really finding your level. And the beginning exercises, with no band work, can be done 2-3 times a day. However, once you hit your level where the 2 sets are challenging, switch to every other day so you can have a recovery day. Rich
@@drblakeshealingsoleHi Dr Blake This video is fantastic. My physical therapist threw me in the deep end right away with red band inversion exercises and it really set me back. I started with active ROM. Before this I started having hip pain. Any advice you can give me on that I assume it’s because my gait has changed
@@charlesboyer8811 Walking weird with any lower extremity injury can put stress on another joint. It is best to walk slower and maintain your normal gait. If you still limp, you really should be on crutches, or in a boot to rest the area more. Rich
That is an interesting point. When the patient fails conservative treatment for chronic sesamoid issues, the 2 areas that are surgeons look at other than simply removing the bad sesamoid is a possible dorsiflexory osteotomy on the first metatarsal if plantarflexed, and tight Achilles lengthening to remove equinus forces. The patient is a vital part of these discussions as each subsequent surgery means more rehabilitation or short term disability. Rich
Hi Richard Blake, i have condition accessory navicular osscil. I get pain that makes it difficult/impossible for me to walk for a week, once a month or so. Would these exercises still help strengthen the tendon and reduce the pain and regularity. Or am I at a point of needing surgery? Thanks
Whether surgery is needed or not, a re-strengthening program to get the involved tendon very strong is so important. An accessory navicular program is typically some use of immobilization with removable boots or cam walkers, strengthening, taping, orthotics, icing and contrasts to reduce inflammation, etc. See more on my blog www.drblakeshealingsole.com Hope it helps. Rich
@@drblakeshealingsole Richard Blake Richard Blake Thanks for your prompt reply Richard, in fact I never thought I'd get one. To answer your question yes and no. The part about strengthening up the tendon makes sense but am I delaying the inevitable. Have you ever dealt with someone who had a sever accessory navicular osscile pain or condition and managed to make a full recovery without the need of surgery. Also, to what degree should I do the exercises, should it hurt a little or am I pushing it too far? I will be sure to look at your website. Many thanks for your help
Billy Y, yes, infact most accessory naviculars heal without surgery, but it can be a long course. The worse it is the most time in the removable boots, the more exact the orthotics must be, the more reliance on taping, etc. The providers helping you have to be skilled at the rehabilitation, at least knowing the steps. Since some of these need surgery, that is always hanging over your head as a possibility, but surgery is not a guaranteed slam dunk either. The posterior tibial tendon exercises that are safe will hurt when you do them, but have no residual (meaning no pain after or the next day). Since the nerve is right there, this is one of the only strengthening exercises I teach that have some element of pain. Hope this helps. Rich
Hi Doc. I’m really enjoying your video. I have had multi ankle sprains in my right ankle spanning 20+ years. I am in extreme Burning pain but in my lateral side. I have always had v flat feet and my foot has further flattened with age. My most recent MRI says my post tibial tendon is anterior to the medial malleolus & it’s attenuated as it extends proximally. It also states I have Type 2 OS Naviculare. Which I’m not sure what that means. I’m v active & cannot do any Yoga, cross fit, barre clsss or even bicycle without pain. Interestingly enough though the pain is lateral. It sometimes is anterior to my lateral malleolus & other times it’s behind the lateral malleolus. Is this a presentation of posterior tibial tendon weakness ? I also have a large ganglion cyst in the sinus tarsi. I feel like I have sinus tarsi syndrome. Can you help me? I’m not able to see an ankle specialist till two weeks from now. Does all this make sense? Can this all be from weakness of the post tibial tendon? Is surgery indicated? Anti inflammatory are not helping.
Unfortunately, if the tendon has slipped to the front of the medial malleolus, surgery is indicated. They normally place it back in its groove, and have to decide if the os navicularis needs to be removed. The lateral pain is normal from the super pronation and pinching the lateral ankle and lateral subtalar joint structures (sinus tarsi). See my video on taping the posterior tibial tendon with leukotape to help you from crowding that lateral side. Rich
Richard Blake - wow! Thanks so very much!!! I really appreciate your videos & you responding to me. I’m so grateful. Will my surgery require any fusion or screws in my ankle?
Maybe not, but it will be the surgeon's decision on what it takes to stabilize the ankle. If possible, try to get several opinions and tell them all your goals of what you want to do post surgery. Good luck!! Rich
Nimi, thanks for the question. Yes, it does happen since the big posterior tibial nerve sits right next to the posterior tibial tendon. See if there are any symptoms when doing the exercises that last into the next day or seem to make matters worse. If not, gradually keep going. Rich
Hello Richard i found your exercises useful in addition to what a podiatrist has already given me to do. Unfortunately, i also have achilles tendinopathy at the same time. How do the two work together? The achilles problem came first then the PTT later. Do the exercises in your video work for both - or might any of the exercises work for one and against the other? I have been resting from hillwalking/climbing for 7 months now and doing rehabilitative exercises but neither problem is showing the slightest sign of going away. Be grateful for your thoughts on this more complex scenario, thank you
Alexandra, this is a very complex question that I would rather handle on my blog. Please go to www.drblakeshealingsole.com. and be as thorough as you can. Thanks Rich
ok, so I should not engage the anterior tib.... any suggestions as to how to avoid this or know if you are doing it wrong? rewatched the video several times... still cant see what is what :(
I know this is hard and confusing. You just want the anterior tibial which is in front of the ankle bone to not work, and the posterior tibial tendon which is behind the ankle bone to work. Most people when they tighten the anterior tibial tendon it really sticks up so easy to see. If you are barefoot, and you pull your toes upwards towards your knee, the anterior tibial should stick out. Then pull your foot towards the other foot, now the tendon is really sticking out. So, then point your foot away from you, and then move the foot towards the other foot without having the anterior tibial pop up. You can now isolate the posterior tibial tendon. Helpful?? Rich
thanks ... I got the anterior tib to pop up... but nothing else seems to be moving when I pivot the foot inward/towards the other foot... if its moving I cant see/ feel it... I will keep trying
