Posterior Tibial Tenosynovitis

Training
1

Anyone with experience of this?

After completing 20 weeks of SSBMVI+II and GBMV I reached the much vaunted 4w/kg at 64kg feeling great with no issues, I rode outside in early August. I probably rode out the saddle a bit more than usual. Over the following week I had increasing pain behind my medial malleolus.

I had an MRI showing posterior tibial tenosynovitis after about 2 weeks. The tendon itself is not thickened, just the sheath.

10 weeks since injury and I have seen physios and sports podiatrist and been given orthotics and a medial heel wedge and a list of exercises. I can do 25+ single heel raises on the affected side, but the tendon is still tender and it still tweaks when walking and riding indoors (only riding I’m doing, after a 10 week break). The pain isn’t too severe, but it’s very off putting knowing that there’s something wrong and not wanting to worsen it in the long run.

Most things I’ve read online are from runners and it sounds like a frequent common injury for them due to the overuse. But it’s not very common in cyclists as it probably isn’t overused on the bike and to add insult to injury the triathletes online all say “at least I can still cycle”!

So just wanting to see if anyone has any advice re:

  • exercises
  • time course
  • operative intervention (last resort of course)
  • saddle height
  • pedalling technique
  • cycling orthotics
  • deep tissue massage/shockwave therapy/ultrasound

Appreciate this is quite a niche question, but grateful for any input.

EDIT: Should mention, I’m 30 with no other injuries or health issues

2

This may apply. My daughter is a high school runner and went through “post tib” on a number of occasions. While she was a runner, it might be your issue as well. We found that when her foot struck and rolled in, it would roll too far inward and stress the post tib repeatedly. Initially, icing helped as did an ankle compression sleeve. She went to a more support shoe that prevented the foot from rolling too far and stressing that tendon. You might check with podiatrist about making special inserts as I’m not sure if they make motion control shoes for cycling - could be wrong.

She did many of the PT exercises you did, working specifically on strengthen foot muscles as well as lower leg.

Any modifications recently to cleat position, shoe, etc. Hope that helps.

3

Thanks for the reply.

Yes, over pronation does seem to be implicated in runners and I’m not sure to what extent it applies to cyclists. I suppose flat-ish arches and no arch support in the cycling shoes might not help (one of the roles of the post tib tendon is maintaining the medial arch). Hopefully the orthotics I’m using will address this and allow it to rest/heal. I hope your daughter has fully recovered!

I’ve had no changes in my (professional physio-led) bike fit recently and sadly I’ve moved city from the very good physio bike fit place I previously attended.

This hit me out of nowhere but has opened by eyes to the concept of pre-hab where I had previously done no flexibility work etc and hadn’t considered my shoewear etc. I’d encourage all cyclists to do some flexibility work and consider visiting a podiatrist before you get problems. It is incredible to read on the forum that people with fibular fractures were off the bike for 6 weeks whereas my trivial tendon inflammation has had me off for nearly double that and it’s still not healed.

4

Agreed. While we were having custom orthotics made, my daughter did order some pretty high arch supports as temporary fix. Again, once the arch collapses during the foot strike phase, it was flattening out and allowing the rolling inward. She is 100% better and hope you get there too.

5

@SweetSpot Was wondering how this has panned out for you? Im 30 years old as well and have been dealing with post tib issues on both ankles from cycling that aren’t healing. Any help would be much appreciated!

6

I lost the better part of 9 months to this in 2011

  • D2 Shoes. They made some changes with the orthotic, and the sole profile. Helped tremendously.

  • Strengthen the pronator chain. It gets weak from cycling. Also, work on side-to-side movement to strengthen and activate the medial glutes. walking lunges ain’t bad, either.

  • Trial, error, and work with a PT to video your pedaling from the front to see where you’re losing forefoot stability in the stroke to fine tune your fore-aft. Too far forward or too far aft and your glutes aren’t in a good position to start firing the pronator chain.

7

Hi @georgevhoffmann

How certain are you re diagnosis?

Thankfully I barely recognise how miserable I was when I wrote my prior message. I get the odd twinge but now much improved doesn’t affect my riding

Bit of rest initially
Orthotics with arch support and medial heel wedge in cycling shoes AND I wear them full time now in all shoes
Static holds on the tiptoes of the affected leg for 30-90s, adding weight if required with dumbbells (I did this in preference to active heel lifts or eccentrics)

Keep on riding but not during rest phase and not if it is triggering it

Hang in there

8

Tib post problems can crop up on anyone, not just runners. In my experience people who pronate tend to be more vulnerable, as mentioned above this stresses the tendon and causes repetitive damage. Look at your everyday footwear, if there’s a lot more wear on one side of the heel than the other then you probably could benefit from an arch support (could be more inside or outside, depending on various factors, but this is by no means definitive one way or the other).

Correcting/controlling this pronation is key to recovery, then strength and mobility is needed to stop it coming back. As SweetSpot says, try static tiptoe holds as well as/instead of more dynamic tiptoe exercises. Also lunges, side lunges (focus on both ankles when doing lunges, not just the side you’re lunging on), single-leg standing/hopping, walking on tiptoe/heel/outside edges. Anything that works your ankle stability.