By Dawn Lewis
Tibialis posterior is located deep in the posterior compartment of the lower leg. It originates from the lateral side of the posterior tibia, the medial aspect of the posterior fibula, and the interosseous membrane between the tibia and the fibula. It inserts on the plantar surface of four of the tarsal bones (namely the navicular, cuboid, medial cuneiform, and intermediate cuneiform) and the 2nd through 4th metatarsals. The job of tibialis posterior is to pull the foot into supination or inversion and plantar flex the foot at the ankle.
Yesterday I had a client that I suspect has poserior tibialis tendon dysfunction or PTTD, which is a wearing of the tibialis posterior tendon that leads to flat footedness and eventually to arthritis in the foot. This condition may be initiated by trauma. This particular client is an acupuncturist and massage therapist (and a student of mine from out of town) who also plays volleyball and has sprained both of her ankles multiple times. Her right ankle and foot have been sprained the most, and that is the side that is noticeably flat footed.
Her pain complaint is mainly in her knees, both knees, but again her right is worse. She told me during the intake that she had been told that her knee pain was coming from inhibited gluteal muscles. I began on her left side because the knee alignment was worse on her left. It took me only a few minutes using SMRT to loosen the tissues in her lower leg and ankle. Her left knee then looked much more aligned and I spent a while longer working her foot and ankle.
When I began to work on her right foot ankle, I noticed three things very quickly. 1) her talus and posterior calcaneus were moved medial. This makes sense to overpronation. 2) in a passive position the flat footedness I had observed when she was actively standing on her foot did not carry through to her forefoot. In other words, when she was passive, she had an arch, or at least the illusion of an arch. Her tarsal bones were very close to one another, not moving, and pulled dorsal. 3) there was significant inflammation on the medial aspect of her ankle, both in the tibialis posterior tendon and in the tibialis anterior tendon.
Using SMRT I released the calcaneal tendon, soleus, and gastroc. Then I worked to remove the scar tissue in the anterior aspect of her ankle. Finally after releasing the other muscles coming across the ankle, I began to work the foot directly. I told her I thought the issue was tibialis posterior. She told me that this was the muscle they had her strengthening with physical therapy the last time she had that treatment.
Wrapping the foot in my hand, I moved the foot slowly and deliberately toward plantar flexion while moving the navicular, cuboid, and cuneiforms closer to one another and toward the talus and calcaneus. Next I slowly and slightly moved her foot toward inversion. At that moment I got the feedback I was looking for and stopped. I held that position for about 30 seconds. When I released it, the inflammation in the tibialis posterior tendon was gone, the tarsal bones were no longer moving in different directions, there was space between the tarsal bones, they were mobile, and her posterior lower leg had more balanced tone.
This was at the very end of the session. There was residual inflammation in the tibialis anterior tendon and her foot needs more work. Thankfully she is coming back in on Monday! When she left she was concentrating on walking and she remarked that her right foot felt like a new, different foot. My question is: is there permanent damage? Her ankles have suffered quite a bit of trauma and she has had this particular pain pattern for four years. Can we stop any more damage from occurring? Can we even heal some of the damage that exists now? I have seen encouraging results with past clients who presented with similar issues, so I am going to think positively.
Learn to use SMRT for the feet, ankles, lower legs, thighs, and knees by joining us in Pittsburgh from December 4-6, 2015. For more information or to register, please go to http://efullcircle.com/workshop-schedule/