Stability starts at the ankle...Part I

The foot is a marvel of architecture with all its joints, axes, arches, ligaments, fascia, and muscles that not only live in the foot but also those muscles that live outside of the foot but still influence the foot.  When treating foot conditions, not all feet are the same, and there may be variation from side to side. This began to be apparent to me when I began to have foot problems during an increase in my running load while living in Ohio during my physical therapy doctoral program. I began to notice pain on the inside of my right foot and in a long and sorted way of self-treating, I began to recognize the beginning of over use of my posterior tibialis muscle.

When considering the muscles of the leg, I do feel it is valuable to first define what the leg is. Although it seems like it could be an obvious regional term, most people only understand the leg to mean that “stem” that runs from the hip joint/socket or pelvis down to the foot. I want to identify that structure that runs from the hip joint/socket or pelvis down the foot as what is appropriately termed the lower extremity. The lower extremity is composed of what is called the thigh, that structure from the hip joint/socket or pelvis to the knee. The leg, is the structure from the knee to the ankle. Then we have the foot.

Now that we have defined what the leg is, let’s consider that the leg has three compartments. The anterior compartment, the lateral compartment, and the posterior compartment. Now let’s talks even more specifically about the posterior compartment. The posterior compartment of the leg is where we find most of the muscle bulk. That is what most people are familiar with, with regards to the common use of the word “calf”. Since we will be discussing the posterior tibialis muscle, it may be helpful to understand that it is a part of the posterior compartment of the leg.

The posterior tibialis muscle is one of three muscles that sits underneath the gastrosoleus complex. The posterior tibilais arises from the tibia, fibula, interosseous membrane. It runs the length of the leg as it then takes a turn and runs behind the medial malleolus or the big bump on the inside part of the ankle. During tasks that involve the foot in a non-weight bearing position, the posterior tibilais contributes to plantar flexion and inversion(collectively called supination) of the foot. When the foot is in a weight bearing position, the posterior tibialis helps to stabilize the foot and absorbs the impact as our foot strikes the ground during walking or running by helping to maintain the main arch of our foot.  When this muscle does not do its job effectively or efficiently, that is when a person can begin to have pain and dysfunction which can really begin to affect how a person is able to walk and or run.

In an in the JOSPT, they found that in group of women, not only did the participates demonstrate plantar flexors weakness but they also noted decreased strength and endurance in the participation gluteus maximus and medius muscle groups. These muscles help to control hip extension and push off during gait as well and controlling the pelvis during gait. This shows us that when one has a foot problem such as the case with posterior tibialis tendon dysfunction, it usually also means they also have a lower extremity problem! Again,  the role of the posterior tibialis muscle is to control the motion of pronation as we walk. If the foot spends too much time in pronation, there is a greater likelyhood of creating overuse and stress to this muscle. This impairment can also be linked to tibial internal rotation, hip adduction, and hip internal rotation.

What I find most interesting about the posterior tibialis muscle is how influential it is in our foot posture. One feature that I also find key in addressing this foot condition is a person’s shoe selection. I personally don’t care what brand of shoe a person wears however when one begins to have foot problems the first thing that will help in managing the condition is getting the right kind of shoe for your foot; one that helps control the heel. Typically, in the case of posterior tibialis tendon involvement and the presence of a collapsed arch, getting the heel in good alignment helps guide the posture of the rest of the foot. When the heel is in good alignment, the foot can better “recreate the needed arch” and then better do its job as providing for a rigid push off during gait.

Corrective exercises:

1)     Proper foot wear- that helps to control the calcaneus aka the heel bone.

2)     Arch Domes – to help support the main arch of the foot

3)     Plantar flexion + supination with a TheraBand

4)     Gentle Heel Raise with Ball

5)     Double leg and single leg balance exercise that help strengthen the extrinsic muscles of the foot

6)     Address other Lower extremity muscles: (such as clams, standing wall clams, hip abduction work, bridges, planks, and side planks)

Reference(s):

Kornelia Kulig, John M. Popovich, Jr, Lisa M. Noceti-Dewit, Stephen F. Reischl, and Dong Kim: Journal of Orthopaedic & Sports Physical Therapy 2011 41:9, 687-694. Women with Posterior Tibial Tendon Dysfunction Have Diminished Ankle and Hip Muscle Performance: