Posterior Tibialis Treatment with Low Level Cold Lasers
Posterior tibialis pain is a common running injury, or to anyone who is walking, hiking, or standing more than usual. It also occurs in athletes who are jumping, such as in basketball. The posterior tibialis muscles helps hold up the arch of the foot during walking and running. It can fatigue with activity, which results in the arch dropping or over pronation. The muscle continues to try and maintain the foot’s arch, but the overwhelming forces create small microtears throughout the muscle and tendon.
Leg pain usually starts as mild tenderness in a few spots behind the tibia. As the condition worsens more of the muscle and tendon is affected, ultimately resulting in pain during running, walking, or jumping. Severe injuries can completely stop your activities and are very tender to the touch; swelling may be present along the tibia.
The lower leg bones are made up of the larger and more weight-bearing tibia in the middle. The smaller fibula bone runs on the outside or lateral aspect of the leg. The femur sits on top of the tibia at the knee. Crossing the knee are several large muscles coming from the upper leg, including the quadriceps, biceps femoris, semimembranosus, semitendinosus. The gastrocnemius starts above the knee and crosses down to the Achilles tendon. The gastrocnemius is a larger muscle seen on the back of the calf that appears to be a big bump, and underneath it is solely a muscle that also performs plantar flexion. On the lateral side of the leg is the fibularis longus and and fibularis brevis muscles that help stabilize the lower ankle. On the medial side of the leg is a posterior tibialis muscle that runs directly behind the tibia and its tendon extends behind the medial malleolus and onto the bottom of the foot. On the anterior side of the tibia starts the tibialis anterior muscle that runs from the knee down towards the ankle and foot.
Rest and ice are always one of the first treatments for any running or lower leg injury. Rest gives it a chance to recover and heal. The small muscle and tendon fibers are trying to lay down more fibers to help support the soft tissue. This is not a fast process and requires time. The bigger the injury, the more rest may be needed. Ice is a great treatment for decreasing pain and inflammation associated with soft tissue injuries. Ice helps slow down the inflammatory cascade and production of molecules that make it painful to run or walk.
If the pain does not subside with rest and ice, over-the-counter anti-inflammatories can be utilized. Some patients respond well to Bio Freeze, BenGay, or any analgesic that helps minimize the pain and provide a relieving sensation on the muscles.
More severe sprains and strains may require treatment in an office. Seeking professional help can often shorten the recovery process and get you back out running much faster than rest and ice alone.
Your healthcare physician will performing an examination to determine the exact injury and any contributing factors to your pain. X-rays may be utilized to rule out stress fractures to the lower leg. Stress fractures can present similarly to tendinitis or medial tibial stress syndromes and should be ruled out, especially if the pain is severe. MRIs or advanced imaging techniques may also be used to evaluate muscles, tendons, ligaments, and periosteum of the lower leg, ankle, and foot. Your physician may examine your running shoes to see if they are the right type for your foot structure, arch height, foot width, and running gait. Often times the foot and ankle specialist can refer you to a quality running store that helps perform an evaluation of your gait to see which shoes are supporting your foot the best while running. Oftentimes footwear is different for standing compared to running.
Orthotics, heel lifts, strapping, taping, orthotics, and immobilization in a cast or walking boot may be prescribed. The physician may recommend NSAIDs or prescribe stronger anti-inflammatory or pain relievers at this time, depending on the severity of the condition. Steroid injections or cortisone injections may also be prescribed, again depending on the severity. They are not commonly utilized as the first line of treatment, however, because of risk versus benefit for this type of injury.
Surgical intervention is usually not needed unless trauma was involved or severe changes are found in your foot structural integrity.
Most commonly patients are referred for physical medicine or conservative treatment for lower leg pain and running injuries. In-office treatments help decrease pain and inflammation while enhancing tissue repair. Physical therapy treatments and modalities can be used to further decrease the inflammation such as ice, heat, electric, ultrasound, taping, or manual therapy. Light stretching exercises will be given to increase strength and endurance in the lower leg and gait mechanics. Often a thorough physical examination of strength, endurance, and functional movement patterns will be performed during the analysis. If the lower legs are absorbing too much force because of weakness in the hip or knee joints, often specific exercises will be given to address these functional weakness patterns.
Running injuries and soft tissue injuries often require specific soft tissue muscle therapy techniques for moderate and severe injuries. Massage therapy helps work all of the muscles of the lower leg to enhance flexibility and functional movements in the tissues. When tightness in other muscle groups contributes to the strain on the tendons, massage therapy helps relieve the excessive stress by increasing the function of those muscles.
Graston technique and active release technique are great therapies and treatments for decreasing fascial adhesions or scar tissue. Active release technique is most known for its use in triathletes and runners, especially at Kona and Ironman events. During the procedure the provider uses his hands and develop sheer force and tension across the muscle to break up knots and scar tissue. Active movements are performed with the therapy. Graston technique is slightly different in that it utilizes stainless steel instruments that slide along the skin and help break up the scar tissue and fascial adhesions with sheer force. Graston technique is very effective in a posterior tibialis sprain because of how the small and thin tendons attach to the tibial bone. Often massage therapy and active release technique have a more difficult time in the tendons insertions near bone. The specific design and structure of the tools allow them to work those small injuries in the tendon against the tibial bone and also on its insertion on the arch of the foot.
Class IV cold laser is becoming a very important treatment modality for muscle and tendon injuries. The high-energy late lasers emit a specific wavelength and frequency that helps trigger reactions within the cells. Specific wavelengths help decrease inflammation and pain. By stopping the production of inflammatory molecules, the pain is reduced and healing mechanisms are accelerated. In addition, different wavelengths help increase enzymes and cellular reactions that increase energy production within the cell. The increased energy or ATP provides a cell with more fuel to help build stronger tissue. When cells have increased ATP reserves they spend that energy on repair. This allows cells to lay down more fibers at a much faster time frame than if they had not been exposed to cold laser.
In the lower leg a class IV cold laser will emit approximately 2300 J of energy for healing and repair. The older class III lasers only produce about 6 J per minute. Additionally they do not have the amount of energy force behind them, which limits the depth of penetration. The older lasers can only help tissue near the very surface of the skin. Meanwhile the class IV cold lasers have a depth of penetration 6 to 8 cm below the surface and can cause reactions to all of those cells deep within the body.
Shin splints and posterior tibialis sprains benefit with both home and office treatments. When the leg pain has developed out of increased activity and exercise, often the best treatments require a combination of heat, ice, electric, exercises, and stretches. Footwear changes may be required in some individuals, and some may benefit from orthotics. Likewise, manual therapy techniques that help address the muscle spasms deep within the lower leg muscles provide a tremendous benefit. Massage therapy, Graston technique, and active release technique are very effective treatments, and each has a very specific benefit compared to the others. Class IV cold laser is one of the newest treatments for decreasing pain and inflammation in soft tissue. It also enhances cellular repair mechanisms within muscles and tendons.