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POSTERIOR TIBIALIS INJURIES If many of your clients are serious athletes, you've probably seen quite a few posterior tibialis strains. The posterior tibialis muscle originates at the medial aspect of the posterior borders of the tibia and fibula (Image 1). Some fibers attach to the interosseous membrane, a structure that attaches those two bones. The tendon travels down posteriorly to the medial ankle and inserts on the navicular, two of the cuniforms, the cuboid, and several of the metatarsal bones. This muscle-tendon unit serves a number of important functions. In addition to inverting the foot, it assists in plantar flexion and plays a key role in supporting the medial arch. Also, together with the peroneous muscles in the lateral lower leg and foot, it helps to provide stability when walking on uneven surfaces; these two structures are often referred to as the "stirrup muscles." TIBIA POSTERIOR TIBIALIS MUSCLE POSTERIOR TIBIALIS TENDON PERONEUS BREVIS HOW AND WHY THESE INJURIES OCCUR This type of injury usually develops slowly as a result of fatigue in running and jumping sports. At first, it feels like a mild irritation somewhere behind the medial part of the ankle or the medial low leg. As the demands of exercise activity increase, it gets progressively worse until, in some cases, it becomes difficult to walk without pain. Predisposing factors include a failure to warm up properly and excessive pronation of the foot. In the latter case, the muscle-tendon unit must constantly strain to compensate for the extreme pronation. Eventually, this becomes too much and the fibers of the tendon begin to strain and then tear. In severe cases where a bad fall Putz/Pabst: Sobotta, Atlas der Anatomie des Menschen, 21st ed. 2000 © Elsevier GmbH, Urban & Fischer München Posterior tibialis injuries can cause two distinctly different sets of symptoms, depending on which portion of the structure is affected. When the muscle is strained, the client feels pain high up at the medial aspect of the tibia. This is commonly referred to as posterior shin splints. When the tendon is strained, the client feels pain just superior to (above) or posterior to (behind) the medial ankle or on the medial foot itself, several inches anterior to the ankle. Although the pain tends to be most intense posterior and superior to the medial malleolus, it can occur at any point along the tendon. or other trauma occurs suddenly, the medial ankle can become quite swollen and blow up like a balloon, making it difficult to assess the injury. (To my knowledge, the posterior tibialis tendon is the only tendon in the body that causes visible external swelling, similar to a sprained ankle.) Such severe, sudden injuries are common in sports like soccer, where two players often hit the ball simultaneously, and forcefully, with the medial ankle. INJURY VERIFICATION People with this injury usually feel pain while walking, running, or rising onto the ball of the foot. But most painful is inward movement (inversion) of the foot against resistance. visit massageandbodywork.com to access your digital magazine 93