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94 m a s s a g e & b o d y w o r k m a r c h / a p r i l 2 0 1 9 for a while, there may also be pain on the lateral side of the ankle. Lateral ankle pain results from bony compression between the distal fibula and calcaneus due to excessive eversion of the foot. Pain and visible or palpable inflammation over the medial side of the ankle may also be present. Sometimes increased temperature is palpable in this region if the inflammation is active. Keep in mind that there could be inflammatory reactions within the tendon that may not be evident due to the tendon's depth in the tarsal tunnel. Pain may also be present on the bottom surface of the foot. Overpronation in gait is another prominent indicator, and a flatfoot deformity frequently exists in conjunction with overpronation. A common method for identifying overpronation is looking at the wear pattern on the sole of the shoe. Excessive wear on the medial side of a shoe's sole can be indicative of overpronation and PT weakness. Inability of the client to stand on their toes is another sign sometimes visible during physical examination, particularly standing on the affected side alone. It may be either pain or weakness that prevents a person from standing on their toes. TREATMENT STRATEGIES Generally, the first treatment goal is to reduce any offending activities that are 4 Calcaneal valgus and flatfoot deformity. this position, it is difficult to get the arch restored and back to a normal position. It is not just biomechanical stress that leads to the tendon weakness in PTTD. Systemic disorders such as Ehlers- Danlos syndrome routinely produce connective tissue weakness and may lead to tendon dysfunction and collapse of the arch. Other conditions such as lupus or rheumatoid arthritis may also lead to tendon dysfunction, although it is not clear why. 3 ASSESSMENT AND EVALUATION As noted earlier, PTTD can be a precursor to numerous foot problems. As a result, focus is often directed on the resulting problem without appropriate attention to the originating PT muscle-tendon dysfunction. Because medial ankle or plantar foot pain symptoms could be other conditions, PTTD can be underdiagnosed and mistaken for other foot disorders. 4 Range-of-motion evaluations are not effective with PTTD due to the limited range of foot eversion (caused by the position of the distal fibula). Because there aren't many signs or symptoms unique to PTTD, there are fewer options for assessing this condition. However, there are some indicators to look for. The most prominent sign of PTTD is the collapsed arch and flatfoot deformity. Arch collapse often leads to calcaneal valgus as well. If this postural dysfunction has been present aggravating the PT. If there is a routine occupational or recreational activity, such as running or jumping, that appears to be a precursor, then those activities must be limited or stopped. At later treatment stages, some strengthening activities for the PT may be beneficial. However, additional strengthening is not the best solution early in the symptomatic stages, especially with activity that causes pain. Ankle braces, shoe inserts, and orthotics may also be used to help reduce biomechanical load and reduce stress on the muscle-tendon unit. This condition results from tendon overuse and muscle overload, so massage can be helpful in reducing either the causative factors or resulting symptoms. It is not possible to fully stretch the PT, as the foot is blocked from going far enough into eversion to really stretch the muscle. As a result, the muscle never gets to lengthen as much as it ideally could. It is possible that this may lead to increased hypertonicity within the muscle and eventual tendon dysfunction. That gives a good rationale for massage treatment aimed at reducing muscular hypertonicity. Unfortunately, due to its location deep in the posterior compartment, it is difficult to access. However, there are some other options for treatment. One of the more effective ways to address the tibialis posterior is with the client in a side-lying position and the medial side of the treatment leg facing up. Working along the tibial border anterior to the gastrocnemius and soleus allows the practitioner to apply indirect pressure to the deep posterior compartment, which can effectively address the posterior tibialis. Slow stripping techniques with a small contact surface are applied along the tibial border (Image 5). An even better treatment is achieved with an active engagement technique that increases the density of the muscle and makes it easier to treat. An active engagement technique can be applied using the same position described above, as long as the client's foot can move through a full range of motion in dorsiflexion and plantar