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     Warmer spring temperatures and upcoming races mean longer runs and an increased risk of overuse injuries. Spring is common time for overuse injuries to the tibialis posterior muscle as it’s function in vital to efficient running. The tibialis posterior is a small, thin, unassuming muscle which plays a vital role in walking and running locomotion. Located on the posterior aspect of the lower leg, the tibialis posterior is deep to the easily recognizable calf musculature (gastroc-soleus muscle complex). The tibialis posterior originates on the posterior side of the fibula and tibia, and inserts on the navicular, second cuneiform, and 2nd , 3rd , and 4th metatarsal bones of the foot. Tibialis posterior weakness or injury can sideline even the most seasoned runner. Evaluation of strength and functional activity is vital to properly detecting tibialis posterior dysfunction.
     The function of the tibialis posterior is much more important than its diminutive presence in the lower leg. It acts to invert (turn inward) the foot and ankle, supinate the foot (raises the arch) and aids in dorsiflexion (upward motion of the foot) of the foot and ankle. Without the tibialis posterior, the stability of the foot and ankle is compromised significantly during walking and running. Consider for a moment a flat foot. The term flat foot has a negative connotation, but pronation (or lowering of the arch of the foot) is necessary to absorb
shock and accommodate to uneven surfaces. Supination, however, is necessary to bring a pronated, flat foot into a position of stability for push-off while walking or running. Efficient, pain-free running is dependent on the ability of the tibialis posterior to bring the foot and ankle into a supported position (through supination). Without the action of the tibialis posterior, the foot and lower leg are subjected to increased tensile strain during the stance and push-off phases of gait. Injuries such as plantar fasciitis, medial tibial stress syndrome (shin splints), knee pain, hip pain, iliotibial band pain, and even low back pain can often be traced in whole or part to a deficient or weak tibialis posterior muscle.
     Prevention and treatment of tibialis posterior dysfunction begins with body awareness and smart training habits. Tibialis posterior specific strengthening exercises include heel raises with slow lowering to the ground. Adding mild inversion as you lower your heel to the ground will bias the tibialis posterior. Band resisted ankle inversion with the ankle in plantarflexion will strengthen the tibialis posterior in non-weight bearing. Gradually increasing your mileage and easing into rough trail terrain will reduce overuse injuries in the tibialis posterior as well. If your calves or feet are tired or painful after running or weight bearing exercise, allow your body to rest, and recover for 1-3 days. If you continue to experience pain after 3 days a physical therapy evaluation may be indicated. Your physical therapist will rule out injuries such as a stress fracture, sprain, strain, compartment syndrome, or circulatory issues for which you will be referred to your physician for diagnostic testing. If the physical therapy evaluation is negative for serious injury, a Sapphire PT physical therapist will test for underlying weakness and-or inflammation responsible for your symptoms. Understanding the mechanics of walking and running and the contribution of other factors such as hip and core strength and running technique will narrow the treatment plan to a concise set of rehabilitative and preventative exercises. Your physical therapist will also guide you in a progressive return-to- activity plan based upon your response to PT treatment. The take home message is to take action when foot or medial ankle pain limits your ability exercise.
John Fiore
Sapphire Physical Therapy
john@sapphirept.com

by John Fiore, PT

Runners are well aware of the importance of strength training to reduce injury risk. Even the most specific strengthening program will fail to produce results, however, if compensatory movement patterns are not addressed. Our modern lifestyle is filled with sitting. We sit at work, sit while driving, sit for relaxation, yet expect our hips, pelvis, and spine to function normally. Hip flexor tightness is synonymous with prolonged sitting. The psoas is in important hip flexor muscle which warrants further discussion to understand the challenge of running injury treatment and prevention.

The psoas is an important core muscle which stabilizes and moves both the lumbar spine and the lower extremity.  Collectively, the psoas and iliacus muscles are referred to as the iliopsoas muscle group. The psoas works in conjunction with the iliacus muscle.  While both the psoas and iliacus insert on the lesser trochanter of the femur (groin area), the iliacus originates in the iliac fossa and iliac crest of the pelvis and sacrum, whereas the psoas originates along the transverse processes of the lumbar spine. The primary function of the psoas muscle is to flex the hip. Secondary actions which are very important for proper lumbar spine and lower extremity function and symmetry include femoral lateral rotation, lumbar extension, and lumbar side bending. In addition, the iliacus tilts the pelvis anteriorly. Both the psoas and iliacus muscles activate unilaterally or bilaterally. Asymmetry between the right and left psoas muscles due to tightness or weakness, therefore, is an important source of one-sided low back and leg pain.  While psoas asymmetry is often overlooked, proper, targeted clinical testing must be included when thoroughly evaluating low back and extremity pain and overuse injuries.

The psoas muscle lifts the hip and leg forward when we walk, run, and climb. Overutilization of the iliopsoas can lead to postural and mechanical issues.  Without the necessary strength in the abdominals, hips, gluteal and small stabilizing lumbar (multifidi) musculature, the psoas becomes shortened, over-active, and irritated.  Gait and postural deviations may present as a laterally-rotated hip, an anteriorly tilted pelvis (unilaterally or bilaterally), or a sway back posture.  An iliopsoas-dominant athlete may develop a myriad of overuse injuries including:  psoas or groin pain, sacroiliac and low back pain, iliotibial band pain, and even knee and foot overuse injuries.

Once a psoas imbalance or overutilization issue is diagnosed, the resulting mechanical asymmetry must be addressed through manual physical therapy techniques. Targeted active release stretching, dry needling, deep tissue release, and muscle energy techniques are effective ways to restore symmetry and proper function to the right and left psoas musculature. Manual therapy alone, however will not “fix” the problem. Strengthening the antagonist musculature will allow the body to maximize efficiency of movement.

Strengthening the weak links in the modern day athlete can be difficult due to ingrained movement patterns.  Strengthening the lower abdominal and gluteal musculature, for example, reduces our reliance on the psoas to “pick up the slack” in lumbar and pelvic stabilization. Functional core strengthening involves the gluteal and abdominal musculature stabilizing in conjunction with sport-specific upper and lower extremity motions.  Sit-ups and crunches alone, however, may exacerbate the problem of tight or dominant psoas  musculature.  It is important, therefore, to include planks (prone and side positions) and single leg weight bearing core exercises to reduce habitual psoas use. Finding your lower abdominals (transversus abdominis) muscles when lifting is key to prevent the anterior pelvic tilt associated with iliacus activation as well as the lumbar sway back associate with psoas activation.  

Our modern day lifestyle of prolonged sitting and very little physical activity other than our “workouts” predisposes us to psoas muscle shortening and dominance.  Sitting inherently shortens the psoas while the antagonist muscle (gluteus maximus) is unable to function the lengthened position of sitting.  The most common area of weakness in present day athletes (based upon my empirical evidence of 24 years in practice) are the gluteus medius and gluteus maximus.  No wonder we have difficulty contracting our gluts when much of our day is spent sitting!  In addition to a physical therapy strength and postural evaluation, a video gait or running analysis will reveal muscle imbalances to address to effectively prevent and treat injuries related to a hip flexor or psoas domain state.  

Finally, for an aging athlete or individual, hip joint compression due to excessive sitting and associated psoas tightness can accelerate osteoarthritis.  Balancing proper muscle flexibility with core stabilization and strength will decrease the impacts of prolonged sitting to permit a healthy, active lifestyle for years to come.  

(John Fiore is the owner of Sapphire Physical Therapy in Missoula. You can reach him at john@sapphirept.com or 406-549-5283)

ARTICLE REFERENCES

  1. McGill,S.(2007) Low Back Disorders: evidence-based prevention and rehabilitation. 2nd ed. Human Kinetics. Champaign, IL. P 60-61, 214-217.
  2. Jones,S. Rivett,D. (2004) Clinical Reasoning for Manual Therapists. Elseier Butterworth Hinemann. New York, NY. P 261-274,
    3. Greives. Grieve’s Modern Manual Therapy. Harcourt Publishers Ltd. 19943
  3. http://www.serola.net/research-entry/iliopsoas/