Pilates for Reducing Pain and Injury Associated with Posterior Tibial Tendon Issues

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1 Pilates for Reducing Pain and Injury Associated with Posterior Tibial Tendon Issues Melissa Zimmerman May 30, 2014 Physiologic Studio Brooklyn, New York

2 Abstract The tibialis posterior is an extremely important leg muscle that stabilizes and supports the arch of the foot. It is not uncommon to see various problems in the tendon of the tibialis posterior, some of which can lead to tendonitis and cause increased pain in the foot. Given the relationship between the foot and the leg, knee and hip, posterior tibial tendon problems can greatly affect the alignment of the feet, ankles, knees and hips. Thus, it is important to have strong muscles and stable joints in the ankles and feet to avoid further problems in the body. This paper focuses on problems associated with posterior tibial tendon stress and identifies a Pilates program appropriate for this condition. The program is intended to ease the tendon s symptoms and strengthen the muscles of the foot, leg, and hip in hopes of preventing further pain, injuries and surgery. 2

3 Table of Contents Abstract 2 Anatomy of Foot 3-7 Case Study 7-8 Pilates Conditioning Program 8-11 Conclusion 11 Bibliography 12 3

4 Anatomy of the Foot The foot is an extremely important structure that forms the base of the human body and influences the entire structure of the body. It is composed of 26 bones, 33 joints and over a hundred muscles, tendons and ligaments. The feet serve to provide stability and balance, support the weight of our body, absorb the shock of hitting the ground and act as a lever to move our foot forward in our everyday walking. These functions depend on the maintenance of the angles and joint movements of the foot. The skeleton of the foot includes all of the muscles and joints involved in the ankle. The ankle joint allows for plantar flexion and dorsiflexion movements. This joint is located between the talus, or anklebone, the medial malleolus of the tibia, and the lateral malleolus of the fibula. Inversion, eversion, supination and pronation take place at the midtarsal joint and the subtalar joint. The strength of the muscles and stability of the joints in the ankle play an important role in the condition of the foot. The calcaneus, or heel bone, is the largest bone of the foot and is connected to the talus at the subtalar joint. 4

5 The extrinsic and intrinsic muscles of the foot provide additional stability and help produce and control movements of the foot. The gastrocnemius and soleus muscles of the lower leg are the primary plantar flexors. These calf muscles join to form the calcaneal tendon of the heel and attach to the calcaneus bone in the heel. They also work subtly to stabilize the ankle joint and foot and to maintain the body s balance. Shin muscles such as the tibias anterior and extensor digitorum longus dorsiflex the foot and extend the toes. The tibialis anterior and posterior are the invertors, and the peroneals and extensor digitorum longus are the evertors. 5

6 There are two true important arches in the foot, the medial longitudinal and the lateral longitudinal, both of which are maintained by the interlocking shapes of the foot bones, strong ligaments, and pulling muscles during activity. They allow the foot to support the weight of the body while standing with the least amount of weight. The medial longitudinal arch stretches from the heel bone over the anklebone to the three medial metatarsals. The lateral longitudinal arch redistributes part of the weight to the calcaneus and the distal end of the fifth metatarsal. Given the role that arches play in the health of our foot, problems with arches cause pain and stability issues. The tibialis posterior is one of the muscles that support the arches of our feet and helps turn the foot inward. The posterior tibial tendon runs behind the inside bump on the ankle, or the medial malleolus, across the instep and into the bottom of the foot. Several factors such as inherited flat feet, obesity, lax ligaments and previous injuries can cause the tendon to have to work harder at doing its job. This extra work puts too much 6

7 stress on the tendon, causing pain and also excessive pronation, or a rolling in of the foot. This can have a domino effect on the rest of the body, contributing to internal rotation and thus misalignment of the knee and hip. Another major part of the body that can affect the feet are the glutes. The largest muscle of the glutes, the gluteus maximus, works to extend and rotate the hips and leg. The gluteus medius sheathes and stabilizes the pelvis and core, while the minimus helps support the hip area. The maximus propels you forward, while the medius and minimus muscles provide balance and control for your femurs, which help keep your hips, knees and ankles aligned. Case Study This case study involved my mother, Cathy Zimmerman. She is a 58-year old woman with inherited flat feet, and has suffered from posterior tibial tendon stress. She has also suffered from knee and hip issues from the misalignment of her feet, knees and hips. She has worn orthotics to help with the pain of everyday walking but it has not fixed the root of her problems. Her condition is most likely due to a combination of factors as she had broken her ankle 10 years ago and never completed physical therapy afterwards, leaving her with weakened ankle joints. She also has inherited flat feet and pronates, putting excess pressure on posterior lower leg muscles and tendons and causing pain from overuse and decreased flexibility. The previous trauma to the ankle combined with her inherited flat feet has made her susceptible to posterior tibial tendon stress. She has difficulty doing basic foot and toe exercises such as picking up marbles with her toes 7

8 because of her weakened muscles. Thus, a Pilates program with emphasis on footwork, lower leg strength and hip strength has been designed to help decrease pain and bring her body back into alignment. Pilates Conditioning Program A proper beginner warm up is crucial in this program, as the client needs to learn about correct alignment and engaging the transverse abdominals before proceeding onto other exercises. A proper mat warm up combined with the reformer footwork warm-up helps prepare the muscles and tendons by increasing blood flow to the legs and foot and bringing oxygen and nutrients to those muscles. This is extremely important for flexibility in the foot as tight muscles cause limited range of motions and are easily overstressed. The footwork helps strengthen the muscles of the feet, ankles, legs and hips, increase the range of motion in the lower limbs and help her work towards leg, foot and ankle alignment. In essence, these exercises can reeducate the lower body mechanics, improving everyday activities such as walking. These exercises can also increase balance and stability of the joints, equalizing the pressure and stress on the limbs and joints during walking and standing. During the footwork exercises, focus should be kept on keeping the feet in neutral alignment with the ankles, knees and hips. Emphasis should be placed on pushing through the big toes and allowing the ankles to get their full range of motion. Footwork 8

9 is crucial for this program as it works on ankle plantar strength, as well hip and knee extensor strength. The abdominal work focuses on pelvic stabilization and neutral pelvis so that she can continue that stabilization throughout the rest of the exercises. I chose to do round back and flat back on the short box as these exercises avoid lifting the head and adding any neck tension. For hip work, I chose to start with fundamental work including Frog, Circles Up and Down, and Openings to focus on hip adductor strength and pelvic lumbar stabilization. This program does not include spinal articulation, nor spinal articulation, however I would not introduce those after the client has received at least 10 sessions and is ready for it. I would do spine Bottom Lift for spinal articulation and stomach massage round back as it is one of the few full body integration exercises that focuses on ankle plantar flexor strength in addition to trunk stabilization and knee extensor strength. I chose the Standing Lunge on the Reformer for a good hip flexor and hamstring stretch. The Arm Supine Series on the Reformer is next followed by the Gluteal Side Lying Series for Leg Work. These exercises strengthen the hips and glutes as weak hip and glutes can further contribute to problems in the lower legs and feet. The glutes help keep our hips, knees and ankles aligned. For Lateral Flexion/Rotation I chose the Side Stretch on the Wunda Chair so that she has the Assistance, and can transition easily to the Back Extension Block, followed by the Swan on the Wunda Chair for Back Extension so that she can have the extra assistance as opposed to resistance. I would then do Back Extension with her on the Mat so that she can end in a Rest position. 9

10 Apparatus BASI Block Exercise Objectives Mat Warm up Pelvic Curl Spine Twist Supine Chest Lift Chest Life w/ Rotation Reformer Foot Work Parallel Heels Parallel Toes V-Position Toes Open V- Heels Open V- Toes Single Leg Heel Single Leg Toes Prances Calf Raises Prehensile Spinal Articulation, Pelvic Lumbar Stabilization, Abdominal Control Hip and knee extensor strength, ankle plantar strength Reformer Abdominal Work Round back and Short back (Short Box Series) Reformer Hip Work Frog, Circles up, Circles Down, Openings Abdominal Strength, Pelvic Lumbar Stability Hip Adductor Strength, Knee Extensor Control, Pelvic Lumbar Stabilization Reformer (after 10 session) Spinal Articulation Bottom Lift Spinal Articulation Hip Extensor Strength Reformer Stretches Standing Lunge Hip Flexor and Reformer (after 10 sessions) Full Body Integration(F/I) Stomach Massage Round Back, Stomach Massage Flat Back Reformer Arm Work Arm Supine Series (Adduction, Up and Down Circles, Extension Triceps Full Body Integration(I/A) N/A Hamstring Stretch Trunk Stabilization, Knee extensor Strength, Ankle Plantar Flexor Strength Scapular Stabilization, Shoulder Adductor and Extensor Strength 10

11 Mat Leg Work Gluteal Side Lying Series- Forward and Lift, Forward with Drops, Side Leg Lift Hip Abductor strength, Pelvic Lumbar Stabilization Wunda Chair Lateral Flexion/Rotation Side Stretch Wunda Chair + Mat Back Extension Swan Basic Back Extension Lateral Flexor Stretch, Ab Strength with Oblique Emphasis Abdominal Control, Back extensor Strength, Scapulae Stabilization Conclusion Our feet are such important parts of the body as they provide a foundation for all of the work we do every single day. Thus it is crucial that we protect our feet by strengthening and correcting alignment in the rest of our body, specifically our hips, knees and ankles. The posterior tendon tibialis can cause several problems in the body, thus it is crucial that people with these tendon issues work to try and correct them. Pilates is a great way to not only correct issues and relieve pain, but also to aid in maintaining proper alignment and preventing future pain and injury. 11

12 Bibliography France, Diane L. (2008). Human and Nonhuman Bone Identification: A Color Atlas. CRC Press. Isacowitz, Rael and Clippinger, Karen. Pilates Anatomy. (2011) Human Kinetics. Isacowitz, Rael. Study Guide, Comprehensive Course. Body Arts and Science International Marieb, Elaine Nicpon; Hoehn, Katja (2007). Human anatomy & physiology. Pearson Education. Tuff, Sara. (2008) Go-To Glutes. ExperienceLife.Com May Skye Physiotherapy & Pilates. (2013). Posterior Tibial Tendon Problems Patient Guide. May 1,

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