Cycling ankle pain: posterior tibial tendon (PTT)

Triathlon Forum
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I’ve been having ankle pain (mostly left, but sometimes right) for a few months which I am nearly certain is due to cycling (and not running). I am also almost certain it’s PTT (I’m a doctor and I’m fairly confident this is the exact spot I’m having the pain).

I’ve done internet searches twice, and can’t seem to find any cycling related information. All I find is running info. I’ve had a bike fit which hasn’t changed this painI’ve changed cycling shoes (the last pair were a tad loose), but no improvementI’ve spent very little time cycling over the past 6 weeks, even a 2 week period of no cycling, and still getting this painI’ve had some knee pain (medial and lateral) which I think I’m getting a handle on by incrementally moving cleats in vs out (per http://bikedynamics.co.uk/kneepain.htm), otherwise no other musculoskeletal problems that I’m aware ofI’ve changed running shoes, focused more on running technique, and just observed when the pain comes on, etc. and I just don’t notice a clear relationship with running. I get ITB pain, but I think that’s unrelated. However, last night I could barely stand on my left ankle after a very easy bike ride on a trainer.I am using speedplay light action pedals and now I’m using Pearl Izumi Tri Fly shoes.
I’m looking for the biomechanical cause of this problem in cycling so that I can change something in order to allow this problem to heal up (cleat position? seat position? Too much float in pedals? I just can’t figure out what it is). I’m desperately looking for advice.

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Posterior tib mm… not the first one you’d suspect on the bike to go down… got a few things for you to consider if you have not already that maybe/might/could/kinda help:

  • is your pedaling motion 100% in the sagittal plane? (maybe also why your knees keep hurting…)

  • consider dropping your seat (or do what you have to do) to “get off your toes” and neutralize your ankle at the bottom and throughout the pedal stroke (think of how much it hurts people with PTT to stand on their toes).

  • Slide your cleat back on your shoe (for the same reason, in attempt to “protect your arch” and get off your toes)

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If you come up with something let me know! I’ve had PTT for months. Presumably from pronation and too much volume last year. I did first feel the pain while on a long run. I’ve been going to doctor, dealing with inflamation and working PT. I swear though, much against the grain of conventional wisdom, that after months of PT I now feel more soreness after a biking session, then after running sessions (which I’m only doing on sneakers with greater stability, and on antigravity treadmills). Very frustrating. Seeing the orthopedic specialist again tomorrow. He did make an interesting comment to me once which I’m going to follow up on, which was that he is sometimes more of a proponent of orthotics for cycling then for running. Good luck and please post if you come up with anything on your situation. Have you ever videotaped your pedaling motion from the side and front to see how much ankle play you actually have? I may try that.

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Ive read that speed plays promote rotaion not only medial and laterally but also vertically inward and outward. Sort of pronation on a bike. A wider platform, keo max, helped with my own posterior tib pain while and after biking. Showed up on the run but I tracked it back to the bike. Ive heard they can also cause achilles issues for the same reasons.
I believe it was Gordo Byrne that wrote about achilles problems and speed plays on his web based blog “Gordos world” which is now Endurance Corner.

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I had some PTT in the past in my left ankle and PF in my left foot. I’ve also had some ITB pain and hip flexor pain in my right leg/hip. To top it all off, I had ACL reconstruction on my right leg about 10 years ago or so. The knee has about the same flexibility pre-surgery, but I was never diligent enough with PT to get my right quad to the same strength pre-surgery.

Right now, I’m cycling relatively pain-free, but this is just n = 1. I found that when I raised my saddle, I had less PTT pain, but the ITB pain increased. Also found that the hip flexor pain in my right hip tended to decrease with a higher saddle, but I recently lowered my saddle just a bit and haven’t had any notable increase in hip pain. I’m fairly flexible but could use more core strength. I also found that more of my leg/feet/ankle pains decreased when I installed my speedplay pedals. I did decrease the amount of float from the normal stock by a couple turns on both cleats though. Whenever the PTT/PF flared up, I found the following to help: icing, NSAIDs, and KT Tape. Also did some ankle strengthening exercises with a resistance band. Those seemed to help as well.

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Thanks for all the responses. Here’s some remarks :slight_smile:

Posterior tib mm… not the first one you’d suspect on the bike to go down…

I agree, and to be honest I’m not 100% sure, but it sure seems most consistent with cycling: pain worse after cycling, if I go a few days with out cycling (but keep running) it gets better, etc. This is part of what’s confusing.

  • is your pedaling motion 100% in the sagittal plane? (maybe also why your knees keep hurting…)

Fair question. The bike fit guy didn’t say anything. What I think I’ll do is have my wife video record me on the bike from different angles and I’ll investigate this further.

  • consider dropping your seat (or do what you have to do) to “get off your toes” and neutralize your ankle at the bottom and throughout the pedal stroke (think of how much it hurts people with PTT to stand on their toes).

  • Slide your cleat back on your shoe (for the same reason, in attempt to “protect your arch” and get off your toes)

I’ve always had my cleats as far back as they’ll go. So I’m guessing this might not be it for me…

… I swear though, much against the grain of conventional wisdom, that after months of PT I now feel more soreness after a biking session, then after running sessions (which I’m only doing on sneakers with greater stability, and on antigravity treadmills). Very frustrating…

Interesting, (as above) I understand the closer relationship with running. I’ve considered that maybe it STARTED due to running, but maybe what I have now is that it is calming down (after changing shoes, doing much better with run form, etc.) and maybe now there is something just exacerbating or perpetuating it with cycling?

…Seeing the orthopedic specialist again tomorrow. He did make an interesting comment to me once which I’m going to follow up on, which was that he is sometimes more of a proponent of orthotics for cycling then for running…

I talked to an orthotic specialist (when I first thought it was due to running). He was just skeptical that orthotics were needed, would be helpful, pointed out they are uncomfortable for long running, etc. He recommended the I try the ones at the drug store, I think Dr. Schoels (sp?) that has the goofy testing booth. They weren’t very comfortable, so only used them a couple rides. I just can’t say if they helped or not. Despite what this specialist told me, I’d be willing to spend the money and try real orthotics if it fixed my problem. I may re-address this if other options don’t work.

This brings up a separate issue, I might need to run this by my orthopedic surgeon friend. I’ve just bugged him with other stuff though and was hoping not to bug him further though. But what are friends for ?

…Have you ever videotaped your pedaling motion from the side and front to see how much ankle play you actually have? I may try that.

Good idea, I’ll try this

Ive read that speed plays promote rotaion not only medial and laterally but also vertically inward and outward. Sort of pronation on a bike. A wider platform, keo max, helped with my own posterior tib pain while and after biking. Showed up on the run but I tracked it back to the bike. Ive heard they can also cause achilles issues for the same reasons.
I believe it was Gordo Byrne that wrote about achilles problems and speed plays on his web based blog “Gordos world” which is now Endurance Corner.

I did not know this. I’ll definitely research this further. When I biked a ton (15 years ago) I used Speedplay, and had no musculoskeletal problems at all. Obviously something is different with my body now though…

I also found that more of my leg/feet/ankle pains decreased when I installed my speedplay pedals. I did decrease the amount of float from the normal stock by a couple turns on both cleats though.

Ahh, so one vote for Speedplay might not being related :slight_smile: But, I’ll still look closer.

I found that when I raised my saddle, I had less PTT pain, but the ITB pain increased. Also found that the hip flexor pain in my right hip tended to decrease with a higher saddle, but I recently lowered my saddle just a bit and haven’t had any notable increase in hip pain. I’m fairly flexible but could use more core strength… Also did some ankle strengthening exercises with a resistance band. Those seemed to help as well.

For me, my flexibility sucks. Bad. I try to stretch and roll every single day and it seems to do nothing. But this is another story. However, I DO think I’ve made some good progress with the calves though (first started on this because of relationship with PTT), so I ‘think’ this is good. Ankle strengthening, though, might be something to work on. I’ve got resistance bands. Thanks.

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  • is your pedaling motion 100% in the sagittal plane? (maybe also why your knees keep hurting…)

Fair question. The bike fit guy didn’t say anything. What I think I’ll do is have my wife video record me on the bike from different angles and I’ll investigate this further.
I found that when I raised my saddle, I had less PTT pain, but the ITB pain increased. Also found that the hip flexor pain in my right hip tended to decrease with a higher saddle, but I recently lowered my saddle just a bit and haven’t had any notable increase in hip pain. I’m fairly flexible but could use more core strength… Also did some ankle strengthening exercises with a resistance band. Those seemed to help as well.

For me, my flexibility sucks. Bad. I try to stretch and roll every single day and it seems to do nothing. But this is another story. However, I DO think I’ve made some good progress with the calves though (first started on this because of relationship with PTT), so I ‘think’ this is good. Ankle strengthening, though, might be something to work on. I’ve got resistance bands. Thanks.

I would be curious to see this as well. Thinking ITB which has commonly been associated with some glute firing / weakness issues I could see a possiblity of the leg adducting moving it medially in the frontal plane to gain a mechanical advantage in the down stroke of the of the pedal cycle possibly exacerbating any pronation at the foot adding undue microtrauma to the PTT. We see this same type of movement pattern with individuals with flexibility issues in the hip. Another question would be Nylon or carbon soles? I have a nylon version of those Tri Fly’s and they are pretty flimsy when you start mashing but I am heavier.
So essentially try to make sure you are also addressing possibilities upstream and downstream from the symptom location.

Here is a video of some things you might think about trying for mobilizing the junkie tissue K Starr Video

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FWIW, the only injury I had last year was my ankle and it was mainly just me pushing too hard on an interval the day before a race and lost form, injured ankle and raced on it the next day. I tried to continue running and biking after that, but after having a bad week of sessions and a run where I limped 2.5 miles back to my house I figured it was time to take a break. I took a week totally off, kept it either wrapped or had an ankle brace on it for basically that whole week (awake and asleep). The first few nights I put my soft boot from when I broke my foot another time on to make sure it didn’t move. Every day I sat in a chair and drew the alphabet slowly with my toes three times a day. I also put my foot next to a table with the foot up and pushed sideways against a table leg for 30 seconds, 3 sets, 3 times a day. It was healed and feeling better within a week’s time.

That is just my experience with my individual injury though.

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Also forgot to add, I switched shoes from Shimano to Specialized. I really like specialized and their high performance BG foot beds. That seemed to also help with decreasing my PTT and PF.

I know a lot of my ITB problems in my other leg though comes from glute/hammy weakness. I also do tend to move my leg medially in the frontal plane, but feel like I do that with both legs to some extent and really only get problems with the ITB in the right leg. Although, I’m wondering if moving my left leg medially may cause or contribute to the PTT in my left ankle.

As far as rolling, I don’t really roll my calves or ankles, but do find that rolling my left hamstring, hip flexor, glutes correlate to decreased instances of PTT pain. Also have found that the PTT pain goes away a lot faster than before (used to be 1-2 weeks before pain free, now usually a matter of days).

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I was told by a podiatrist that once you tweak your PTT, it can linger for a long time. With my PTT problems, I only feel pain on the bike if I’m climbing out of saddle when I’m in full TT position it’s fine during the ride. Post-ride it can be sore but not as sore as if I ran.

I’d taken weeks off here and there and the PTT problem is still here. The only thing that helped me is going to a PT for massage, stim, exercise/stretches for it. Also rolling it has helped me a ton as well.

My cause is flat feet so no arch support which stresses my PTT more than normal. So perhaps you tweaked it a bit during a run and then the cycling took it over the edge and now it’s just always a problem.

Good luck…

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I’d taken weeks off here and there and the PTT problem is still here. The only thing that helped me is going to a PT for massage, stim, exercise/stretches for it. Also rolling it has helped me a ton as well.

What rolling exercises did you use for your PTT? Besides rolling the bottom of my foot for PF, I’m not familiar with any rolling techniques and am interested. I also have somewhat flat feet with little arch support which stresses my PF and PTT. Do you find if you raise your saddle that your PTT pain lessens any? Thanks!

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What rolling exercises did you use for your PTT? Besides rolling the bottom of my foot for PF, I’m not familiar with any rolling techniques and am interested. I also have somewhat flat feet with little arch support which stresses my PF and PTT. Do you find if you raise your saddle that your PTT pain lessens any? Thanks!

The tendon goes up the inside of your calf/ankle. So I roll that part similar to rolling the calf but just with the leg turned to get the inside on the roller. It’s the muscle that the tendon connects to I guess or something like that is what the PT told me. Anyway, it worked for me as at first when I had lots of pain it was super painful to roll that part. Now, my PTT isn’t horrible and rolling isn’t as painful.

I hate to mess with my saddle/position even though it may suck and right now with winter I’m not cycling hardly at all.

Good luck…

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What rolling exercises did you use for your PTT? Besides rolling the bottom of my foot for PF, I’m not familiar with any rolling techniques and am interested. I also have somewhat flat feet with little arch support which stresses my PF and PTT. Do you find if you raise your saddle that your PTT pain lessens any? Thanks!

The tendon goes up the inside of your calf/ankle. So I roll that part similar to rolling the calf but just with the leg turned to get the inside on the roller. It’s the muscle that the tendon connects to I guess or something like that is what the PT told me. Anyway, it worked for me as at first when I had lots of pain it was super painful to roll that part. Now, my PTT isn’t horrible and rolling isn’t as painful.

I hate to mess with my saddle/position even though it may suck and right now with winter I’m not cycling hardly at all.

Good luck…

Ahh, so you’re not rolling underneath the ankle bone where the tendon wraps around, but more along the side of your inner calf down to the ankle bone?

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Yes.

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I’m rehabbing for this right now. Are you SURE it isn’t running induced? As soon as I got the diagnosis I did tons of reading and everything revolves around running. I have a very flat right arch combined with 2 marathons & a HIM last year. I had way more running miles then cycling miles (sadly enough). Just curious if you are positive cycling is the cause.

I know for me, I feel some tenderness around the ankle in the aero position while riding for a few minutes or while standing especially with higher resistance (on a climb in spin class), but overall mine feels MUCH better after cycling followed by some icing.

My ortho discovered I have a really flat right arch and suggested SuperFeet Green premium insoles ($40.00) to address my arch issues. I put them in my running shoes and while I am not allowed to run for at least 2 more weeks :frowning: they definitely improve my foot while walking in them. I’ve been wearing my running shoes with them in a lot more. My feet feel much more comfortable. Not that it is a solution for everyone but it could work.

Whatever the issue I would figure it out sooner rather then later even if that means choosing either biking or running and stopping for a while to figure out the cause and fix it. I began having issues about 2/3 of the way through marathon training and just ignored it. So then I added PF & some really bad tightness in my calf and some hip soreness along with the Post Tibial Tendonitis. Please be careful!

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So, a little update on my issue.

I’m rehabbing for this right now. Are you SURE it isn’t running induced? As soon as I got the diagnosis I did tons of reading and everything revolves around running. I have a very flat right arch combined with 2 marathons & a HIM last year. I had way more running miles then cycling miles (sadly enough). Just curious if you are positive cycling is the cause.

…

Whatever the issue I would figure it out sooner rather then later even if that means choosing either biking or running and stopping for a while to figure out the cause and fix it. I began having issues about 2/3 of the way through marathon training and just ignored it. So then I added PF & some really bad tightness in my calf and some hip soreness along with the Post Tibial Tendonitis. Please be careful!

Ya, I’ll hit on this…

My ankle pain referred to in the original post has changed somewhat. The pinpoint area of pain I had before, mostly on the left side, which I attribute to PTT pain is less bothersome (though still there a bit). I’ve really been focusing on running form every single time I go out on a run and I’m still (after 2-3 months) only built up to about half of the running volume I was doing before this problem. I “think” that running was the main reason why this started in the first place (see next comment), and I think the initial rest, form work, calf strengthening, and calf stretching is why this is getting better. ITB is better with form work too (I think it’s mostly related to maintaining a neutral pelvis btw).

I’m still having “ankle pain” though, and I still feel it while pedaling and it aches most after biking (i.e. ‘only’ did 30 min on a trainer last night) for a few hours to a day. However, what I feel now is a little more diffuse (which is different than what I’m describing above). My thought has been for awhile that these two things are somehow related but yet two separate problems (one running and one biking related).

I’ve tried to address my knee issues, which have been mild, but actually worsened after my original post. I thought it might be related to the ankles. I have raised my seat by 1/8" increments and am currently at 3/8" of a raise. Lowering the seat was something that occurred at the bike fit, which preceeded these pains. This seems to be helping. I’m also doing strength training (quads, hams, abbducters, adducters, leg press, squats), which would guess helps, but I’m convinced it’s mostly due to biomechanics. I’m hopeful the remaining discomfort (now just one side and resolves after 10-15 minutes of warming up) will continue to resolve.

So… I’m still left with this ankle pain which is medial and diffuse, worse with pedal strokes. As I try very hard to pay attention to my body (I suck at kinesthetic sensing) I notice a lot of play in my pedals (Speedplay). I know it’s always been there. 15 years ago I never had any of these problems and liked the free floating of these pedals, but I’m 15 y older now… and I’m wondering if that’s the issue, so I ordered new pedals. Look Keo 2 Max. No exact reason why I chose those, but I think from my reading that they will have less play. Let’s hope that fixes the problem. During all of this, with the exception of finally trying a long ride last weekend, I haven’t ridden more than a couple hours a week with low intensity for a few months. I really want to get out on long rides again …

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My update is that I am just finishing rehab for the PTT and will probably begin building a running routine again over the next few weeks. I have one more PT appt. and one more ortho appt. to get full clearance. But based on your last comment I wanted to share a couple thoughts. First is that when the PTT was really achy it felt like my whole foot hurt from the ankle down so I couldn’t really pinpoint pain. It would also tend to hurt a bit on the bike especially in the aero position or if I did spin class and was standing on really heavy tension. (The latter could have been the PF . . but as I said above it was hard to tell.)

One thing that helped TREMENDOUSLY with the PTT is K-tape. I was a skeptic but am not a huge believer. The therapist tapes from my arch up just behind the ankle and then about 2/3s of the way up my calf. I have a picture some where I can send you. The tension on the tape is from the arch to just above the ankle. This has REALLY taken the strain off the ligament day to day and has allowed it to heal. I also notice the PF more which is good because I thought it was completely better.

Anyway . . . the tape might be food for thought for you.

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I’ve just had another flare up of PTT on my left ankle. Had been trying to build up my run volume, and I knew I should have backed off some. Didn’t. Went out for a ride, and it came back. Again, the typical treatments seem to be working. Icing, resting, taping, etc. I’ve been more diligent about rolling my calves and that seems to help out more than anything. It’s interesting though because people talk about their pain as being something that lingers and takes months to subside. Usually, within a week at most, my pain is 95% gone, and I’m back at it. It may flare up again, but it’s usually about 3 months or so between episodes.

Another note, I’ve found Rocktape to be a better product than KT Tape. It’s not pre-cut (which some may or may not prefer), but I’ve found the adhesive to be a lot better than KT Tape.

Has anyone tried compression socks or ankle wraps as well?

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Again, the typical treatments seem to be working. Icing, resting, taping, etc. …… It’s interesting though because people talk about their pain as being something that lingers and takes months to subside. Usually, within a week at most, my pain is 95% gone, and I’m back at it.

I imagine the first and second part of the text above are linked. If you get on it early it will not become a lingering issue.

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I am willing to bet its saddle hight. Try lowering in .5cm increments. Had the same problem this past summer. took 1 cm out of the seat hight and the pain went away in about a week.