Posterior tibial tendonitis, or stress fracture?

Triathlon Forum
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I have an appointment with Sports Medicine in 3 days, but want to know if I should be doing “absolutely nothing” before then, or if I can at least ride my bike -

Last Tuesday I did some speed work in the morning (running), and then ran 4 miles easy in the afternoon. After the afternoon run I noticed some soreness around my right ankle, but nothing too interesting. Wednesday I ran 10 miles easy, and again didn’t feel anything remarkable during the run - certainly I wasn’t accommodating pain or changing my gait or anything. I had an ice bath immediately after my run.

Thursday, I couldn’t walk at all without significant discomfort. On the inside of my right leg, about an inch above and slightly behind the peak of the ankle bone, is a localized area of considerable pain. If I push on it, it hurts. There is swelling and tenderness around the area, but that area in particular is really sensitive.

I’ve run all this by a PT buddy of mine, and he has some confidence that it’s a post tib tendonitis. But in my research, including here at ST, I’m not experiencing some things that seem to go with PTT. I’m not having issues (that I can identify, anyway) with my arch, or with pain radiating down towards my arch. That said, I am wearing an arch support right now and it does seem to provide a small bit of relief. It hurts to raise up on my toes on that leg, but once up on my toes there’s little pain. And the point of pain is just really localized. If I roll my ankle in, the pain is in that particular area - not all the way down or through my ankle to the arch. I’ve also been icing, massaging, ultra sounding, and k-taping since Friday and have really noticed no change to anything, even in the hours or so immediately after treatment - it just plain hurts. None of this is consistent with my experience with other tendonitis issues.

Walking hurts, running is too painful so I stopped after .25 miles on Saturday. Going up and down stairs - particularly down - is pretty painful. But doing nothing, I can still feel it.

Any insights from anybody who’s suffered wither PTT or a stress fracture? I have a 13.1 in May that I am really committed to in my heart, I’ll be disappointed if plans have to change. I’ll be hoping for a bone scan at my appointment this week, but I’d appreciate any insights in advance. You know how it is when you’re hurt, you think you’re the only guy in the world to go through it and want it healed up yesterday. Appreciate any perspectives or advice.

PS - I’m 6’0, 190, and I wear Kinvara 3. I’ve worn them without issue for 2 seasons. Maybe a less minimal shoe is worth considering? I generally prefer light and less, and have experienced more issues with more tech. Any ideas there are appreciated, too.

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I’ve had a few tibial stress fractures and it does sound like you may have one. Localized pain when pressing on it and too painful to walk on let alone run on. I usually do the hop test (hop on one foot) and if I’m in too much pain after one or two that’s a good indication as well.
Saying that… I’ve both swam and cycled through all three of my stress fractures so I see no reason why you can’t do that provided it doesn’t cause any discomfort. Just keep the bike in an easy gear and no pounding on the pedals and just push off the wall using your good leg in the pool

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Thanks - and shit. What was the recovery/rehab on that for you?

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One of them I ran on for way too long before stopping and that took several months to heal.
It should be 6-8 weeks. Come back slowly so that you don’t have to deal with again

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Thanks for the advice. Any other perspectives out there are appreciated.

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My .02, this does not sound like a stress fracture. Pain at the area you describe, however may be an acute tear ( partial ? ) of the posterior tib. if you’re seeing a sports med doc, make sure you get an mri and take all of the guess work out of it.

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Hard to tell with your description, but a physical exam by any competent specialist should be able to differentiate. My gut feeling is some PT tendon issue(s) as well, but you would likely be better off with a distal tibial stress fracture - they heal more predictably and usually in less time.

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Hope it’s something that doesn’t set you back too many weeks. The nice thing about the sport or triathlon is that you have 3 discipline. If you get injuries in one, you have two other areas to focus on. You said it doesn’t bother you cycling so just think of it as a big cycling block so it doesn’t mentally get to you.

I’m 5’11 and right about 170. I train in 12 oz shoes and will race in 9oz shoes. 90% of my runs are on soft surface…Trails.

Hope it’s nothing major!

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Nitrox - what was your diagnosis? I’m experiencing the same symptoms…saw an ortho last week who thought it was tendonitis and prescribed a transdermal cream which did NOTHING. He said three days of the transdermal cream and I could start running again. Trying to get scheduled for a bone scan to figure out if it might be a stress fracture. Just a few days before I got knocked out with this I committed to running a leg on a marathon relay in early November. UGH.

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I’m sorry - transdermal cream?!?! The typical treatment for PTT is the dreaded boot or a cortisone injection.

If it’s PTT, you should be resting. Typically, the injury is due to overuse, and the posterior tibialis tendon is one that is used for normal walking which is why the boot is a treatment. Get a second opinion, but you should be healed by November no problem.

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Iam just getting over after 4 months of a stress fracture. I went to hard on bike and swimming in 1st 2 months and it didnt help. I have had 2 MRis and 2 opinions. Rest is best and lighten loads to easy phase, swim 1/2 the time w/ a pull bouy. I also gt a Bone Stimulator to help healing. Google Exogen bone stimulator. This sucks as I have gained 10 #! But I hear only dont overdue it because, you start the clock at zero again if you re injure. Good luck!

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I’m reading this sitting in the waiting room for an MRI to try to determine the same thing. I’ve had both before and have seen some pretty top professionals. Consensus is that the localized pain, which doesn’t get better during the course of a light run, plus the hop test, all means that a stress reaction (if not fracture) is a distinct possibity. My people say lay off running until you get full diagnosis, ok to swim and ride, with the same caveats as this poster states. Regardless of whether tendinitis or stress fracture, you MAY have similar recovery time. I believe fast diagnosis is key so you can determine what you can and can’t do.

The worst thing would be to greatly worsen it and turn a short term issue into a long term one.

That said, I’m holding my breath too for the next few hours until get the scans done and read.

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Sounds like exactly what I had (PTT). Went through the X-rays, mris, pt, etc. even rest didn’t really work. Had to even be careful clipping in and out of bike pedals, pushing off pool walls, etc.

I missed 2 races I had signed up for. It took me about 4-5 months to come back. Here’s what ultimately worked:

  • new running shoes (same model, new pair)
  • new work shoes interestingly
  • a PT routine of the “alfredson technique” which is really a lot of calf and ankle eccentric exercises (only one enlightened doc of 4 even knew about this)
  • coming back VERY slowly, starting at 20 min of pain- free running and adding 5 min per week after that.

I wound up having a good year of PRs after that so no worries. Be patient and good luck!
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I had very similar symptoms starting late summer in 2012. Sat out running for ~10 days, they came back right away. Spent the remainder of 2012 cutting back on running volume, and various visits to PTs and ortho. After nothing helped got an MRI late in 2012, diagnosis was PTT (surprise, but on the positive side, at least nothing worse). Sat out running for 3 months over the winter, then in the spring experimented with different running shoes and had my pedorthist update my orthotics. Symptoms were still there, although did not get as bad as in 2012. Eventually found a shoe that - in combination with the orthotics - allowed me to walk/run relatively pain-free, which is the shoe I’m wearing all day everywhere (different pairs for running/at home/everywhere else). Walking barefoot or even in Birkies would after a couple of hours bring back the (PTT) pain.

Recently started working with a new PT (for different reasons) that takes a much more holistic approach than the previous practitioners I have worked with, but last visit I asked him about the still somewhat lingering PTT. His first step was to make me do some ‘funny human tricks’ (like single-leg squats). Came back suggesting alignment issues, and we worked on pelvic tilt and rotation. And lo and behold, within just a few days the pain is virtually gone. First time in 17+ months. Not just that, but after running my knees feel a lot less strained. Obviously my body posture/running form was flawed, but the PT also suggested that there probably was some event that caused PTT to become as prominent as it did.

Thinking back, in mid-2012 I started running in new shoes, after Saucony stopped making the Grid Tangent (my go-to trainer) and I had run out of my private reserve (stockpile I acquired when EOL was announced for the Tangent). I went to zero-drop shoes (Tangent had something like 8 or 10 mm, IIRC), and looking at my training logs sure enough, the PTT symptoms came on within 1-2 months after switching. The shoes I’m in now (Asics DS Racer) have 10 mm drop again, and within a few days after going back to non-zero drop shoes the PTT pain noticeably improved.

Now, I’m not saying zero-drop is what caused my PTT, rather a combination of flawed form, flat arches to begin with, and having run in non-zero drop shows all my life (I’m 45). But adding the drop back in, and working with an amazing PT that does not just focus on the local pain, but the complete body posture/form, did the trick for me.

Hope you get resolve on your issue, good luck!

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