essential skills By Ben E. Benjamin

102 & bodywork september/october 2009 Anterior Tibialis Injuries

In the last issue (“Posterior puffiness at the front of the or a creaking sound when the is Tibialis Injuries,” Massage moved. (The creaking sound indicates an inflammation of the thin sheath & Bodywork, July/August covering the , a condition referred to as tenosynovitis.) This 2009, page 92), we looked injury can easily be confused with a compression of the L4 nerve root by at the posterior tibialis, a a protruding disc, a serious low-back injury that causes loss of control of the anterior muscle-tendon unit located foot during walking (“foot drop”). tibialis Injuries to the anterior tibials at the posterior medial lower muscle are colloquially referred to as “shin splints.” When the tendon is leg. In this article, we’ll strained, pain may be felt anywhere anterior from the inner arch of the foot to examine its counterpart at tibialis about four inches above the ankle. In tendon some cases, only a small portion of the anterior portion of the the tendon is painful; in others, pain is felt throughout the entire tendon. leg: the anterior tibialis. How and Why These Contraction of this muscle-tendon Injuries Occur unit both inverts and dorsiflexes On occasion, a severe anterior tibialis the foot. The anterior tibialis plays injury may happen suddenly as the a key role in walking and , result of a fall, a long jump, or another helping to control the foot’s descent event that causes extreme stress, such as to the ground as the muscle lengthens running a marathon without adequate (eccentric contraction) and to lift the preparation. Typically, however, these Putz/Pabst: Sobotta, Atlas der Anatomie des Menschen, 21st foot off the ground as the muscle injuries develop slowly, gradually ed. 2000 © Elsevier GmbH, Urban & Fischer München shortens (concentric contraction). worsening over a period of several If you dorsiflex your foot with your weeks or months. Often, the discomfort shoes and socks off, you can see the the lateral surface of the . As it first appears after a hard volleyball or anterior tibialis tendon protruding progresses distally toward the foot, it soccer game, a long run, a rigorous at the anterior aspect of your ankle. attaches to various structures, including hike, or another strenuous activity that Try tracing the tendon’s path with the interosseous membrane between causes the muscle to fatigue and excess your finger. As you follow it distally, the tibia and fibula, the deep surface stress to be absorbed by the tendon. it crosses the center of the ankle and of the , and the intermuscular While the pain is not too bothersome at extends to the middle of the medial arch septum, ending at the anteriomedial first, as the weeks progress it is present on the medial aspect of the foot. As dorsal aspect of the foot. It inserts more often and for longer periods of you follow it proximally, it leads to its into the medial cuneiform bone and time. It seems better with rest, but gets controlling muscle (Image 1). the base of the first metatarsal bone. bad again when the person is active. The anterior tibialis muscle When the anterior tibialis muscle- When the injury becomes severe, originates at the lateral condyle of tendon unit is injured, it is painful simply walking or dorsiflexing the foot the tibia and the upper portion of to walk. There may also be some causes pain. If only the muscle fibers are

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injured, the pain is felt in the anterior Friction of the Anterior lower leg. A tendon injury is generally Tibialis Tendon experienced as a pain or ache on top Sit at the base of the table facing the of the foot, just anterior to the ankle, affected foot. While stabilizing the but may also be felt in the tendon when foot with one hand, place the tip of it crosses in front of the ankle . your thumb or index finger on one Individuals whose feet are edge of the anterior tibialis tendon. excessively pronated, with the arches Apply a posterior pressure and snap falling in medially, are more likely to through the tendon in a medial- develop this injury. The anterior tibialis to-lateral direction (Image 3). Do tendon works to hold up the arch, so this for a few minutes, then change when the arch pronates, it twists the positions so that you move through tendon and places additional Photos by Melinda Bruno. the tendon in the opposite direction. on it. Another predisposing factor is After using friction therapy to break severe tension in the lower leg muscles, down some of the scar tissue, massage which makes those muscles vulnerable the foot, , and shin to enhance to early fatigue and subjects the tendon circulation into the tendon area. to unnecessary stress. Additional contributing factors may include When the injury is in the muscle ineffective warming up and running rather than the tendon, healing or jumping on concrete surfaces. often takes longer, because many more fibers are damaged. Instead Injury Verification of friction, perform cross-fiber Resisted Dorsiflexion massage (using a lubricant) on the Ask the client to dorsiflex the foot by injured structure. Together with the saying, “Bring your toes toward your therapeutic exercises described on head and hold them there.” Then, page 107, this treatment is usually place one hand under the client’s effective within six to eight weeks. heel for support and the other hand on the forefoot just proximal to the Treatment Choices toes. Ask the client to hold the foot in Self-Treatment Clients with chronic anterior tibialis that position and not let you move it. This injury often takes a long time to strain related to excessive pronation Apply great force, trying to pull the heal on its own because the anterior can benefit from using orthotic foot into plantar flexion (Image 2). tibialis muscle-tendon unit is used to devices—custom molded arch supports walk every day, and thus is constantly made of leather, plastic, hard rubber, or Heel Walking irritated. Rest usually helps over even Styrofoam inserted into the shoe. From a standing position, have the four to six weeks, but if the feet are They help to improve foot alignment client lift the balls of the feet off the chronically pronated, the injury is so that the body’s weight is distributed floor, balancing on the heels for a likely to recur. The person should evenly throughout the foot. For the moment and taking a few steps. This not take long walks, hikes, or runs if best results, have the person see a can be done either barefoot or in shoes, those activities cause pain. If the pain sports podiatrist for custom orthotics whichever is more comfortable. is severe or persists for more than two rather than buying something at the weeks, it’s important to seek treatment. drugstore. If the strain is rather mild, One or both of these tests should removing the pressure with the orthotic reproduce or increase the person’s Friction Therapy and Massage may be curative as well as preventive. pain. To locate the exact area of Friction treatment usually gives relief injury, palpate various places along rather quickly, because the tendon is Exercises the tendon and muscle while the easily accessible. Typically only four Begin teaching these exercises in client holds the foot in dorsiflexion. or five treatments are required. the second week of treatment, but only if they can be done without pain. After starting the person off

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with one or two exercises, add the others in one at a time in subsequent Without an understanding of sessions. The general principle is to start slowly, with a light weight and what’s happening, it’s likely small number of repetitions, then build up the weight and the number that the person will continue of reps as the person gets stronger and the exercises begin to feel easier. to aggravate the injury. Heel Walking Have the client try walking on his or her heels, with shoes on, for increasing periods of time. Start with 30 seconds take a brief rest, and repeat. Don’t use A Clear Path to Healing and build up to three minutes. too much weight to start; begin with a For any client with an anterior tibialis lighter weight and gradually build up to tendon strain, the most valuable Ankle Flexion using 5–10 pounds over the course of service you can provide is giving an From a sitting position on a table, with the treatment. The client should begin accurate assessment. Without an legs dangling down, have the client to feel tired after 5–10 repetitions. If understanding of what’s happening, dorsiflex the ankle so the toes come the exercise causes pain, it means the it’s likely that the person will continue toward the . Ask the person to hold person either is using too much weight to aggravate the injury. When the feet this position for one or two seconds, or is not yet ready to begin exercising. are excessively pronated, even walking then point the foot into plantar flexion can put significant strain on this and hold that position for one or two Outer-Ankle Lift structure. The good news is that once seconds. Begin with five repetitions This exercise requires the same props you’ve made your assessment (which of flexing and pointing, and then as the Inner-Ankle Lift, but is done is relatively easy to do), the prognosis rest and repeat 8–10 times. After a from a side-lying position on a couch for healing is quite good. Of the many week or two, or when that becomes or bed. Have the client start with the different structures athletes injure, the easy to do, tie a long, tubular sock bent, injured ankle on top, and anterior tibialis is one of the easiest containing a one-pound weight around then extend the top leg off the edge of to treat and quickest to heal. the anterior forefoot, just behind the the couch or bed (while wearing the toes. Now repeat the exercise, with the weight or the shopping bag). Then, Ben E. Benjamin, PhD, holds a doctorate in action of the foot lifting this weight have the person lift the outside of the education and . He is founder and then slowly lowering it. Begin foot toward the ceiling—10 times with of the Muscular Therapy Institute. Benjamin with just two sets of five, eventually the foot in plantar flexion and then has been in private practice for more than 45 building up to 30 repetitions. When another 10 with the foot in dorsiflexion. years and has taught communication skills as a this becomes easy to do, add another Build up slowly to three sets of 10 trainer and coach for more than 25 years. He half-pound or pound of weight. repetitions in both foot positions. teaches extensively across the country on topics including SAVI communications, ethics, Inner-Ankle Lift Heel Raises and orthopedic massage, and is the author of This exercise requires the use of Start with the client standing, feet Listen to Your Pain, Are You Tense? and props—either weights that attach parallel, holding on to something Exercise Without Injury, and coauthor of to the foot in some way or a small for . Have the person rise up The Ethics of Touch. He can be contacted plastic shopping bag containing a one onto the balls of the feet, without at [email protected]. to five pound weight. To begin, have bending the knees, and stay there for the client sit in a chair and cross the a moment before coming down again. Editor’s note: Massage & Bodywork is injured leg over the good leg, with After five repetitions, repeat this same dedicated to educating readers within either the weight apparatus or the exercise with the knees slightly bent. the scope of practice for massage loaded shopping bag across the front Build up slowly to eight repetitions therapy. Essential Skills is based on author part of the foot, just behind the toes. of five, for a total of 40 repetitions. Ben E. Benjamin’s years of experience Now instruct the client to raise the and education. The column is meant foot toward the ceiling 5–10 times, to add to readers’ knowledge, not to dictate their treatment protocols.

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