Following our discussions on the Tibialis Posterior muscle and its treatment with acupuncture, this blog post delves into the specific application of dry needling for Tibialis Posterior trigger points, a technique highly influenced by the pioneering work of Travell and Simons.

They describe the tibialis posterior as the “Runner’s Nemesis” since it is such an important muscle in stabilizing the foot and ankle during walking and running. It typically presents with trigger points in other lower leg muscles like the big toe flexors and peroneal muscles when trigger points are present.

Prior blog posts about the tibialis posterior:

• Tibialis Posterior Explained

• Acupuncture for Tibialis Posterior Pain

Indications for Tibialis Posterior Trigger Points

• Metatarsal Head Pain

• Plantar Lesser Toe Pain

• First Steps in the Morning Feel as if Walking on Nails

• Posterior Ankle Pain

• Tight Achilles Tendon

• Heel Pain

• Plantar Great Toe Pain

• Plantar Midfoot Pain

• Posterior Leg (Calf) Pain

Signs and Symptoms of Posterior Tibialis Trigger Points

• Pain in foot especially when walking or running - especially on uneven surfaces

• Pain that is felt in the arch of the foot, Achilles tendon, heels, toes, or calf

• Medial shin pain or shin splints

• Plantar fasciitis type pain

Causes of Tibialis Posterior Pain

Overuse or trauma to a muscle is a common cause, here are some specific to this muscle:

• Running or jogging on uneven surfaces

• Poor fitting shoes and footwear

• Chronic postural overload

The importance of exercising on even surfaces with good footwear is highlighted by the case of tennis players. Tibialis posterior trigger points are not commonly found in tennis players despite the excessive use of the lower leg muscles.

This is likely due to their typical exercise environment, which involves playing on flat, smooth surfaces, and their use of well-supported footwear. On the other hand, wearing shoes that are excessively worn and promote foot eversion and rocking can increase the likelihood of trigger points developing in this muscle.

A certain degree of pronation during the early stance phase of walking is normal. However, excessive pronation can overburden the tibialis posterior muscle. This excessive strain not only has the potential to activate trigger points in the muscle but also plays a significant role in maintaining them.

Factors contributing to excessive foot pronation may include a hypermobile midfoot, limited ankle dorsiflexion (ankle equinus), muscular imbalances, or structural variations like a Morton's foot. These conditions can place additional stress on the tibialis posterior muscle, heightening the risk of trigger point development.

Tibialis Posterior Trigger Points

Where are Tibialis Posterior Trigger Points?

• Trigger points can form along the muscle - typically in the upper half where the belly of the muscle it

• Palpating and needling this muscle is more complicated than other muscles since it lies deep in the posterior lower leg compartment close to a number of neurovascular structures

Tibialis Posterior Trigger Point Referral Pattern

• Posterior tibialis trigger points are typically felt in the posterior lower leg medial to the shin. They can travel down to the calcaneal tendon area and affect the arch of the foot, sole of the foot, and heel area.

• They are concentrated above the heal around the Achilles tendon.

• Referral pain can also extend from below the knee, over the calf, through the entire heel, and down to the plantar surface of the foot to the toes.

• Tibialis posterior trigger points can cause pain that mimics plantar fasciitis symptoms.

Associated Trigger Points

• Flexor digitorum longer

• Flexor hallucis longus

• Peroneal muscles

Differential Diagnosis

• Shin Splints

• Posterior tibial tendon dysfunction

• Plantar fasciitis

• Ankle sprain

• Medial Tibial Stress Syndrome

• Tarsal Tunnel Syndrome

Dry Needling Treatment for Tibialis Posterior Pain

Dry needling, targeting the Tibialis Posterior trigger points, can be an effective approach to treating pain and dysfunction associated with this muscle.

Procedure

• Involves inserting fine, sterile needles directly into the trigger points.

• The goal is to elicit a local twitch response, which can help release muscle tension and alleviate pain.

• The practitioner may manipulate the needles to enhance effectiveness.

Benefits

• Provides immediate relief from muscle tightness.

• Helps improve range of motion and overall muscle function.

• Can be a crucial component in a comprehensive treatment plan, especially for athletes or individuals with chronic lower leg issues.

Safety

• Since the tibialis posterior lies deep in the lower leg - safe practice is very important when needling this muscle.

• One study using cadavers found that needling via a posterior/medial approach is safer than an anterior needling approach.

• The posterior/medial approach crosses the flexor digitorum longus.

• The anterior approach crosses the tibialis anterior and interosseus membrane.

• It is important to have dry needling done by a skilled practitioner with appropriate training since ultrasound studies show the proximity of the muscle to neurovascular structures in the lower leg.

Incorporating Dry Needling with Other Treatments

• While dry needling can be highly effective, it's often part of a broader treatment strategy.

• Complementary therapies like traditional acupuncture, physical therapy, corrective exercises, and stretching can further enhance recovery and prevent recurrence.

Improving Body Mechanics for Tibialis Posterior Health

For individuals with active trigger points in the tibialis posterior muscle, particularly those who run or jog, it's essential to maintain proper body mechanics to alleviate and prevent discomfort:

• Choose Smooth Running Surfaces:

  • Running or jogging on even, smooth surfaces helps minimize undue strain on the tibialis posterior muscle.

• Wear Supportive Footwear:

  • Shoes with adequate arch support are crucial. This support is particularly important for correcting hyperpronation caused by a hypermobile midfoot.

• Correct Structural Imbalances:

  • If a Morton foot structure is present, shoe inserts beneath the first metatarsal head can be beneficial. Adjustments to the shoe's insole can initially feel uncomfortable due to referred tenderness from the trigger points, but comfort typically improves as the condition of the tibialis posterior muscle ameliorates.

• Alternative Exercise Options:

  • If trigger point activity persists despite treatment, consider replacing high-impact activities like jogging with low-impact exercises such as swimming or cycling.

• Opt for High-Quality Shoes:

  • Always choose well-fitted shoes that provide good lateral foot stability. Ensure that the heel counter of the shoe fits snugly and doesn’t allow excessive movement.

• Avoid High Heels:

  • Shoes with high or spike heels should be avoided as they can exacerbate the problem. High-top shoes might be necessary for additional support if other measures are insufficient.

Strengthening and Conditioning

Strengthen Tibialis Posterior and Peroneus Longus:

• Targeted exercises

  • Engage in exercises aimed at enhancing the endurance and aerobic capacity of the tibialis posterior and peroneus longus muscles.

  • This can help address issues related to painful hyperpronating feet.

• Be Mindful of Footwear:

  • Ensure the footwear provides sufficient support and does not contribute to exacerbating the issue, especially in the case of hyperpronation.

• Consider Shoe Modifications:

  • If necessary, shoe modifications such as added padding or custom inserts can provide additional support and correction for foot imbalances.

These measures, when consistently applied, can significantly aid in managing and preventing discomfort associated with tibialis posterior trigger points, improving overall foot health and function.

Conclusion

Dry needling for Tibialis Posterior trigger points offers a targeted approach to treating pain and dysfunction in the lower leg. Based on the principles established by Travell and Simons, this technique provides a valuable tool in the repertoire of treatments for muscle-related pain.

Additionally, it is important to understand and address underlying factors that could contribute to posterior tibialis trigger points.

If you're experiencing symptoms indicative of Tibialis Posterior issues, consider dry needling as a potential solution.

Over to you

If you liked this article, please share with friends and family who may want to learn more about the tibialis posterior muscle.

Sources:

• Travell, J. G., Simons, D. G. (1993). Myofascial pain and dysfunction: The trigger point manual. London: Lippincott Williams & Wilkins.

• Biel, A., & Dorn, R. (2010). Trail guide to the body: A hands-on guide to locating muscles, bones and more. Boulder, CO: Books of Dicovery.

• Janda, Vladimír. “Muscle Function Testing.” (1983).

• Corcoran NM, Varacallo M. Anatomy, Bony Pelvis and Lower Limb: Tibialis Posterior Muscle. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539913/

• Rhim, H. C., Dhawan, R., Gureck, A. E., Lieberman, D. E., Nolan, D. C., Elshafey, R., & Tenforde, A. S. (2022). Characteristics and Future Direction of Tibialis Posterior Tendinopathy Research: A Scoping Review. Medicina (Kaunas, Lithuania), 58(12), 1858. https://doi.org/10.3390/medicina58121858

• Willegger, M., Seyidova, N., Schuh, R. et al. The tibialis posterior tendon footprint: an anatomical dissection study. J Foot Ankle Res 13, 25 (2020). https://doi.org/10.1186/s13047-020-00392-1

• Riegleman, D. L., & Creech, J. A. (2021). Successful Treatment of Medial Tibial Stress Syndrome with Interosseous Membrane Acupuncture: A Case Series. Medical acupuncture, 33(2), 150–152. https://doi.org/10.1089/acu.2020.1448

• Pérez-Bellmunt, A., López-de-Celis, C., Rodríguez-Sanz, J., Koppenhaver, S. L., Zegarra-Chávez, D., Ortiz-Miguel, S., & Fernández-de-Las-Peñas, C. (2022). The posterior/medial dry needling approach of the tibialis posterior muscle is an accurate and safe procedure: a cadaveric study. BMC musculoskeletal disorders, 23(1), 570. https://doi.org/10.1186/s12891-022-05530-3

• Albin SR, Hoffman LR, MacDonald CW, et al. Ultrasonographic Validation for Needle Placement in the Tibialis Posterior Muscle. IJSPT. 2021;16(6):1541-1547. doi:10.26603/001c.29854

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