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Integrated functional anatomy of the tibialis posterior. Attachments, nerves, palpation, joint actions, arthrokinematics, fascia, triggerpoints, the muscle's role in shin splints, running/sprinting mechanics, and behavior in postural dysfunction. Examples of common activation exercises, subsystems, and strength exercises of the tibialis posterior.

Tibialis Posterior

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This course describes the anatomy and integrated function of the tibialis posterior muscle (a.k.a. post tib, tib post, deep calf muscle, tibial posterior muscle, or posterior tibialis muscle). This muscle is located deep to the calf muscle and posterior compartment, in the deep posterior compartment, and the tibialis posterior tendon courses posterior to the medial malleolus and underneath the foot (near the posterior tibial artery, and tendons of the long toe flexors). The muscle is composed primarily of type II muscle fibers (based on animal studies) and crosses both the ankle joint and foot joints.

The tibialis posterior is the primary invertor of the ankle, will contribute to plantar flexion of the ankle, and is a supinator of the foot (tarsal joints). Further, the tibialis posterior will eccentrically decelerate dorsiflexion, eversion, and pronation (as seen in adult-acquired flatfoot, or flatfoot deformity). This course also describes the role of the tibialis posterior in ankle (talocrural) joint arthrokinematics, fascial integration (Achilles tendon), postural dysfunction, and subsystem integration. Additionally, the location of the tibialis posterior is discussed relative to the anterior tibial artery, posterior tibial artery, fibular artery, sciatic nerve, tibial nerve, common fibular nerve, deep fibular nerve, and the fascial sheaths that comprise the deep posterior compartment, including the interosseus membrane and transverse intermuscular septa.

Sports medicine professionals (personal trainers, fitness instructors, physical therapists, massage therapists, chiropractors, occupational therapists, athletic trainers, etc.) must be aware of the integrated function of the tibialis posterior for the detailed analysis of human movement, and the development of sophisticated exercise programs and therapeutic (rehabilitation) interventions. Further, this course is essential knowledge for future courses discussing injury prevention and physical rehabilitation including pes planus (a.k.a. flat feet, flatfoot deformity, adult acquired flat foot, functional pes planus), tibialis posterior tendinopathy, (a.k.a. posterior tibial tendonitis, posterior tendinopathy, tibialis posterior tendon inflammation, tibial tendon dysfunction, tendon tears, tendon sheath damage), and surgical interventions (tendon tear repair, deep posterior compartment release, tibial tendon dysfunction surgery, tendon transfers). Tibialis posterior exercises and techniques are also introduced in this course (e.g. tibialis posterior activation, integration, and strengthening.)

Brookbush Institute’s most recommended techniques for the Tibialis Posterior (see videos below):

Activation: Tibialis Posterior Isolated Activation (Plantarflexion and Inversion)

Activation: Tibialis Posterior Reactive Activation

Subsystem Integration: Single-leg Touchdown with Posterior Pull

Cadaver dissection of tibialis posterior on the lower leg

 Course Description: Tibialis Posterior

Introduction

 perhaps relating to the shape of the bone. 

 is the form of the root as an adjective 

http://dictionary.reference.com/browse/tibia

Posterior - Latin, comparative of posterus, meaning coming after, a derivative of post meaning after.

The location of the tibialis posterior underneath the gastrocnemius and soleus

Tibialis Posterior Note: In this illustration, the gastroc and soleus have been removed. http://upload.wikimedia.org/wikipedia/commons/4/49/Tibialis_posterior.png

Attachment and Innervation

The attachment of the tibialis posterior on the tibia

Attachments & Innervation: Tibialis Posterior

Relative Location

Neumonic for remembering the order of the tibialis anterior, flexor digitorum longus, artery, nerves, and flexor hallucis longus 

Where is the Tibialis Posterior Located?

Palpation

Cadaver dissection of the tibialis posterior on the tibia

Palpating the Tibialis Posterior

Introduction to the Tibialis Posterior

Actions

Plantar flexion (although the tibialis posterior comprises a significant portion of the cross-sectional area of the posterior leg muscles (up to 30%), its contribution to plantar flexion is relatively small - potentially as little as 6% in the healthy adult (3, 8, 16, 18).

Inversion of the ankle, adduction, and supination of the forefoot (8). The tibialis posterior is the primary supinator (18).

The adduction moment of the tibialis posterior may contribute to relative external rotation of the tibia on the foot (3).

Cross-sectional view of the lower leg muscles including tibialis posterior, gastrocnemius, soleus, and fibularis muscles

Cross Section of Lower Leg -Note the deep location of the Tibialis Posterior - https://d3j7fudf8o8iuo.cloudfront.net/var/ezwebin_site/storage/images/media/images/e-anatomy/lower-limb-anatomy-illustrations-and-diagrams/human-anatomy-cross-sectional-diagram-leg-muscles-tendon-bone-en/2522735-1-eng-GB/human-anatomy-cross-sectional-diagram-leg-muscles-tendon-bone-en_medical512.jpg

Stabilizes the ankle (tibiotalar and talocalcaneal joints), all transverse tarsal joints, and tarsometatarsal joint 2 through 4.

The tibialis posterior eccentrically decelerates dorsiflexion, calcaneal eversion, and pronation of the mid-and forefoot (8).

It is active during the stance phase of gait to eccentrically decelerate pronation.

This muscle acts synergistically with the soleus, gastrocnemius, and plantaris, fibularis muscles, 

flexor hallucis longus (FHL), and flexor digitorum longus (FDL)

 muscles to produce plantar flexion torque.

This muscle may be the prime mover of inversion acting synergistically with the 

, soleus, medial gastrocnemius, FHL & FDL, and 

The insertion of the tibialis posterior makes it perfectly adept at supporting the medial longitudinal arch and resisting excessive pronation. This would imply a complex synergistic relationship with the 

 and FHL in supporting the first ray, and a synergistic relationship with FDL and short flexors in support of metatarsals 2 through 4 and the plantar surface of the foot (18).

Tibialis Posterior Muscle Actions

Arthrokinematics

The tibialis posterior, the talonavicular joint, and motion of the talus:

 The tibialis posterior creates a compressive force, superior glide, and lateral rotation of the navicular on the talus, similar to the force created by the 

 on the talonavicular and the cuneonavicular joint. This force is imperative to the optimal motion of the talus, as the posterior and superiorly directed force on the navicular is transferred to the talus, preventing excessive anterior glide - a motion commonly associated with 

 and foot/ankle impairment. The force couple of these two muscles ensures that during both plantarflexion (via the posterior tibialis) and dorsiflexion (via the 

) the motion of the talus remains optimal.

The tibialis posterior and the transverse tarsal and tarsometatarsal joints:

 The forces created at the transverse tarsal and tarsometatarsal joints are similar to those of the first ray and talonavicular joint. Compression, lateral rotation, and superior glide are imperative to the relative rigidity of the mid-and forefoot during supination. A lack of tibialis posterior strength may lead to medial rotation and inferior glide of the cuneiform and cuboid, subluxation of the 2nd, 3rd, and 4th metatarsals, and a flexible pes planus (flat foot).

The insertion of the tibialis posterior on the plantar surface of the navicular and cuneiform bones of the foot

Note the attachment of the tibialis anterior and tibialis posterior on the plantar surface of the navicular and medial cuneiform - http://upload.wikimedia.org/wikipedia/commons/thumb/5/59/Gray269.png/640px-Gray269.png

Fascial Integration

My Fascial Hypothesis: Large fascial sheaths not only play a role in the transmission of mechanical force but may also play a role in dictating the function of muscular synergies. This is likely caused by reducing or increasing tone of invested musculature via reflex arcs formed between mechanoreceptors embedded in the connective tissue and the attached musculature. In this way, my view of fascia differs slightly from noted expert on the subject Tom Myers. I think of these large fascial sheaths (specifically the thoracolumbar fascia, iliotibial band, and abdominal fascial sheath) as nature's "motherboard." A place for mechanical information to be communicated to the nervous system for more efficient recruitment of the muscular system. Despite having a slightly different philosophy it does not change the fact that fascia plays an important communicative role in the human body and we have Tom Myers to thank for his work.

Image of the fascial system of the body connecting muscles

 Tom Myer includes the tibialis posterior muscle in the "Deep Front Line" along with the 

flexor hallucis longus and flexor digitorum longus

 via the interosseus membrane (6). The shared fascia of the interosseus membrane and shared function of these muscles as invertors, supinators, and adductors of the foot/ankle provides evidence of a fascial influence on muscle recruitment. Further, I find it interesting that the 

, an evertor/pronator of the foot/ankle, shares the anterior intermuscular septa with the fibularis longus, the primary evertors of the foot/ankle – while the 

 invertor/supinators of the foot/ankle share the interosseous membrane with the tibialis posterior, FHL and FDL.

, tibialis posterior and fibularis longus (peroneus longus) share an intimate relationship in their attachment to the navicular and medial cuneiform. Although an adequate image of a cadaver navicular with muscular attachments could not be located, the interwoven tendinous insertions may imply a connection via the periosteum of the navicular and congruity of more superficial fascia that aids in the communication and relative change in activity of these muscles during functional activities, for example, the constant change in pronation and supination need to maintain balance during walking on uneven surfaces, especially at slower tempos. (19). This relationship is imperative to controlling the motion of the navicular, medial cuneiform, the first ray, and is especially important in optimal arthrokinematic motion of the talus. As no muscle originates or inserts into the talus, these muscles likely have the most direct impact on talar mechanics.

The tendon of the tibialis posterior muscle in a cadaver dissection

Tibialis Posterior Tendon - http://www.rvuanatomy.com/uploads/1/3/4/5/13457421/pc4b.gif

Behavior in Postural Dysfunction

. Activation, integration, and strengthening of the invertors (

. Supporting this sentiment is recent research showing evidence of decreased knee valgus in squat mechanics when an integrated program including tibialis posterior activation was used (15).

 the tibialis posterior plays no significant role.

Lumbo Pelvic Hip Complex Dysfunction (LPHCD)

, a decrease in tibialis posterior activity and strength results in excessive pronation and eversion of the foot/ankle complex. This may contribute to, or be partially caused by, altered reciprocal inhibition stemming from a short/over-active fibularis longus and synergistic dominance of the 

. The cascade of compensatory actions resulting from a decrease in activity and increase in tibialis posterior length may include abduction of the forefoot, a loss of dorsiflexion, knee valgus on a "flexible flat foot" (pes planus), or knee varus via tibia on foot eversion on a "rigid foot" (pes cavus).

In a study by Kamiya et al, tibialis posterior tendon dysfunction resulted in hindfoot valgus, forefoot abduction, and decrease in height of MLA resulting in flatfoot deformity (18). Paradoxically, research has suggested greater activity of invertors in individuals with excessive pronation, leading to trigger points and the tibialis posterior becoming a source of pain (posterior shin splints) (7,8). Often this leads to a treatment strategy that includes release and stretching of the tibialis posterior; however, that would seem to be counter-intuitive given the actions associated with a "flexible flat foot (eversion, pronation)". Although release of this muscle may contribute to better function, lengthening techniques would only exacerbate the dysfunctional pattern. It is my belief (and the belief of many human movement professionals), that the increase in activity is actually due to the increased eccentric load associated with a pronated foot and greater peak eversion during gate, and the tibialis posterior attempting to overcome this force in a lengthened position (20).

In short, the tibialis posterior has a propensity to become 

. Based on the studies mentioned above, release of the tibialis posterior may benefit those who are experiencing pain originating from this muscle, but a strengthening program should follow - not a lengthening program. Further, the discussion above on arthrokinematics may imply that ankle mobilization, first ray mobilization, and cuboid mobilization may assist in optimal function.

Feet flatten during a standing postural assessment

Achilles tendonitis (long term over-activity = rupture?)

Signs of Altered Length/Tension and Tone:

Asymmetrical weight shift - Long/under-active unilaterally

Tibialis Posterior MMT for an active population

Palpation results in tenderness (trigger points or tender points) and may result in radiating symptoms along the posterior leg up through the popliteal fossa.

The trigger points and referral pain patterns of the tibialis posterior

Tibialis Posterior Trigger Point and Referral Pain Pattern - http://muscularhealth.massagetherapy.com/Tibialis_Postrp.jpg

Postural Dysfunction and the Tibialis Posterior

For a complete look at activation and integration techniques check out:

Seated Band Resisted Plantar Flexion and Inversion

Seated "Pigeon Toed" Calf Raise with Band Resisted Inversion

Dr. Brent Brookbush demonstrating a tibialis posterior activation exercise

Standing "Pigeon Toed" Calf Raise with Band Resisted Inversion

Leaning Single Leg Calve Raise

Tibialis Posterior Reactive Activation: Step Back to Soft Landing

Single-Leg Balance (Sample Integration Exercise)

Hop Down to Stabilization (Sample Tibialis Posterior Power Integration)

Self-Administered Ankle Mobilization

Exercises and Techniques for the Tibialis Posterior

Phillip Page, Clare Frank, Robert Lardner, 

Assessment and Treatment of Muscle Imbalance: The Janda Approach

NASM Essentials of Corrective Exercise Training

NASM Essentials of Personal Training: 4th Edition

Diagnoses and Treatment of Movement Impairment Syndromes,

David G. Simons, Janet Travell, Lois S. Simons, 

Travell & Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition

Joint Structure and Function: A Comprehensive Analysis: Fifth Edition

Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani_

Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004

Murley GS, Landford KB, Menz HB, Bird AR: Effect of foot posture, foor orthoses and footwear on lower limb muscle activity during walking and running: a systematic review, 

Bell, D. R., Oates, D. C., Clark, M. A., & Padua, D. A. (2013). Two-and 3-dimensional knee valgus are reduced after an exercise intervention in young adults with demonstrable valgus during squatting. 

Yao K, Yang TX, Yew WP. (2015). Posterior tibialis tendon dysfunction: overview of evaluation and management. Orthopedics. 38(6): 385-391.

Frank, RM, Hsu AR, Gross CE, Walton DM, Lee S. (2013). Open and arthroscopic surgical anatomy of the ankle. Anatomy Research International. 1-9.'

Kamiya T, Uchiyama E, Watanabe K, Suzuki D et al. (2012). Dynamic effect of the tibialis posterior muscle on the arch of the foot during cyclic axial loading. 

Murley GS, Menz HB, Landorf KB. (2014). Electromyographic patterns of tibialis posterior and related muscles when walking at different speeds. Gait & Posture. 39:1080-1085.

Rabbito M, Pohl MB, Humble N, Ferber R. (2011). Biomechanical and clinical factors related to stage I posterior tibial tendon dysfunction. JOSPT. 41(10): 776-784.

Tasic, D., Dimov, D., Gligorijevic, J., Velickovic, L., Katic, K., Krstic, M., & Dimov, I. (2003). Muscle fibre types and fibre morphometry in the tibialis posterior and anterior of the rat: A comparative study. Medicine and Biology, 10(1): 16-21.

Bibliography

Questions, comments, and criticisms are welcome and encouraged

Tibialis Posterior

Related Courses:

Course Description: Tibialis Posterior

Introduction to the Tibialis Posterior
3 Sub Sections

Tibialis Posterior Muscle Actions

Arthrokinematics

Fascial Integration

Postural Dysfunction and the Tibialis Posterior

Exercises and Techniques for the Tibialis Posterior
8 Sub Sections

Bibliography

Related Courses:

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Tibialis Posterior

Related Courses:

Course Description: Tibialis Posterior

Introduction to the Tibialis Posterior3 Sub Sections

Tibialis Posterior Muscle Actions

Arthrokinematics

Fascial Integration

Postural Dysfunction and the Tibialis Posterior

Exercises and Techniques for the Tibialis Posterior8 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Introduction to the Tibialis Posterior
3 Sub Sections

Exercises and Techniques for the Tibialis Posterior
8 Sub Sections