Patient Presentation and History
A 25-year-old male presented with chronic pain and dysfunction associated with Posterior Tibialis Tendon Dysfunction (PTTD). The initial injury occurred in 2023 while running, consistent with an overuse injury. The patient had been actively engaged in physical therapy (PT) since the onset of symptoms, achieving consistent, measurable improvement.
However, the patient experienced a significant plateau in recovery starting in April 2025, indicating that the current conservative management was no longer sufficient to resolve the persistent symptoms and restore full function. Due to this refractory nature of the condition, Shockwave Therapy was introduced as an adjunctive treatment.
Treatment Protocol: Extracorporeal Shockwave Therapy (ESWT)
The patient received a total of five ESWT sessions over a period of one month. The treatment protocol for each session was multifaceted, utilizing various modes of shockwave application:
1. Muscle Smoothing: Applied to the surrounding musculature for broader myofascial relief.
2. Pain Zone Treatment: Focused application on the area of maximum patient-reported tenderness.
3. Direct Posterior Tibialis Treatment: Targeted application along the anatomical course of the muscle and tendon.
The treatment was delivered to multiple anatomical locations associated with the PTT complex: the fascial layer around the tibia, the posterior tibialis muscle belly, the tendon proper, the origin, and the insertion (navicular/cuneiforms).
Session-by-Session Clinical Response
The patient’s response was monitored both immediately post-treatment and in the days following. The discomfort level was tracked using a numeric rating scale (NRS) for pain/discomfort, where 0 represents no discomfort and 10 represents the worst imaginable discomfort.
Session 1.
| Metric | Pre-Treatment | Post-Treatment | Post-Treatment Change | Notes |
| Discomfort (NRS) | 4/10 | 1/10 | Immediate Reduction | Patient felt an immediate and significant difference, suggesting an initial analgesic anddesensitization effect. |
Session 2.
| Metric | Pre-Treatment | Post-Treatment | Interval Symptom Change | Notes |
| Discomfort (NRS) | Mild | No significant difference | Soreness for 2 days | Patient reported typical post-ESWT soreness for two days, which did not limit functional activity. The initial analgesic effect was not as pronounced as Session 1. |
Session 3.
| Metric | Pre-Treatment | Post-Treatment | Interval Symptom Change | Notes |
| Discomfort (NRS) | Mild | Improved symptoms | Able to run short distances | Patient was able to complete short runs as usual without experiencing any post-activity aggravation of symptoms, marking an important functional milestone. Subjective symptoms improved following the treatment. |
Session 4.
| Metric | Pre-Treatment | Post-Treatment | Interval Symptom Change | Notes |
| Discomfort (NRS) | Exacerbated (Not specified, likely ≥ 4/10) | Significantly Improved | Exacerbation for 3 days due to travel | Symptoms were aggravated due to an external factor (significantly increased time on feet during travel), providing a stress test. The patient required a session to address thisflare-up, which resulted in significant immediate improvement. |
Session 5.
| Metric | Pre-Treatment | Post-Treatment | Interval Symptom Change | Notes |
| Discomfort (NRS) | Mild/Low | N/A (Focus on long-term outcome) | Able to complete a long run | The patient achieved a major functional goal: completing a long run without experiencing any discomfort afterwards. The patient reported a feeling of steady and consistent improvement, indicating the ESWT course successfully broke the prior treatment plateau. |
Discussion and Conclusion (Draft)
This case study illustrates the utility of Extracorporeal Shockwave Therapy (ESWT) as an effective adjunctive treatment for chronic Posterior Tibialis Tendon Dysfunction (PTTD) that had become refractory to standard physical therapy.
Prior to the intervention, the patient had reached a therapeutic plateau in April 2025. The introduction of the five-session ESWT protocol over one month led to a rapid and consistent reversal of symptoms and functional limitations.
Patient’s comment: “When I started shockwave, my 2-3 mile runs would usually take 2-4 days for the inflammation cycle to resolve. This was quite consistent over the past months. A month into the therapy, I was able to go on a 6-miler with almost no symptoms in the following days.While there is still sometimes a slight irritation in the PTTD (close to where it terminates in the foot) sometimes, the improvement is undeniable.”
Key Observations:
● Immediate Analgesia: Session 1 demonstrated a profound immediate reduction in discomfort (4/10 to 1/10), suggesting an initial neurophysiological/analgesic effect.
● Functional Progression: The patient progressed from mild soreness (Session 2) and the ability to tolerate short runs (Session 3) to successfully completing a long run without aggravation (Session 5).
● Resilience: The episode of exacerbation due to travel (Session 4) demonstrated that
while the tendon was not fully healed, it was responsive to further ESWT intervention,
with the treatment successfully managing the flare-up and restoring progress.
● Breaking the Plateau: The overall success is evidenced by the final reported outcome in
Session 5: the patient felt improvement was steady and consistently getting better,
successfully moving beyond the chronic plateau.
Conclusion: In this case of chronic PTTD, a five-session course of multi-modal ESWT effectively managed a significant flare-up and enabled the patient to overcome a two-month therapeutic plateau, leading to a meaningful return to running activity. ESWT appears to be a valuable tool for restoring the healing process in chronic tendon pathology when conservative treatments alone become insufficient.
