If you work with athletes or someone with flat feet, you may have already encountered tibialis posterior tendonitis (TPT). A person with TPT may feel pain in the arch of the foot, medial side of the ankle and/or deep in the calf. A tibialis posterior pain reduction massage might be in order.

I’ve found 2 keys to helping a client walk out of my office in less pain: 1. Look for pain in 3 places 2. Give the right dose of pressure.

Lost Arch—Almost

My first true case of working with a tibialis posterior condition turned out to be a tendon tear. In the past, Tom had come to see me for a stiff neck and a frozen shoulder. But when he came in with extreme pain in his arch/ankle with reduced foot functionality, I knew he was waay beyond anything I could do to help him.

He went to the orthopedist and eventually found out that his tib posterior tendon was 80% torn. Yikes! If it went completely, the surgeon said, Tom would completely lose his arch and wouldn’t be able to do the recreational activities that he loved, like running and basketball.

Tom had his tib post surgically repaired and it was a huge success. Now I work on his tib post for minor aches and pains. Since Tom, I’ve worked on many runners with tib post tendonitis. Needless to say, I’ve gotten to know the tib post quite well.

The Tib Post Big Picture

The tibialis posterior is the deepest muscle in the posterior calf (underneath the gastrocnemius and soleus). It’s main attachments are the inner posterior borders of the medial tibia and fibula, the interroseus membrane (membrane between the tibia and fibula), the tuberosity of the navicular bone, the plantar surface of the 1^st cuneiform and at the bases of the 2^nd, 3^rd and 4^th metatarsals.

Tib Post in 3 Sections

I divide the tib post into 3 parts to make it easy to remember. Here they are: 1. Foot, 2. Tendon, 3. Body.

Foot Attachments—Find the Tuberosity of the Navicular Bone

In the foot, the tib post attaches at the base of metatarsals 2, 3, and 4, the navicular tuberosity and the middle cuneiform.

(Picture from https://commons.wikimedia.org/wiki/File:Slide2wewe.JPG)

Don’t sweat the attachments. If you find the navicular tuberosity, the rest is gravy. Why? Because the navicular tuberosity is an area that you’ll really want to investigate, and once you find it, you can use it as a reference point to locate the middle cuneiform and metatarsals.

In this video, Finding the Tibialis Posterior Navicular Attachment, I show you the quick and easy way to locate tib post navicular attachment.

Tendon Section

To locate the tib post tendon, put your fingers on the medial malleolus. Now go slightly posterior of the malleolus and down.

If you’re doing a parts body massage, have the person invert her foot as you resist with your hand and the tendon will become more prominent.

Calf Section

Now for the body of the tib post: In your brain, draw a straight line from the Achilles tendon ¾ of the way up the lower leg. At the ¾ mark up the calf is approximately the location of the interroseus membrane, one area where tib post attaches. Between the Achilles and the interroseus membrane is the body of the muscle.

Goldilocks Pressure for the Tibialis Posterior Pain Reduction Massage

Once you locate the tibialis posterior, your next goals are to find the areas of pain and then reduce the pain. You are going to reduce pain by applying a therapeutic (pain relief) pressure.

Too much pressure may cause your client to tighten up and/or may add to an unwanted inflammatory response. Not enough pressure and it’s unlikely you’ll facilitate a pain relief response.

The right amount of pressure can be easily determined by introducing a pain scale to your client. The scale is 1 to 10. One is a little bit of pain. And 10 is a whole lot of pain.

Press on a pain area and ask your client to tell you when the pain reaches a 4 on her pain scale. Hold at that 4 pressure for less than 10 seconds. Ask the client if the pain stayed the same or went up or went down. If the pain went down, you may try applying a little more pressure when you come back to that area again during the massage. If it didn’t, lighten the pressure and try again until the pain goes down.

Once you get your client’s “4”, you don’t need to check in with her regarding pressure except when you’re in doubt.

In this video, I show you how to use the pain scale to find the right pressure: Pain Relief Massage–How to Find the Right Pressure.

Some clients know which pressure is best for them because they’ve had a lot of massage. In those cases, I would, more often than not, go with the client’s request.

Tibialis Posterior Pain Reduction Massage Combined with Relaxation Massage

Here’s what post tib work could look like if you were incorporating it into a relaxation or body parts massage: Tibialis Posterior: How to Do Pain Relief Massage Video

Tibialis Posterior Pain Reduction Massage Cliff’s Notes

Here’s your quick reference guide:

a. Navicular: Find the tuberosity of the navicular bone. Then you can find all the other foot attachments if necessary.

b. Tendon and Body: The tendon is on the medial ankle side. The body of he muscle is in the middle of the calf and deep.

Video: Finding the Tibialis Posterior Navicular Attachment.

c. Keep pressure at 4 if you’re unsure.

Video: Pain Relief Massage–How to Find the Right Pressure

d. Integrate into relaxation.

Video: Tibialis Posterior: How to Do Pain Relief Massage

Tibialis Posterior Pain Reduction Massage + ?

Lastly, a massage is not going to cure tibialis posterior tendonitis. It can help someone on the road to recover, but the cause (or perpetuating factors) for the tendonitis needs to be addressed.

Personally, I reach out to podiatrists, orthopedists, physical therapists, coaches, and select body movement instructors (e.g. Pilates and yoga). For me, a combined efforts approach has produced great outcomes both for my clients and my business.

Want more information about pain relief massage?

Check out My (Simple) Secret To Pain Relief Massage.

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I built my practice on massage for pain relief. You can, too. And you don’t need to shell out thousands of dollars to learn how to do it. Why? Because on some level with every massage you do now, you’re already doing pain relief massage.

You can make pain relief massage your signature massage by doing these 3 things: 1. Calibrate your pressure, 2. Double down on therapeutic rapport, and 3. Follow a treatment plan.

I Thought I Had the Answer

I became certified in neuromuscular massage therapy (NMT) in 1999 because I wanted to get people better. In my mind at the time, here’s how things would go down: I’d work on clients, they’d get better and then they’d never come back.

But what I didn’t understand was that pain was complicated. It may have a non-musculoskeletal origin. And even if it had a musculoskeletal origin, the NMT intervention may not be effective.

Embarrassed to Take my Client’s Money

When some clients started coming back to see me on a regular basis, I felt like a failure because I didn’t get them better. Instead I only gave them some temporary (not forever) pain relief.

Fortunately, even though at the time I didn’t value pain relief massage, my clients did. And in a relatively short period of time I had enough clients to open my first office. Soon after, I couldn’t deny that pain relief massage was having a huge, positive impact on my clients’ lives. And I became interested in figuring out how I could give the most effective pain relief massage possible.

Calibrate Your Pressure

I found that the appropriate pressure is the single most important element to pain relief massage. With acute pain, too much pressure can aggravate a condition. Conversely, for someone with recurring pain who responds well to deep pressure, not enough pressure is ineffective and a waste of her money.

When in doubt about pressure, try this technique that I was taught in NMT training. Say to the client: “Imagine a pain scale that goes from 1 to 10. One is the lowest amount of pain and 10 is the highest. As I press on a tender or tight spot, I want you to give me a pain rating.”

If you get a 5 or above response, lighten your pressure. In most cases if you work between a 3 and 4, you’re going to, ultimately, lessen your client’s pain, not increase it.

Double  Down on Therapeutic Rapport

Pain is not just a biomechanical response. How we interact (and connect) with our clients can actually lessen or increase their pain. If you’re having trouble connecting to a client, try my Elderly Grandmother technique.

Imagine that your client is your elderly grandmother. How are you going to treat her?

First, you’re going to slow down and take your time. Then you’re going to make sure that you understand what she’s saying and that she understands what you’re saying. Lastly, you’re going to do everything in your power not to upset Granny. And subsequently, you’ll create a calm and supportive environment.

An abbreviated way of looking at therapeutic rapport is: It’s all about Granny for the next hour!

[If you want specifics about developing great therapeutic rapport, check out my article in Massage & Bodywork Magazine—Four Lessons on Chronic Pain (Notes from a Mountain Guide).

In this article, Maximizing the Placebo Effect, I explain how to increase the placebo effect (a positive response) through therapeutic rapport. In a more recent article, I explain how the placebo effect can be fine tuned. Here is an interview I did about the article.

Follow a Massage for Pain Relief Plan

A treatment plan is essential in order to do an effective pain relief massage. When you have a plan you’ll be on target to address the pain issues the client wants you to address. A plan also puts your client’s pain in a massage framework for current and future discussions. And a plan is something that you can go back to and adjust if your client doesn’t feel better. If he does feel better, you know what to do the next time.

The treatment plan I follow comes from my research and experience.  It’s universal in the sense that it works with any type of massage modality.

a. Pre-massage: identify pain areas before the client gets on the table.

This ensures that you will always find the problem areas once the client is on the table. And it builds therapeutic rapport. For more about this read My Simple (Secret) to Better Pain Relief Massage.

b. During the massage: commit to a course of action.

Let’s say your plan is to work the upper-trap for a neck/shoulder condition. But once you get the client on the table you find that the levator scapulae is the tight muscle. No problem. Change your course of action–but stick with the new plan. In Get Your Client Out of Pain: Put a Stake in the Ground, I explain why having a course of action can make or break a pain relief massage.

c. Post-massage: tell the client what you did, what you found, then provide recommendations and follow-up.

Now it’s time to lay it on the line. Once you’ve done your work, go over the highlights of the massage (e.g., I found you’re piriformis to be tight) and then make recommendations to further lessen the pain (e.g. self massage at home). Follow up in a couple of days.

If the massage helped, great! If not, it’s time for Plan B if you think it’s warranted.

Your Massage for Pain Relief Practice Starts Now

You can build a practice quickly by making pain relief massage your signature massage. And it’s not a far stretch from what you’re already doing. If you focus on

1. 1. 1. calibrating your pressure
      2. doubling down on your therapeutic rapport
      3. following a treatment plan

you’re going to see big changes with your client retention.

Seriously, you got this! Just follow this formula to start. Over time you’ll make it your own.

Free Course to Jumpstart Your Massage Business

If you’re just starting a massage business and want to incorporate pain relief massage into your business model, this free course will get you to your 30K a year: Jumpstart.

If you’re trying to take a meh massage business and make it a dream massage business, go here: Accelerator.