Sock Doc 20: ‘When Things Don’t Go As Planned’ – Tibialis Posterior and Vertigo

August 11, 2023


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On this episode we have The Sock Doc, Dr. Steve Gangemi, joining us. Steve is a natural health care doctor who founded and practices at Systems Health Care, an integrative wellness center in Chapel Hill, NC. Steve is also a longtime endurance athlete and is a wealth of knowledge for athletes looking to optimize wellness.

We are starting a new series called “When Things Don’t Go As Planned” that will dissect your health and injury issues that come up when you least want them and can negatively affect your training and race season–how to heal, prevent and overcome going forward of common (and not so common) issues that athletes face. Send us your requests for topics! Future episodes may include sciatica, rhabdomyolysis, GI issues, recurrent ankle sprains, migraines and so on.

Part 1: Tibialis Posterior Issues & Injuries 

Post tib anatomy/connections/basic function

  • Where is located?
  • Tibia, fibula, foot arch, etc.
  • Tendon – inner ankle, by medial malleolus 

What it does

  • Foot/arch support
  • Natural pronation, shock absorption, natural rolling inward of your foot
  • Its role in supination

Functions with/relates to

  • Big toe
  • Plantar fascia
  • Medial arch
  • Tibialis anterior


  • Why so commonly injured in runners?
  • Who’s most at risk?
  • What warning signs should we be aware of on this issue? i.e. when there’s a little niggle/pain in that general area – when to take it more seriously, right away?
  • Explain the role of post tib issues being from an imbalance between anterior/posterior?

Tie in with overtraining/excess stress:

  • “Another significant and perhaps more common reason for muscle imbalances resulting in pronation/supination problems is overtraining. Yup, too much stress will have a dramatic effect on the lower leg muscles, particularly the tibialis posterior muscle that supports the main arch of the foot. There is a common connection between this muscle and the adrenal glands, which is where the major sdtress hormone cortisol is produced. So high levels of stress result in high levels of cortisol and tibialis posterior problems and then overpronation. Shin splints and plantar fasciitis are two common injuries that accompany this problem too.” 
  • The ROOT of INJURY: “You get injured from being too anaerobic and that could mean either the training is too anaerobic or there’s too much stress in your life creating anaerobic excess. And that’s really how people get injured. They get injured from basically trying to handle more than what they can. And that results in injuries along possibly with the wrong type of footwear.”


Rehab/prehab/trigger point work:

  • Things we can do at home ourselves!?
  • Exercises and manual therapy/trigger points* — identify the spots to work on
  • What about stretches? Or NO to stretching these issues? What if PF or stiff big toe is related- stretch/roll?
  • Footwear recs? (And what to avoid here)
  • Lifestyle recommendations to incorporate
  • Preventing recurrence – ongoing “maintenance”

Part 2: Vertigo/Dizziness

Article: The Dizzy Athlete

  • “Among patients who present with dizziness, vertigo accounts for approximately 50% of the cases. Furthermore, approximately 80% of these patients have peripheral vestibular dysfunction, whereas the remaining 20% have a central cause [28].”

The Right diagnosis

  • “The first step in evaluation involves defining dizziness as either presyncope, vertigo, disequilibrium, or nonspecific dizziness.”
  • What else would you look for and ask a patient? 
  • Self-diagnosing this for those who have symptoms but haven’t been to the dr (can it be confused with something else; is it safe for us to assume what it is and deal with on our own)?

What is vertigo?

  • Spinning sensation, etc.
  • Other symptoms?
  • e.g. sensory issues, overwhelm, imbalance, migraines, hearing problems, vision disturbances, confusion, etc. 

Types of vertigo


  • The 80% with peripheral – the problem can be w/ the part of the inner ear that controls balance (the vestibular labyrinth or semicircular canals) or with the vestibular nerve, which connects the inner ear to the brainstem.
  • Benign positional paroxysmal vertigo (BPPV) is 50% of peripheral causes and is due to stimulation of vestibular sense organs by canalith (define what this means)
  • Let’s talk about BPPV and inner ear, etc?

Central –

  • Way less common, e.g. tumors, MS, etc.

Reasons/causes of vertigo?

  • Any particular profile of who’s most “at risk” for this?
  • Inner ear/vestibular issues (crystals in ear and their role in proprioception/spatial orientation; explain this?)
  • Can come after bacterial or viral infections 
  • Has there been an uptick since Covid – i.e. symptom of covid/post-covid infection?
  • Neck tightness/neck alignment?
  • Why would an athlete experience a sudden onset with seemingly no warning signs, i.e. during a race?
  • Is vertigo also stress induced to some degree? (e.g. friend who said after a lot of travel and life stress was having vertigo symptoms)


  • Epley’s maneuver – what is this, is it effective and supported by functional/holistic practitioners?
  • article says: BPPV treatment involves head rotation maneuvers to displace the canalith causing symptoms.
  • Conventional/traditional treatment? most people probably go to their primary, what would they do? (ie prescription drugs/meds – of which I’m sure there are plenty of nasty side effects)
  • On the other hand, what about holistic/natural treatments, what can we do or do with a functional/natural dr?
  • Prevention / prevent recurrence? (especially if experienced previously)
  • Supplements to consider?
  • Lifestyle awareness – anything in particular? 

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