Posterior Tibial Tendonitis

Understanding Posterior Tibial Tendon Dysfunction

The posterior tibial tendon runs from the calf muscle, behind the inner ankle bone, and attaches to bones in the midfoot. It's one of the most important tendons in your lower leg, responsible for supporting the arch and helping you push off when walking.

When this tendon becomes inflamed, overstretched, or torn, it can no longer support the arch properly. This condition, called Posterior Tibial Tendon Dysfunction (PTTD), is a common cause of acquired flatfoot in adults. Without treatment, it can progress and lead to significant foot and ankle problems.

Stages of PTTD

Stage I: The tendon is inflamed but not torn. Mild pain along the inner ankle, arch is still intact.
Stage II: The tendon is partially torn or stretched. The arch begins to flatten, foot becomes more flexible.
Stage III: Significant tendon damage, flatfoot is rigid and cannot be corrected by positioning.
Stage IV: Arthritis develops in the ankle joint due to altered mechanics.

Early treatment in Stage I or II can prevent progression to more severe stages.

Symptoms

Pain and swelling along the inner ankle and arch
Pain that worsens with activity, especially walking or standing
Flattening of the arch
Foot turning outward at the ankle
Difficulty standing on tiptoes on the affected foot
Pain on the outer ankle (later stages, due to impingement)
Weakness when pushing off

Risk Factors

Age: Most common in women over 40
Obesity: Excess weight stresses the tendon
Diabetes: Affects tendon health
Hypertension: Can reduce blood flow to the tendon
Previous Injury: Ankle sprains or trauma
High-Impact Sports: Basketball, tennis, soccer
Inflammatory Conditions: Such as rheumatoid arthritis

Diagnosis

Physical Examination: Testing strength, flexibility, and observing your gait
Single-Leg Heel Rise Test: Difficulty rising on tiptoes suggests PTTD
X-rays: Assess bone alignment and arch collapse
MRI: Evaluate the extent of tendon damage
Ultrasound: May be used to visualize tendon condition

Treatment Options

Non-Surgical Treatment

Most cases of early PTTD can be managed without surgery:

Rest: Reducing activities that aggravate the tendon
Immobilization: Walking boot or short leg cast for severe inflammation
Custom Orthotics: Arch supports to reduce stress on the tendon
Bracing: Ankle-foot orthosis (AFO) for more advanced cases
Physical Therapy: Strengthening and stretching exercises
Anti-inflammatory Medications: Pain relief (note: steroid injections are generally avoided as they can weaken the tendon)
Supportive Footwear: Stable shoes with good arch support

Surgical Treatment

When conservative treatment fails or for advanced PTTD, surgery may be recommended. Surgical options depend on the stage:

Tendon Debridement: Cleaning up damaged tendon tissue (early stages)
Tendon Transfer: Reinforcing the posterior tibial tendon with another tendon
Osteotomy: Cutting and realigning bones to restore arch
Fusion: Joining bones together for severe, rigid flatfoot