What Is Posterior Tibial Tendon Dysfunction?

Medically Reviewed by Mahammad Juber, MD on October 06, 2022
6 min read

Posterior tibial tendon dysfunction is a painful condition that affects your foot and ankle. This article will look at the causes and symptoms of this condition. It will also detail the methods used to diagnose and treat the condition, including surgical and nonsurgical treatment options.

The tendons in your body connect your bones to your muscles and extend along the joints to help you carry out bending movements. One such tendon is the posterior tibial tendon. This tendon originates in the calf and extends down to the inner part of the ankle, where it is connected to the bone in the middle of your foot. 

The primary responsibility of the tendon is to support the arch of the inside of the foot. This helps you step on your toes as you walk. 

Posterior tibial tendon dysfunction (PTTD) is a condition that leads to inflammation or a tear in this tendon. When the tendon is damaged, it can no longer support the arch. This condition is also known as posterior tibial tendonitis or posterior tibial tendon insufficiency, and it can cause acute pain in the foot and ankle. An inflamed posterior tibial tendon can also impede specific foot and ankle movements, such as standing, walking, running, and standing on your toes.

The inability of the tendon to support the arch of the foot leads to a condition known as a “flat foot.” The American Academy of Orthopaedic Surgeons defines a flat foot as a condition in which the foot’s arch lies flat on the inner side and the foot points outwards. PTTD is one of the most widely reported causes of acquired flatfoot in adults.

PTTD typically occurs in four stages.

  • Stage 1. In the first stage, the tendon is stretched but not damaged and causes pain in the instep, especially when walking. Sometimes, the tendon may swell, but you’ll still be able to stand on your toes on a single leg.
  • Stage 2. In this stage, the tendon is torn to some extent, and the pain and swelling become more severe. The flat foot becomes more prominent in this stage, and you’ll be unable to stand on your toes on one leg.
  • Stage 3. Your foot will be considerably deformed, and you'll lose flexibility in your heel.
  • Stage 4. This is the most severe stage of posterior tibial tendon dysfunction. In this stage, the ankle and the foot both become deformed, and you may experience arthritis in the ankle.

A major injury caused by a fall could lead to a tear or inflammation in the posterior tibial tendon. The tendon can also rupture due to extensive use. This is usually the case in athletes participating in high-impact sports or activities like tennis, soccer, basketball, or long-distance running. If the tendon tears or is inflamed, the arch will slowly collapse.

Other risk factors include:

  • Obesity
  • Hypertension
  • Diabetes
  • Steroid use
  • Previous surgery in the area
  • Conditions like Reiter’s syndrome that cause inflammation
  • Too much force placed on the foot (for instance, when running on an inclined road)
  • Tissue injuries in the foot or ankle
  • Existing joint conditions

Additionally, as you grow older, the tendon becomes weak or can break down completely. That’s why PTTD is more common in women and people over 40. Instances of younger people reporting this condition are rare but can still occur due to an injury. 

Some of the common symptoms of PTTD are:

  • Swelling on the inner or outer part of your ankle and foot
  • Collapse of the arch
  • Inability to stand on the toes
  • Difficulty walking on uneven surfaces
  • Difficulty going up and down stairs
  • Shoes on one foot wearing out differently than those on the other
  • Pain when you stand on your toes
  • Pain and swelling along the inside of your foot and in the ankle (worse when you do any activity like standing or walking) 
  • Inward rolling of the ankle
  • Pain on the outside of the ankle (caused by the collapsing of the foot, which puts added pressure on the outside ankle bone)
  • Foot and toes beginning to turn outward

Your doctor will base the diagnosis on a physical examination and medical history. A foot and ankle surgeon may inspect the area. These specialists will ask you to perform specific movements to check whether your heel and ankle are functioning properly.

One such test is the single-limb heel raise. In this, you’ll need to stand with your back to the wall, raise your healthy foot in the air and then stand on the toes of the affected leg. If your heel rolls inward, that’s a sign that your heel is okay. If it doesn’t, that’s an indication of posterior tibial tendon dysfunction. The doctor may also notice whether you can complete eight to 10 raises without discomfort. Even in the second stage of PTTD, you’ll be unable to complete even one heel raise.

Another test to diagnose the condition is the “too many toes” sign. Here, the doctor observes your foot from behind to identify whether the foot’s arch is flat or if the toes point outward. When you look at a normal foot from behind, you can usually see only the fifth toe (called the pinky toe) and a portion of the fourth toe (called the ring toe) on the outside. If you have PTTD, though, your doctor may be able to see more toes projecting out.

Your doctor may perform additional tests such as an x-ray, MRI, ultrasound, or CT scan to help with the diagnosis. These scans can identify joint and tendon degeneration and locate possible fluid build-up in the tissues surrounding the tendon, which are all signs of early PTTD.

Your doctor will decide on the best treatment depending on the severity of your symptoms. If your doctor detects damage to the tendon in the early stages of PTTD, that allows them to treat the condition non-surgically. This usually includes:

  • Immobilization. Your leg will be placed in a cast or a walking boot for roughly two months to reduce inflammation and aid healing.
  • Braces. A custom-made ankle brace may support the ankle and the foot in the initial stages of PTTD. This reduces the strain placed on the tendon and could help avoid surgery in some cases.
  • Medicines. Your doctor may prescribe non-steroidal anti-inflammatory drugs like aspirin and ibuprofen to manage the pain and inflammation. Steroids (cortisone) may also be prescribed sometimes. Make sure that your doctor is aware of your medical history and any other medications that might interact with these drugs. 
  • Physical therapy. Therapy and adequate rest help strengthen the muscles and tendons around the affected area.
  • Orthotics. These are medical devices prescribed by your doctor. They are typically shoe inserts that support your arch and tendon. Sometimes, your doctor may prescribe a cast or an orthotic brace customized for your foot.

If nonsurgical treatments don’t reduce your pain after six months, you may need to explore surgical methods to treat the condition. A specialist will determine the best treatment depending on the location of the pain and the extent of the tendon damage. 

Some surgical options may include:

  • Tenosynovectomy. This treatment involves cleaning the tendon by removing any inflamed tissue around it. Surgeons take this option in mild PTTD cases.
  • Osteotomy. This surgery realigns your heel bone. Sometimes, this may involve removing a part of the bone.
  • Tendon transfer. This surgery removes healthy fibers from another tendon to replace those in the affected posterior tibial tendon.
  • Arthrodesis. This is the process of fusing two or more bones to prevent movement of the affected joint. It helps prevent the condition from worsening.

PTTD is a painful condition that generally takes a few months to heal. As your foot heals, you’ll have to change your daily routine and take precautions before you ease back into your normal activities.