Posterior Tibial Tendon Dysfunction

posterior tibial tendon dysfunction


Posterior tibial tendon dysfunction (PTTD) describes the damage to a tendon called the posterior tibial tendon, which travels down the side of our lower leg, crosses the inside of our ankle, and attaches to the underside of the foot. The posterior tibial tendon plays a very important role in the structure of our foot and arch, as well as helping support healthy and pain-free movement every time we take a step.




Posterior Tibial Tendon Dysfunction Causes


PTTD is an overuse condition, meaning that it is caused by repetitively overloading and straining the tendon past what it can safely handle, resulting in damage, inflammation and ultimately the inability of the tendon to carry out its role. Contributing factors to the development of PTTD can include:


  • Having a naturally flatter foot type
  • Biomechanical or alignment issues in the feet
  • Wearing flat, unsupportive footwear which overloads the posterior tibial tendon
  • Walking or working on hard surfaces, which increases the stress on the feet
  • Regular physical activity such as running, long-distance walking, hiking and climbing stairs
  • Increased weight, which increases the demand on the tendon
  • Conditions such as diabetes and hypertension
  • Previous injury to the ankle or the tendon


Symptoms Of PTTD


PTTD often affects one foot, though can develop in both. Without effective management, the symptoms of PTTD tend to progressively worsen to result in a partial or even complete tear of the tendon. It can also lead to a complete arch collapse, with PTTD being the most common cause of Adult Acquired Flatfoot.



PTTD can be characterised into four stages of progression: 


Stage one

Stage one of PTTD is often missed because it comes with little or no symptoms. Medical imaging will also not reveal anything abnormal. However, you may have some mild inflammation of the tissue surrounding the tendon, which may be your first sign.


At stage one, you can also still perform a single heel raise test. To perform the test, hold onto the wall or a chair, beginning in a standing position and lift the unaffected foot up off the ground. Now, attempt to lift onto the toes of the affected foot. At stage one, you will still be able to do this. 


Stage two

At stage two of PTTD, there is a torn tendon that affects regular function. You will notice that your foot has become flatter. A radiological investigation will reveal an arch collapse deformity. During physical examination, you will no longer be able to complete the single-leg heel raise test.


Stage three

This stage is characterised by significant degeneration and deformation at the ankle, which is rigid, meaning it cannot be corrected by hand. Physical examination at this stage will reveal severe sinus tarsi pain while a radiological exam will reveal subtalar arthritis and arch collapse deformity. You cannot complete a single heel raise test.


Stage four

By stage four, the deltoid ligament is compromised and there are degenerative changes at the ankle joint. The flatfoot deformity is worse and rigid throughout the foot. A physical examination will reveal ankle pain and severe sinus tarsi pain. As for radiography, it will show an arch collapse deformity, subtalar arthritis, and a talar tilt.



Symptoms of PTTD in the early stages can include:


  • Pain and tenderness on the inside of the ankle
  • Swelling
  • Redness and warmth
  • Flattening of the arch
  • Pain exacerbated by activity
  • Pain on palpation of the inside of the ankle behind the bony bump (medial malleolus)


How is PTTD treated?


Early intervention is recommended to stop the progression of painful symptoms and further damage to the posterior tibial tendon. The PRICE principles (protection, rest, ice, compression and elevation) can be used initially to help reduce painful symptoms. Treatment then needs to focus on addressing the cause of the PTTD and may include:


  • Custom foot orthotics to support the posterior tibial tendon, support the arch, and correct any other biomechanical or alignment issues
  • Supportive footwear that stabilises the foot at the ankle and limits the foot rolling in and hence placing more strain on the posterior tibial tendon
  • Stretching and strengthening to address tight or weak supporting muscles
  • Strapping the ankle to reduce strain on the tendon
  • Activity modification to reduce the strain on the posterior tibial tendon while it heals
  • Where injury to the tendon is severe, such as a significant tear, a brace or cast may be required to completely off-load the tendon


If the PTTD is severe, a referral to explore surgical options may be necessary.



What is the recovery time for PTTD?

On average, we see patients with posterior tibial tendon dysfunction recover in between 6-8 weeks. This varies depending on the severity of the injury, how well you maintain all the treatment modalities such as consistently wearing your orthotics, and whether any other structures were damaged alongside your tendon.


Does ACC cover treating PTTD?

If your injury was sustained as a result of an accident, then you may be eligible for ACC. We will fill out your paperwork and submit a claim, it is up to ACC whether or not you are covered.


Can I treat PTTD at home?

You can help manage the symptoms of PTTD at home by applying ice to the painful, swollen area for 20 minutes at a time, 3-4 times per day. This will help manage your pain until you are able to see a podiatrist. As you engage your posterior tibial tendon every time you take a step, it is often difficult to recover from PTTD without professional care.


How can I prevent PTTD in the future?

Your podiatrist will discuss the best ways to help prevent the recurrence of PTTD in the future based on your unique foot type, foot and leg biomechanics, and your circumstances. This may include a combination of calf stretching and other strengthening exercises for the posterior tibial tendon, wearing your foot orthotics when you’re active and on your feet, wearing supporting footwear, and modifying the way you perform certain activities to limit tendon overuse.


Which shoes should I be wearing for PTTD?

We like a sports shoe (walking/running/cross trainer) with a firm heel counter and good support around the ankle to limit unwanted side-to-side movement. The deeper the heel cup the better. Having in-built arch support can also help support the posterior tibial tendon. At your appointment, our podiatrists can also recommend the best shoe for your foot type and with regard to your symptoms. With this said, we always recommend a custom foot orthotic in your shoes for an optimal result.