What Is Posterior Tibial Tendon Dysfunction?

Posterior tibial tendon dysfunction (PTTD) is a common cause of pain along the inside of the ankle and progressive flattening of the foot. It can make everyday activities such as walking, climbing stairs, and standing for extended periods increasingly uncomfortable. Without appropriate treatment, this condition can lead to worsening foot deformity and difficulty with mobility.

The good news is that early diagnosis and treatment by a podiatrist can help relieve pain, improve foot function, and prevent the condition from progressing.

What Is Posterior Tibial Tendon Dysfunction?

The posterior tibial tendon is an important structure that runs along the inside of the ankle and attaches to bones on the inside of the foot. It plays a critical role in supporting the arch, stabilizing the foot, and helping the foot function properly during walking.

When this tendon becomes inflamed, stretched, or damaged, it may no longer provide adequate support to the arch. This condition is known as posterior tibial tendon dysfunction. It is also commonly associated with adult-acquired flatfoot deformity.

PTTD often develops gradually and may worsen over time if left untreated. Although it can affect adults of various ages, it is particularly common in middle-aged and older adults.

What Causes Posterior Tibial Tendon Dysfunction?

Several factors can contribute to the development of PTTD, including:

• Overuse and repetitive stress: Activities that place repeated strain on the tendon, such as running, walking long distances, or prolonged standing.
• Age-related changes: Tendons can lose strength and elasticity as we get older.
• Obesity: Excess body weight increases the mechanical stress placed on the tendon and the structures supporting the arch.
• Flat feet: Individuals with preexisting flatfoot deformities may place additional strain on the posterior tibial tendon.
• Injury: An ankle sprain or other trauma can damage the tendon.
• Medical conditions: Diabetes, inflammatory arthritis, and other conditions that affect tendon health may increase the risk of dysfunction.

In many cases, PTTD develops from a combination of these factors rather than a single identifiable injury.

What Are the Symptoms of Posterior Tibial Tendon Dysfunction?

Symptoms typically begin along the inside of the ankle and may gradually extend into the arch of the foot.

Common signs and symptoms include:

• Pain or tenderness along the inside of the ankle.
• Swelling around the posterior tibial tendon.
• Pain that worsens with walking, running, or prolonged standing.
• Weakness or fatigue in the affected foot.
• Flattening of the arch.
• The heel turning outward and the foot rolling inward.
• Difficulty standing on the toes of the affected foot.
• Pain along the outside of the ankle as the foot deformity progresses.

As the condition advances, patients may notice that their foot appears flatter than it used to or that more of the outside of the foot becomes visible when viewed from behind.

Persistent inner ankle pain, swelling, or a newly developing flatfoot should be evaluated by a podiatrist. Early treatment may help prevent further tendon damage and structural changes.

How Is Posterior Tibial Tendon Dysfunction Diagnosed?

A podiatrist can evaluate the posterior tibial tendon and determine whether it is functioning properly. An examination typically includes:

• Medical history: Reviewing symptoms, activity levels, previous injuries, and relevant medical conditions.
• Physical examination: Checking for tenderness, swelling, tendon weakness, and changes in foot alignment.
• Gait evaluation: Observing how the foot and ankle move during walking.
• Heel-rise test: Assessing the ability to rise onto the toes of the affected foot, which helps evaluate posterior tibial tendon function.
• Imaging studies: Weight-bearing X-rays may help identify changes in foot alignment and arch height. Ultrasound or MRI may be recommended to evaluate tendon inflammation, degeneration, or tearing.

An accurate diagnosis allows the podiatrist to determine the severity of the condition and develop an appropriate treatment plan.

How Can a Podiatrist Treat Posterior Tibial Tendon Dysfunction?

Treatment depends on the severity of the tendon damage, the degree of foot deformity, and the patient’s symptoms. In many cases, conservative treatment can provide meaningful relief, particularly when the condition is identified early.

1. Custom Orthotics and Arch Supports

Custom orthotics are frequently used to help manage PTTD. These devices are designed to support the arch, improve foot alignment, and reduce excessive strain on the posterior tibial tendon.

Depending on the severity of the condition, a podiatrist may recommend prefabricated arch supports or custom-molded orthotics. More advanced deformities may require a more supportive device.

Orthotics can help improve comfort and function, although they do not guarantee that the deformity will stop progressing.

2. Bracing and Immobilization

When pain and inflammation are more significant, a walking boot may be recommended to temporarily immobilize the foot and ankle. This reduces stress on the tendon and allows irritated tissues to recover.

An ankle-foot orthosis (AFO) or other supportive brace may also be prescribed to stabilize the foot and ankle during walking.

Once symptoms improve, the podiatrist can determine when it is appropriate to transition to supportive footwear or orthotics.

3. Activity Modification

Reducing activities that aggravate the tendon is an important part of treatment.

A podiatrist may recommend temporarily limiting running, jumping, prolonged standing, or long-distance walking. Low-impact activities may be appropriate alternatives, depending on the patient’s symptoms.

Gradually returning to normal activities helps avoid placing excessive stress on the tendon before it has recovered.

4. Physical Therapy and Strengthening Exercises

Physical therapy can help improve strength, flexibility, balance, and overall foot and ankle function.

A treatment program may include:

• Strengthening exercises for the posterior tibial tendon and surrounding muscles.
• Calf stretching to address tightness that may contribute to abnormal foot mechanics.
• Balance and stability exercises.
• Gait training to improve walking mechanics.
• Progressive strengthening to support a safe return to normal activities.

Exercises should be tailored to the patient’s condition. Performing strenuous exercises too early may aggravate an already damaged tendon.

5. Anti-Inflammatory Treatment and Pain Management

Depending on the patient’s medical history and individual needs, a podiatrist may recommend ice, temporary activity modification, or appropriate anti-inflammatory medication to help manage pain.

Medication should be selected with consideration for other medical conditions and potential interactions. It is important to remember that reducing pain alone does not correct the underlying mechanical problem.

6. Surgical Treatment

When conservative treatments fail to provide adequate relief, or when significant deformity develops, surgery may be considered.

The appropriate procedure depends on the extent of tendon damage, the flexibility of the foot, and whether arthritis is present.

Surgical options may include:

• Tendon repair or reconstruction: Repairing damaged tendon tissue or reconstructing its function.
• Tendon transfer: Using another tendon, commonly the flexor digitorum longus tendon, to help restore support to the arch.
• Calcaneal osteotomy: Realigning the heel bone to improve foot mechanics.
• Ligament reconstruction: Addressing damaged ligaments that contribute to arch collapse.
• Joint fusion: Fusing selected joints in cases of severe, rigid deformity or significant arthritis.

Some patients require a combination of procedures to restore alignment and improve function. Recovery generally involves a period of immobilization followed by rehabilitation.

A podiatrist can discuss the potential benefits, risks, and expected recovery associated with surgery and determine whether referral to a foot and ankle surgeon is appropriate.

Can Posterior Tibial Tendon Dysfunction Be Prevented?

Although PTTD cannot always be prevented, several measures may help reduce excessive stress on the tendon and support overall foot health.

• Wear supportive shoes that provide adequate arch support.
• Avoid sudden increases in exercise intensity or walking distance.
• Maintain a healthy body weight to reduce stress on the feet.
• Address foot and ankle injuries promptly.
• Follow a strengthening and stretching program appropriate for your needs.
• Seek evaluation for persistent pain along the inside of the ankle or arch.

People with flat feet or other biomechanical abnormalities may benefit from a podiatric evaluation to determine whether additional support is appropriate.

When Should You See a Podiatrist?

You should schedule an appointment with a podiatrist if you experience persistent pain or swelling along the inside of your ankle, difficulty rising onto your toes, or a noticeable change in the shape of your arch.

Early evaluation is particularly important if one foot is becoming flatter than the other or if pain is interfering with your ability to walk comfortably.

Seek prompt medical attention if you develop sudden severe pain, cannot bear weight, or experience significant redness, warmth, or swelling.

Protect Your Feet With Expert Podiatric Care

Posterior tibial tendon dysfunction can affect much more than the tendon itself. As the tendon weakens, the arch may collapse, the heel may shift out of alignment, and additional structures in the foot and ankle can become stressed.

Early intervention is key to managing symptoms and preserving foot function. Through a comprehensive examination, custom orthotics, bracing, activity modification, physical therapy, and surgical treatment when necessary, a podiatrist can help patients manage PTTD and maintain an active lifestyle.

If you are experiencing inner ankle pain, arch discomfort, or changes in the shape of your foot, don’t ignore the symptoms. Schedule an appointment with your podiatrist to determine the cause of your discomfort and explore the treatment options available.

At Hollowbrook Foot Specialist, P.C., we understand how important healthy feet are to your mobility and quality of life. Our goal is to help you stay active, comfortable, and moving forward.

By Dr. Yavor Geshev, DPM, FACPM, DABFAS, DABPM