Posterior Tibial Tendon Dysfunction Symptoms and Treatment

What is Posterior Tibial Tendon Dysfunction?

Posterior tibial tendon dysfunction (PTTD) is often referred to as adult acquired flat foot.  The posterior tibial tendon serves a vital function in the biomechanics of the foot and pathology of this tendon can lead to debilitating pain and possibly arthritis of foot and ankle.

Posterior tibial tendon dysfunction also known as adult acquired flat foot is a condition where the tendon has gone through changes, which makes it unable to support the arch of the foot, resulting in flattening of the foot.  Posterior tibial tendon dysfunction is the most common cause of flat feet in adults, hence “adult acquired flatfeet”. This condition can happen in one foot or both feet and in general it tends to be progressive in nature, especially if it is not treated early. Posterior tibial tendon dysfunction is classified into four stages which helps with treatment of this condition.


What are Signs and symptoms of Posterior Tibial Tendon Dysfunction:

  • Loss of arch height (flat foot)
  • Swelling to medial ankle (inside of the ankle along the course of the tendon)
  • Inability to rise on the toes (single heel raise)
  • Pain to medial ankle with weight bearing
  • Lateral foot pain (sinus tarsi pain)
  • Inward rolling of the ankle
  • Toes starting to point towards the outside


What Causes of Posterior Tibial Tendon Dysfunction:

  • Overuse of the tendon
  • Not wearing supportive shoes
  • Foot sprain / trauma
  • Engaging in activities that involves the tendon: running, walking, hiking and climbing


Imaging Studies:

  • MRI may be a valuable tool in evaluating the integrity of the posterior tibial tendon
  • X-ray is utilized to assess for arthritis and alignment of the joint


Classification of Posterior Tibial Tendon Dysfunction

Posterior tibial tendon dysfunction (adult acquired flat foot deformity) has been classified into four stages:

Stage I Posterior Tibial Tendon Dysfunction:

The first stage presents with pain and inflammation of posterior tibial tendon. At this stage, posterior tibial tendon is still functional.

Stage II Posterior Tibial Tendon Dysfunction:

Stage two is characterized by alignment changes of the foot, mainly observed while patient is standing. The deformity is supple meaning the foot is freely movable and a “normal” position can be restored on exam.  Single heel raise is performed to test the tendon and at stage two of this condition is characterized with the inability to perform a single-leg heel rise.

**Majority of patients with posterior tibial tendon dysfunction are at stage 2 by the time they seek treatment.

Stage III Posterior Tibial Tendon Dysfunction:

The third stage is characterized as the dysfunction of the posterior tibial tendon an a flatfoot deformity that is stiff because of arthritis of the hindfoot joint.

Stage IV Posterior Tibial Tendon Dysfunction:

The stage four is a flatfoot deformity  with involvement of the ankle joint. This occurs because the major supporting ligaments on the inside of the ankle, fails to provide support.


What are Some Conservative Treatments for Posterior tibial tendon Dysfunction:

PTTD Is progressive and early evaluation and treatment of this condition is strongly advised. If treated early enough, your symptoms may resolve without the need for possible surgical intervention.

In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle, and increasing limitations on walking, running, or other activities.

In many cases of PTTD, treatment can begin with non-surgical approaches that may include:

  • Immobilization. Sometimes a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or you may need to completely avoid all weight-bearing for a while
  • Orthotic devices or bracing. Custom foot orthotics or Ankle Foot Orthosis (AFO) to support the arch and decrease tension on the tendon.
  • Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization.
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
  • Shoe modifications. Your foot and ankle surgeon may advise you to change your shoes to something more supportive. (Please refer to our comprehensive shoe list to find the appropriate shoe based on you foot type)


When is Surgery Needed for Posterior Tibial Tendon Dysfunction?

Advanced progression or failed conservative treatment options of PTTD may require surgical intervention to address your pain and foot deformity.