Is posterior tibial tendon dysfunction causing my flat foot?

I work in a physical therapy clinic that sees a large number of complicated foot and ankle injuries.  The owner of our clinic is known as a foot and ankle, as well as, an orthotic expert.  Because of this, we see a lot of different conditions which include posterior tibial tendon dysfunction.  This is a very senious condition that can lead to permanent deformity and pain in the foot.  The good news is that it can be treated successfully if caught early on.  However, it is harder to treat the longer it is allowed to progress.  Read on to learn more about this condition.  Let’s start with anatomy!

What is the tibialis posterior?

The tibialis posterior is a muscle that is located in the back of the lower leg.  It is located underneath the calf muscle.  It attaches to the back of the lower leg bones (fibula and tibia).  It then travels down the leg and transitions to tendon above the ankle.  The tibialis posterior tendon moves behind the medial maleolus (the big bump on the inside of your ankle) to the arch of the foot where it attaches to several bones on the inside bottom area of the foot.  This muscle performs inversion (rolling the ankle and arch inward) and plantarflexion (pointing the foot down).  The tibialis posterior plays a vital role in supporting the main arch of the foot and improving the activation of the calf muscle.

What is posterior tibial tendon dysfunction?

Posterior tibial tendon dysfunction (PTTD) is a progressive condition that causes pain and eventual collapse of the arch of the foot.  It typically occurs in only one foot.  PTTD is the most common cause of adult-acquired flat foot deformity.  It begins with inflammation of the tendon of the tibialis posterior.  Without treatment the tendon degenerates and will eventually rupture causing the arch of the foot to collapse.  This will cause tension and stress on the ligaments.  Ligaments are tough pieces of tissue that support joints.  The stress on the ligaments will cause arthritis in the joints of the foot and can eventually progress to the ankle.  This will lead to a permanent deformity in the foot and severe difficulty and pain with movement.  The progression of PTTD is broken down into stages.

• Stage 1
  • The tendon of the tibialis posterior is inflamed
  • Arch is still intact
  • Able to stand on tip toes on affected foot
  • Pain in the arch and inside of the foot and ankle
• Stage 2
  • Tendon is painful, stretched out, and may have ruptured
  • Arch is collapsed but correctable with orthotics
    • This is called a flexible flat foot deformity
  • Unable to stand on tip toes on affected foot
• Stage 3
  • Arch is no longer correctable with orthotics
    • This is called a rigid flat foot deformity
  • Arthritis and degenerative changes in the joints of the foot
  • Pain in the sinus tarsi (outside of the foot)
• Stage 4
  • Arthritis is now present in the foot and ankle
  • Pain and difficulty with walking
  • Stiffness and pain on inside and outside of foot and ankle

What are the symptoms of PTTD?

There are several symptoms associated with PTTD.  These include:

• Pain and swelling in the inside area of the foot and ankle
• Pain increases with activity
• Pain and difficulty standing on tip toes of affected foot
• Difficulty going up and down steps and walking on grass
• Poor balance
• Feeling of walking on the inside of the foot and ankle
• Pain on the outside of the foot and ankle with later stages of PTTD

What causes PTTD?

PTTD is an overuse injury.  Repetitive loading on the posterior tibialis tendon from prolonged standing, walking, and/or running can cause microtrauma and irritation to the tendon.  Without treatment, this can lead to PTTD.  The prevalence of PTTD is up to 10% of middle age women.

What are the risk factors of PTTD?

There are several risk factors associated with PTTD.  These include:

• Middle age women
• Young athletes
• Hypertension
• Obesity
• Diabetes
• Hypermobility of the feet
• Flat feet
• Steroid therapy
• Previous trauma
• Overuse
• Psoriatic arthritis
• Rheumatoid arthritis

Special considerations

PTTD is a potentially debilitating condition that can make walking and mobility very difficult and painful.  Stage 3 and stage 4 often warrant surgical treatment to correct the fixed deformity.  The outcomes of these surgeries are mixed and patients can have residual symptoms.  However the outcomes of conservative treatment with stage 1 and stage 2 are very good with return of full strength of the foot and ankle after 4 months.  It is very important to begin treatment as soon as you suspect a problem in the foot.

Who should I see?

• Physical therapy – PT plays a crucial role in conservative treatment, as well as, after surgery.  Physical therapy can help decrease the pain and swelling with techniques including manual therapy and dry needling.  PT can evaluate and address abnormal joint mobility, muscle weakness, and flexibility.  Some PT’s, or an orthotist, can measure your foot for custom made orthotics.   Orthotics are needed to put your foot in the proper position while standing, walking, or running.  Your PT will also assess your gait, shoe wear, training schedule, and technique to prevent the problem from happening again.
• Orthopedic physician – An orthopedist that specializes in the foot and ankle will be necessary if your PTTD is a higher grade or the condition is not responding to physical therapy.  Depending on the stage, you may be placed in a walking boot for several weeks to allow the posterior tibialis tendon to rest and heal.  Your orthopedist can order imagining to determine the extent of the damage and arthritis in the foot and ankle.

What can I do at home?

• Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to treat PTTD.  Basically stay away from the activities that are causing pain.  This gives the tendon and foot time to rest and heal.  If you keep doing what is causing the injury, it is not going to get better.  Swimming and biking would be good alternative activities that do not put much stress through the ankle and foot.
• Ice – Ice can help decrease the pain and swelling at the tendon.  Ice the painful area for 15 to 20 minutes at a time.  I would recommend using an ice pack several times per day if the pain is constant or preventing you from participating in an activity.  Ice immediately after activity.

• Stretching – Stretching the calf muscles can help improve the motion at the ankle.  This includes stretching the gastrocnemius and the soleus.  See the video below.
  • Video calf stretching

• Strengthening – It is important to strengthen the tibial posterior, calf muscles, and the muscles of the knee, and hip.  All of these muscles work together to stabilize the ankle and foot while running, cutting, and jumping.  Using loop resistance bands , resistance bands and ankle weights can increase strength and difficulty of the exercises.  See the videos below.

• See the videos below.

• Balance – Working on balance is important in strengthening the foot and ankle but also improving proprioception.Improving proprioception will help improve the overall stability of the ankle.  See the video below.

• Shoe wear and orthotics – Having flat feet is a huge risk factor for PTTD because it puts an increase pull on the tendon.  Changing shoe wear or using orthotics to place the foot in a neutral position will help decrease the stress on the tendon.  An overpronation shoe might help or you might need orthotics.  Most running stores will evaluate your foot type and suggest appropriate shoe wear and/or orthotics.  Your PT can also evaluate your foot and help determine appropriate shoe wear.
• Bracing – Using a stability brace or ankle sleeve can be helpful to decrease pain and improve stabilization at the ankle.  This is especially useful for those that have chronic ankle instability or who have suffered from previous ankle injuries.
• Compression socks – Compression socks can help decrease swelling and pain by improving circulation while standing, running, and walking.

In review

• The tibialis posterior is a muscle that is located in the back of the lower leg.
• This muscle performs inversion (rolling the ankle and arch inward) and plantarflexion (pointing the foot down).
  • The tibialis posterior also plays a vital role in supporting the main arch of the foot and improving the activation of the calf muscle.
• Posterior tibial tendon dysfunction (PTTD) is a progressive condition that causes pain and eventual collapse of the arch of the foot.
  • It typically occurs in only one foot.
  • PTTD is the most common cause of adult-acquired flat foot deformity.
• Symptoms include pain on the inside ankle and foot when standing, walking, and running.
• Risk factors include flat feet, hypertension, diabetes, and being a middle-age female.
• Physical therapy is a vital component of conservative treatment.
• An orthopedist who specializes in the foot and ankle will also be necessary.
• There are several things you can do at home.
  • Relative rest
  • Ice
  • Stretching
  • Strengthening
  • Balance
  • Shoe wear
  • Bracing
  • Compression socks

As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.

Additional resources

https://www.physio-pedia.com/Posterior_Tibial_Tendon_Dysfunction

https://www.ncbi.nlm.nih.gov/books/NBK542160/

https://www.choosept.com/guide/physical-therapy-guide-posterior-tibial-tendon-dysfunction-acquired-flat-foot-adults#:~:text=Your%20physical%20therapist%20may%20have,and%20ankle%20to%20restore%20flexibility.