Posterior Tibial Tendon Dysfunction (PTTD)

Posterior tibial tendon dysfunction / syndrome

Posterior tibial tendon dysfunction or PTTD is a dysfunction of the posterior tibialis muscle, resulting in a fallen arch, or flat feet. The tibialis posterior tendon supports the arch of the foot so if it becomes impaired, or is not working properly the arch of the foot collapses.


Symptoms of posterior tibial tendon dysfunction

Symptoms of posterior tibial tendon dysfunction may vary depending on the extent of the condition and how far it has progressed.

  • In the early stages, as the arch flattens, there is likely to be pain on the inside of the ankle and under the foot.
  • Symptoms follow the path of the tendon.
  • There may also be redness and swelling.
  • As the condition progresses the arch will fall more, rotate outwards and the ankle will roll inwards.
  • Eventually, as the foot collapses flat, pain may be more likely on the outside of the foot.
  • Arthritis may also develop in the foot.
PTTD flat foot

The patient may also have a history of injury to the tibialis posterior muscle. Pain in the foot may be a symptom although this may also be associated with a secondary condition, such as a tendinopathy or a muscle or tendon tear in the foot.

What is Posterior tibial tendon dysfunction?

Tibialis posterior tendinopathy

There is often confusion over the name of this condition. It is referred to by any of the following names:

  • Posterior tibial tendon dysfunction (PTTD)
  • Posterior tibial tendon syndrome
  • Tibialis posterior syndrome
  • Posterior tibial insufficiency
  • Adult acquired flatfoot

All of these conditions are the same and so we will interchange them in this article.

The tibialis posterior muscle originates from behind the shin bone or tibia and runs into a tendon that passes behind the bony bit on the inside of the ankle called the medial malleolus. The function of tibialis posterior is to plantarflex the ankle (point the foot down) and also to invert the foot or turn the sole of the foot inwards.

What causes PTTD?

A common cause of posterior tibial tendon dysfunction is overuse. Particularly sports like long-distance road running and walking can cause repetitive strain of the muscle which gradually weakens. If a muscle is not allowed to recover after hard training then it will eventually be injured.

There is sometimes confusion between this condition and that of tibialis posterior tendinopathy and the terms are often used interchangeably. The true meanings of these conditions are slightly different, however.

  • Tibialis posterior tendinopathy is a degenerative, painful injury to the tendon of the tibialis posterior.
  • Posterior tibial syndrome is slightly different and is a dysfunction of the muscle, resulting in a fallen arch, or flat feet.

Because the Tibialis Posterior muscle is responsible for inverting the foot, if it is not working correctly, then this causes the arch of the foot to flatten when we stand, walk or run. The fallen arch or flat feet can then cause further injury problems such as plantar fasciitis.

Posterior tibial tendon dysfunction treatment

Posterior tibial tendon dysfunction is a progressive condition. This means it will become gradually worse, therefore, early diagnosis and treatment is important. If it is caught early enough, then it is likely conservative treatment (without surgery) should be sufficient.

Treatment of any associated conditions such as tibialis posterior tendinopathy is also important. If the injury is painful or acute, then rest and application of ice or cold therapy can reduce pain, inflammation, and swelling.

Correcting biomechanical dysfunction

  • A professional therapist such as a Podiatrist can do a full assessment including gait analysis to identify problems such as overpronation.
  • They may prescribe arch support insoles or orthotic insoles to help correct biomechanical problems of the foot.

PTTD braces

  • Specialist PTTD braces or ankle supports can help take the strain off the tibialis posterior muscle whilst it is healing.
  • They can help prevent PTTD progressing, or help with recovery after surgery.

Sports massage

  • Deep tissue massage to the muscles at the back of the lower, particularly the tibialis posterior muscle can help relax the muscle and remove and tight knots, lumps, and bumps.
  • These are areas where the muscle has tightened up or gone into spasm, and therefore unable to work optimally.
  • Getting a regular sports massage can help identify potential muscle injuries before they become full-blown injuries.

Exercises for PTTD

Exercises to strengthen the tibialis posterior muscle are an important part of treatment and rehabilitation. This is done in a similar way as strengthening the calf muscles with plantar flexion type exercises but with inversion of the ankle as well.

Begin with strengthening exercises using a resistance band and as pain allows and strength improves move onto calf raise type exercises.

Tibialis posterior muscle exercise

The Tibialis Posterior muscle works to both invert and plantarflex the foot ankle. These movements can be recreated using an elastic rehab band for resistance.

  • The resistance band is looped around the midfoot and pulled out to the side as shown.
  • The foot is then moved into inversion by turning the sole inwards and plantarflexing (pointing the toes down) at the same time.
  • Initially, aim for 3 sets of 10 repetitions increasing to 3 sets of 20 twice a day.
  • If the exercise then becomes too easy the strength of the resistance band can be increased.

Inversion using a step

This exercise is a more advanced tibialis posterior muscle strengthening exercise, using bodyweight as resistance.

  • Stand (in bare feet) long ways on a step with the inside of the foot halfway over the step.
  • Gently roll the foot inwards (evert or pronate) so the inside of the foot rolls in and downwards.
  • Return to the starting position by inverting it so it is flat on the step again.
  • Aim for 3 sets of 10 repetitions and gradually build up to 3 sets of 30 repetitions.

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