Posterior Tibial Tendon Dysfunction

The tibialis posterior muscle is the main dynamic stabilizer of the foot's medial longitudinal arch, and it also inverts, adducts, and plantarflexes the foot. Its dysfunction leads to a flattening of the longitudinal arch, contributing to pain and functional impairment in PTTD.

PTTD causes

Tibialis posterior tendon dysfunction (PTTD) is a complex condition with a multifactorial etiology, meaning there is no single universally accepted cause. It is generally understood as a degenerative condition characterized by pathological changes in the posterior tibialis tendon, which often leads to the collapse of the medial longitudinal arch, a valgus deformity of the hindfoot, and forefoot abduction. This process involves a weakness of the tibialis posterior muscle and its tendon. Here are the key factors identified as contributing to the development of PTTD:

Mechanical Stress and Overuse:

• Excessive stress on the posterior tibial tendon can lead to tendinopathy.
• It is an overuse injury, particularly associated with sports-related activities where the repetitions and speed of loading are significantly increased.
• Mechanical factors include tendinopathy impairment, functional impairment, abnormality of the talocrural joint, soft tissue tension/traction, pre-existing flatfoot, and excessive functional pronation.
• The anatomic course of the tibialis posterior tendon, which makes a severe turn around the medial malleolus, may also contribute to the condition.

Foot Deformity and Biomechanics:

• PTTD is most often accompanied by pes planovalgus foot deformity (flatfoot). There is a consensus that PTTD and pes planovalgus are closely connected. However, it is unclear whether the muscle-tendon dysfunction is a result of the foot deformity or if it is the cause of the foot deformation.
• Patients often present with a pronated foot posture and an increase in pronation in the talo-navicular joint region during weight-bearing activities like hopping or jumping.
• Biomechanical studies indicate that PTTD is associated with increased forefoot abduction and rearfoot eversion during the gait cycle.
• Weak hip and ankle performance and poor balance are also associated findings.

Demographic and Systemic Factors:

• Age and Gender: PTTD is commonly seen in middle-aged women, particularly those over 40 years old. Most studies on PTTD recruit patients with mean or median ages greater than 40, and predominantly or entirely female participants.
• Body Mass Index (BMI): Patients with PTTD tend to have a higher BMI, often categorized as overweight (BMI > 25 kg/m$^2$). Abnormal loading of the arch due to obesity is considered a factor.
• Inflammatory Disorders: Conditions such as rheumatoid arthritis and other inflammatory diseases are identified as causes.
• Trauma: A history of acute traumatic injury can be reported.
• Metabolic Conditions: Factors like increased cholesterol, menopause, diabetes, and hypertension are linked to PTTD.
• Other Risk Factors: Infection, the aging process, pregnancy, microvascular or macrovascular impairment, smoking, localized steroid exposure, long-term use of medication, and previous rearfoot trauma/surgery are also noted.
• Leg Length Discrepancy (LLD): Studies suggest that a higher prevalence of LLD and greater absolute/relative LLD values are found in PTTD patients, indicating LLD may be a risk factor.

PTTD is a progressive condition. The Johnson & Strom classification divides PTTD into stages, with Stage I and II involving a flexible foot structure that is typically amenable to non-surgical treatment, while Stage III and IV involve a rigid flattening of the longitudinal arch and other degenerative changes. The lack of an early or missed diagnosis can risk the progression of the disorder.

The diagnosis of Posterior Tibial Tendon Dysfunction (PTTD) is primarily a clinical diagnosis that relies on the healthcare professional's experience, knowledge, and interpretation of the patient's symptoms and objective findings. It's crucial for early diagnosis, as PTTD is a progressive condition that can lead to severe foot deformity if not treated effectively.

Clinical Assessment: Subjective and Objective Findings

A thorough clinical examination involves gathering subjective reports from the patient and conducting objective tests.

Patient-Reported Symptoms:

• Pain and Swelling: Patients commonly complain of pain and swelling behind the medial aspect of the ankle (medial malleolus). This discomfort can extend further up the leg towards the knee or feel deep in the proximal medial and posterior aspect of the tibia. The pain is often described as an overuse injury, worse with activity, and causes focal tenderness. As the condition progresses, pain may also be reported on the lateral aspect of the ankle or in the sinus tarsi area.
• Foot Flattening/Deformity: Patients may notice a progressive flattening of the foot, a loss of the medial longitudinal arch, and a feeling of walking on the inside of the foot. This can lead to decreased walking stability, especially on uneven surfaces.
• Functional Limitations: Individuals often experience difficulty with activities like increasing training levels, gentle jogging, or walking. They may also report an inability to go up on their tiptoes without extreme pain.

Physical Examination:

• Visual Observation in Static Stance:
  • A dropped arch profile.
  • A medially drifted talo-navicular joint.
  • An abducted forefoot (often called "too many toes sign," where more toes are visible from behind the patient than usual).
  • An everted calcaneus (heel bone turned outwards).
  • Mild swelling and tenderness slightly behind the medial malleolus upon inspection and palpation.
• Functional Tests:
  • Single and Double Heel Raise Tests: These are crucial for assessing tibialis posterior function. In a positive test for PTTD, the patient will find it difficult or impossible to perform due to pain and weakness, and the calcaneus (heel bone) may not invert (turn inwards) as it normally would. The single-limb heel raise is considered the most reliable clinical test for Tibialis Posterior Tendinopathy (TPT), an earlier stage of PTTD.
  • Resistance Testing: Pain will be elicited when palpating the tibialis posterior tendon behind the medial malleolus, and weakness may be observed in foot invertors and evertors. Patients with PTTD often show reduced subtalar inversion and forefoot adduction strength.
  • Gait Analysis: May reveal rearfoot valgus and overpronation in midstance. Biomechanical studies characterize PTTD with increased forefoot abduction and rearfoot eversion during the gait cycle. Patients with PTTD also exhibit altered postural control mechanisms during gait, with a medially shifted center of pressure (COP) movement during the single-support phase of walking, indicating a more cautious and conservative postural strategy. They may have a higher double stance ratio and decreased anterior-posterior COP movement and velocity.
  • Navicular Drop Test: This test can assess the height of the medial longitudinal arch, with findings like navicular prominence being 2-3mm under the line noted.
  • Balance Tests: Patients with PTTD often have a reduced success rate in unipedal standing balance tests compared to controls and may show increased anterior-posterior center of pressure displacement.

Classification of PTTD Stages:

The Johnson & Strom classification system, often with the Myerson modification, is widely used to classify PTTD into four progressive stages, which helps guide treatment decisions.

• Stage I: Characterized by a normal tendon length, gradual onset of mild to moderate pain, tenderness around the medial malleolus to its navicular insertion, mild swelling, and mild weakness in a heel-rise test, but with an intact medial longitudinal arch.
• Stage II: Involves an elongated tendon, evolves over several months to years, with moderate swelling and tenderness. The single-heel-raise test becomes abnormal, and there is a flexible flatfoot deformity with the characteristic "too many toes sign".
• Stage III: The tendon is elongated or disrupted and may be less painful. There are degenerative changes at the subtalar joint, a fixed flatfoot deformity develops, and pain may shift to the lateral rearfoot/sinus tarsi area due to impingement.
• Stage IV: Involves degenerative changes at both the subtalar and ankle joints, with the hindfoot becoming fixed in eversion and ankle incongruency, often due to deltoid ligament compromise leading to lateral tibiotalar arthritis.

It is important to note that while PTTD is often used interchangeably with "adult-acquired flatfoot deformity" (AAFD), recent proposals suggest using "Tibialis Posterior Tendinopathy" (TPT) for early stages (Johnson and Strom Stage I and part of Stage II) to specifically refer to the tendon pathology itself, distinguishing it from the broader foot deformity. Despite the high prevalence, PTTD is often not formally diagnosed until later stages, leading to potential delays in appropriate management.

TBD

Non-surgical treatments are typically recommended for early stages of posterior tibial tendon dysfunction (PTTD), specifically Stages I and II, before the foot structure becomes rigid.

The most effective non-surgical treatments for PTTD often involve a combination of approaches, with a particular emphasis on specific types of exercise and the use of foot orthoses.

• Combination of Foot Orthoses and Exercise:
  • A high-quality randomized controlled trial found that patients with PTTD benefit most from a combination of foot orthoses and exercise after a 12-week intervention period.
  • Systematic reviews indicate that orthoses along with stretching and strengthening exercises had more favorable outcomes than orthoses and stretching alone. This combination leads to a greater treatment effect.
• Eccentric Strengthening Exercises:
  • Eccentric resistance training is highlighted as a clinically beneficial and effective method for pain reduction and muscle strength improvement in tibialis posterior tendinopathy when prescribed at an appropriate dosage.
  • Sources suggest that eccentric exercises appear to have a bigger impact on alleviating symptoms and improving quality of life when compared with stretching and/or concentric exercises.
  • One randomized controlled trial showed that the largest improvement in Foot Function Index (FFI) scores was seen in patients performing eccentric tibialis posterior tendon exercises, compared to those doing only orthoses with stretching, or orthoses with stretching and concentric exercises.
  • This superiority of eccentric exercises is attributed to the ability to apply higher loads through the tendon during these exercises, which is crucial for eliciting physiological changes within the tendon. The intention of these exercises is to improve muscle strength.
  • A systematic review concluded that eccentric exercises may be superior for improving pain, disability, and self-reported overall foot function than concentric exercises and foot orthoses and stretching alone.
  • Examples of eccentric exercises include heel lowering movements performed on the edge of a stair from a calf-raised position, often with increasing load.
• Foot Orthoses (and Supportive Footwear):
  • Foot orthoses are generally considered the first-line approach for non-surgical treatment.
  • They aim to stabilize the foot, prevent it from adapting to a flattened position, and reduce stress on the tibialis posterior tendon during weight-bearing activities.
  • Custom-made orthoses, designed with features like medial longitudinal arch support and a bowl-shaped heel, are used to promote rearfoot stability and correct the foot position.
  • The use of supportive footwear in conjunction with orthoses can optimize the chances of non-surgical recovery.
  • Studies have shown that orthoses can lead to decreased pain and increased function, helping patients avoid surgery in a significant number of cases.
• Patient Education and Load Management:
  • It is essential that patients are educated about the nature of PTTD and the importance of rehabilitation to prevent progression.
  • Appropriate load management is considered the most important component of rehabilitation for tendinopathies. This involves both reducing compressive and tensile loads on the tendon.

References:

Adukia, V., Trivedi, R., Houchen-Wolloff, L., Mangwani, J., O’Neill, S., Divall, P., & Vaishya, R. (2025). Non-operative and operative management of posterior tibialis tendon dysfunction – A systematic review and meta-analysis. Journal of Arthroscopic Surgery and Sports Medicine. https://doi.org/10.25259/JASSM_43_2024

Concannon, M. (2012). Treatments for posterior tibial tendon dysfunction. Practice Nursing, 23(8), 389–393. https://doi.org/10.12968/pnur.2012.23.8.389

Samardzic, V., & Zlatičanin, R. (2023). Eccentric exercise in the treatment of tibialis posterior tendinopathy: A case report. International Journal of Medical Reviews and Case Reports. https://doi.org/10.5455/IJMRCR.172-1662322943

Blasimann, A., Eichelberger, P., Brülhart, Y., El-Masri, I., Flückiger, G., Frauchiger, L., Huber, M., Weber, M., Krause, F. G., & Baur, H. (2015). Non-surgical treatment of pain associated with posterior tibial tendon dysfunction: Study protocol for a randomised clinical trial. Journal of Foot and Ankle Research, 8(1). https://doi.org/10.1186/s13047-015-0095-4

Rhim, H. C., Dhawan, R., Gureck, A. E., Lieberman, D. E., Nolan, D. C., Elshafey, R., & Tenforde, A. S. (2022). Characteristics and future direction of tibialis posterior tendinopathy research: A scoping review. Medicina, 58(12), 1858. https://doi.org/10.3390/medicina58121858

Ross, M. H., Smith, M. D., Mellor, R., & Vicenzino, B. (2018). Exercise for posterior tibial tendon dysfunction: A systematic review of randomised clinical trials and clinical guidelines. BMJ Open Sport & Exercise Medicine, 4(1), e000430. https://doi.org/10.1136/bmjsem-2018-000430

Dooley, S. W., Evashwick-Rogler, T., Murawski, C. D., Guyton, G. P., & Smyth, N. A. (2022). Flexor digitorum longus transfer for posterior tibial tendon dysfunction is the standard of care: Does the evidence support it? Foot & Ankle Orthopaedics, 7(1). https://doi.org/10.1177/2473011421S00180

Wang, J., Latt, L. D., Martin, R. D., & Mannen, E. M. (2022). Postural control differences between patients with posterior tibial tendon dysfunction and healthy people during gait. International Journal of Environmental Research and Public Health, 19(3), 1301. https://doi.org/10.3390/ijerph19031301

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