Tibialis posterior dysfunction is a broad term for injury or disease in the tendon of one of the muscles in the calf. It is also called posterior tibialis tendon dysfunction (PTTD), posterior tibialis tendinitis, tendinosis or tendinopathy, and posterior tibialis insufficiency. All of these terms describe different types or degrees of injury to the tendon.
The posterior tibialis muscle lies deep at the back of your calf. It begins near the knee, joins its tendon just above the ankle and runs down to attach to a bone (the navicular) on the inner side of your foot. This lets it support the arch of the foot, which is important for normal, painless walking. The muscle is also partly responsible for pointing your foot down (‘plantar flexion’) and in (‘pronation’).
Tibialis posterior dysfunction means injury or disease of the tendon, the strong band of tissue that connects muscle to bone. The tendon is injured when it is overstretched or strained. Lots of tiny tears in the tendon cause inflammation, which is called tendinitis.
PTTD can cause pain along the inner side of the lower leg, ankle or foot. It is also linked with the development of flatfoot deformity.
Symptoms
Early symptoms of PTTD are redness, swelling and pain along the tendon (the inner side of the foot and ankle). This may cause pain when walking or running, and pain when lifting the foot or putting weight on the balls of the feet. Your doctor may notice that your feet flatten (over-pronate) as you walk, though you probably cannot see this yourself.
Later symptoms come from poorly balanced muscles around the ankle and foot. You may notice your foot gradually deforming or twisting, and less muscle strength.
Doctors use stages to assess how severe PTTD is. There are four stages:
- Stage 1– the inflamed tendon is painful and swollen along the inner surface of the ankle.
- Stage 2– Pain is more severe and the foot gradually flattens as the arch begins to collapse.
- At this point, you may notice you struggle to stand on your toes and your heel seems to roll outwards as you walk.
- Stage 3 – By this point you may have pain all over your foot. Your arch is now fixed flat, and your heel rolls out more obviously as you walk.
- Stage 4 – At stage 4, PTTD is affecting your ankle, which becomes painful, swollen and stiff from the strain. The deformity in the foot itself is also more exaggerated.
Most people with PTTD do not progress all the way to stage four.
Causes
Posterior tibial tendinitis happens when the tendon has been strained by overuse. When the tendon is injured, the arch of the foot flattens, which puts extra strain on the tendon. This sets up a vicious cycle, in which further injuries make long term problems more likely.
Some people are born with flat arches or develop flat feet for other reasons. This also puts too much strain on the tendon during walking and running and makes it easy to injure.
Risk Factors
People at increased risk for developing tibialis posterior dysfunction include:
- You can develop PTTD at any age, but middle aged women are the most likely to have symptoms.
- Flat feet – Many people who develop this condition already have flat feet. Overuse or constantly high demands on the tibialis posterior tendon can make it inflamed and irritated.
- Other factors – obesity, other medical conditions including hypertension and diabetes.
Investigations
A doctor or specialist will examine your foot and ankle. X-rays are used for diagnosis and to assess arthritis and the alignment of the joints in the foot and ankle. You may also need an X-ray of your other foot for comparison.
Sometimes ultrasound, CT or MRI scans are used to confirm inflammation in the tendon.
If your doctor is worried about rarer causes of tibialis dysfunction, they may order blood tests.
Complications
There are a number of complications that may develop. These include:
- Deformity. Over many years of PTTD, the bones and soft tissues that support the foot start to warp and wear down. This leads to two common types of deformity, equinus and varus. In equinus deformity the foot points down, like a ballerina. In varus deformity the foot points inward. Either or both may occur in PTTD and may need correction to help walking or reduce pain. Much of the special supportive footwear used in PTTD treatment aims to prevent deformity.
- Rupture. An inflamed, irritated tendon is at risk of tearing completely (rupturing). This is very painful, with severe redness and swelling. The tendon can be repaired with surgery.
Other complications include arthritis in other joints used in walking (such as the hips, knees and lower back), and ulcers or calluses where the deformed foot rubs
Treatment
There are non-surgical and surgical treatments for tibialis posterior tendon dysfunction. The choice depends on how severe your condition is and how it is likely to progress. Your doctor or surgeon will assess this and discuss it with you.
There are many treatments that do not involve surgery. They are often very successful and include medicines, exercises and physical support for the foot. The aims are to:
- Rest the tendon, relieving the strain of weight-bearing.
- Retrain the muscles and ligaments around the ankle and foot to prevent re-injury or worsening of the dysfunction.
Non-surgical treatments recommended for most people with PTTD include:
- Rest. When a tendon is inflamed, it needs rest to recover. This can mean not walking, walking with elbow crutches, or walking in a special boot that reduces weight through the tendon. Without the strain, the inflammation settles so pain and swelling ease and healing is helped. Your consultant will tell you if this is right for you and how to rest.
- Ice. Apply ice packs to your foot for 20 to 30 minutes every 3 to 4 hours for the first 2 to 3 days, or until the pain goes away. After that, ice your foot at least once a day until the other symptoms are gone. For ice massage, freeze water in a cup and peel back the top of the cup. Massage the ice into the painful tendon for 5 to 10 minutes.
- Elevation. Keeping your lower leg and foot above the level of your chest helps drain blood and fluid out of the leg and reduces swelling. Sleeping with your foot on several pillows is a good way to do this.
- Medication. Painkillers and anti-inflammatory medicines help with pain and inflammation, and so reduce discomfort.
Footwear and physical therapy are also very successful treatments for posterior tibialis tendinitis.
- Footwear. Good shoes can minimise discomfort from tibialis posterior tendon dysfunction. Choose shoes that are stiff and supportive. A shoe is stiff enough if it is hard to bend in half when you hold it in your hands. Lace-up boots that also limit ankle movement are very helpful. Weight loss. Inflammation of the tendon is greatly reduced if your body weight is in the normal range.
- Orthotics. There are several orthotic options, either insoles or a sturdier ankle support. Both fit in your shoes and help your foot and ankle work better.
- Taping. An orthotist or podiatrist may recommend strong tape across the sole of the foot to support the arch.
- Plaster Cast. Occasionally your doctor may put a cast on your ankle to stop weight bearing and rest the tendon. This is usually only for a short time.
- Physiotherapy treatment to reduce inflammation of the tendon and improve muscle flexibility and strength can ease the pain. Exercises from a physiotherapist can speed recovery and the return to normal activities, including sport.
If non-surgical treatment does not improve pain and deformity then surgery may be considered.
What are the surgical options for Tibialis Posterior Tendon Dysfunction?
There are several types of surgery for tibialis posterior tendon dysfunction. These include:
- Tendon Debridement. This removes inflamed and irreversibly damaged parts of the tendon. It can be very effective for pain relief in mild tendon inflammation where the bones and arch of the foot are still normal.
- Achilles tendon lengthening. A tight or short Achilles tendon adds to the symptoms of PTTD, and simply correcting this may be enough to relieve pain.
- Tendon grafts. Your surgeon may be able to take tendon from another part of your foot, usually the flexor digitorum longus tendon, and use it to reinforce the tibialis tendon. This operation can relieve pain and improve walking.
- Osteotomy. Osteotomy is a term used to describe reshaping of the bones.
- Corrective fusion of hindfoot. This is a drastic form of surgery, usually only recommended as a last resort. More information about this form of surgery can be found in Arthrodesis of the Foot.
For moderately severe PTTD, surgeons may combine Achilles lengthening, grafts and osteotomy to restore function to the foot.
Recovery from tendon debridement is fairly quick. In contrast, rehabilitation from the more involved repair surgery may be long, with an intense physiotherapy program while the tendons and bones heal.
Seeking Advice
See your doctor if you have lasting pain when walking despite rest and pain relief from the chemist.
Your Family Doctor (GP)
Your family doctor can diagnose your problem and help treat it. They can:
- tell you about your problem
- advise you of the best treatment methods
- prescribe you medications
- and if necessary, refer you to Specialists (Consultants) for further treatment
Prevention
Maintaining a healthy weight and wearing comfortable, well-fitting shoes can help protect your feet.
Arch supports are a good way to limit the progression of PTTD.
F.A.Q. | Frequently Asked Questions
When can I return to my normal activities?
Everyone recovers from an injury at a different rate. Return to your activities depends on how soon your injured tendon recovers, not on how many days or weeks have passed since the injury. In general, the longer you have had symptoms before starting treatment, the longer it takes to get better. The goal of rehabilitation is to return you to your normal activities as soon as it is safe. If you return too soon you may make the injury worse.
You may safely return to your activities when each of these is true, starting from the top of the list:
- You have full range of motion in the injured leg and foot compared to the uninjured leg and foot.
- You have full strength of the injured leg and foot compared to the uninjured leg and foot.
- You can walk straight ahead without pain or limping.
References
Beals, T. C., et al., ‘Posterior Tibial Tendon Insufficiency: Diagnosis and Treatment’, Journal of the American Academy of Orthopaedic Surgeons, Vol. 7, No. 2, March–April 1999, pp. 112–118.
Haendlmayer, K. T., Harris, N. J., ‘Flatfoot deformity: an overview’, Orthopaedics and Trauma, Vol. 23, No. 6, pp 395–403.
Weinraub, G. M., Saraiya, M. J., ‘Adult flatfoot/posterior tibial tendon dysfunction: classification and treatment’, Clinics in Podiatric Medicine and Surgery, Vol. 19, 2002, pp 345–370.