Posterior Tibial Tendon Dysfunction (PTTD)

What is posterior tibial tendon dysfunction?

Posterior tibial tendon dysfunction (PTTD) is an issue that causes foot and ankle pain. It’s also known as posterior tibial tendonitis or posterior tibial tendon insufficiency. The posterior tibial tendon connects your calf muscle to bones on the inside of your foot. The main purpose of the tendon is to support the arch on the inside of your foot. When the tendon is injured or breaks down, it may no longer be able to support the arch. It can be a painful injury that negatively affects foot and ankle movements, including walking and running. PTTD is the most common cause of adult-acquired flatfoot.

What are the stages of posterior tibial tendon dysfunction?

There are four posterior tibial tendon dysfunction stages:

• Stage I: The tendon is injured but otherwise intact.
• Stage II: The tendon is torn (ruptured) or not working properly. The foot is deformed.
• Stage III: The foot is significantly deformed. There are degenerative changes to the connective tissue (cartilage) in the back of the foot.
• Stage IV: There are degenerative changes to the ankle joint.

Who does posterior tibial tendon dysfunction affect?

PTTD most frequently affects women and people over the age of 40. The tendon often degenerates, or breaks down, as you get older. However, it can also affect those with conditions including:

• Obesity.
• High blood pressure (hypertension).
• Diabetes.
• Foot or ankle tissue injuries.
• Joint disorders.
• Prior surgery.
• Steroid use.

The tendon can also experience damage from a fall or overuse. People who participate in high-impact sports or activities, including football, basketball, soccer, track and long-distance running, may tear the tendon from repeated use.

How does posterior tibial tendon dysfunction affect my body?

PTTD is a painful condition. If you have PTTD, making certain movements will be difficult for you. These movements may include standing, walking, running or standing on your toes.

What are the symptoms of posterior tibial tendon dysfunction?

Signs of PTTD may include:

• Pain and swelling along the ankle or inside of the foot. This pain may increase with activity, including standing or walking.
• Pain when standing on toes.
• Ankle rolls inward.
• Difficulty walking on uneven surfaces.
• Difficulty walking up and down stairs.
• A previous limp that gets worse.
• Unusual or uneven wear on shoes.

What causes posterior tibial tendon dysfunction?

Strong, repetitive forces can injure the posterior tibial tendon. As you get older, the tendon can break down. In people with obesity, additional body weight can cause the tendon to break down faster. Prior ankle, foot or joint injuries can also cause the tendon to break down quickly.

In younger people, PTTD is uncommon. It often occurs after an injury.

How is posterior tibial tendon dysfunction diagnosed?

Your healthcare provider will look for swelling along the posterior tibial tendon in your ankle and foot. They’ll move your foot from side to side and check your ankle’s range of motion. Swelling, tenderness and pain or weakness when moving your foot or ankle are early signs of PTTD.

Your provider will examine your foot from behind to look for any changes in its structure or shape. Your heel may point outward, and your inner arch may rest flat on the ground. The front of your foot may also move away from your body to counterbalance the changes to the heel and inner arch.

From behind your foot, your provider will also look for a “too many toes” sign. In a normal foot, only the fifth toe (pinky toe) and part or all of the fourth toe (ring toe) are visible on the outside of the foot. In those with PTTD, more toes may be visible.

A single-limb heel rise test can also determine the health of your posterior tibial tendon. For this test, you’ll stand next to a wall or chair to support your balance. Then you’ll raise your healthy foot off the ground and attempt to lift onto the toes of your affected foot. With a healthy tendon, you should be able to complete eight to 10 heel raises comfortably. In the early stages of PTTD, it may not be possible to complete one single heel rise.

What tests can diagnose posterior tibial tendon dysfunction?

Imaging tests can help your healthcare provider confirm the diagnosis, including:

• X-rays: X-rays of the front, back and sides of both feet will provide detailed images of the bones. X-rays help spot arthritis or fallen arches. They also help spot joint degeneration in later stages of PTTD.
• Magnetic resonance imaging (MRI): An MRI can determine the health of your tendon and any surrounding muscles. In the early stages, an MRI may be used to plan nonsurgical treatments. In later stages, an MRI may be used to plan surgical treatment.
• Computerized tomography scan (CT scan): A CT scan creates a 3D image of your soft tissues and bones. It provides more detailed images than an x-ray. A CT scan may help spot arthritis or confirm PTTD.
• Ultrasound: An ultrasound can examine the size of your tendon, observe any tendon degeneration or spot fluid in the tissue that surrounds the tendon, which may appear in the early stages of PTTD.

How is posterior tibial tendon dysfunction treated?

PTTD treatment depends on how severe your symptoms are. If tendon damage is identified in its earliest stages, many symptoms will go away with nonsurgical treatment, including:

• Rest: Stop participating in activities that cause or worsen the pain. Low-impact exercises can help you maintain your overall health without affecting the tendon. These include bicycling, yoga, elliptical training and swimming.
• Ice: You can apply an ice pack covered in a light towel to the most painful areas of your foot or ankle for up to 20 minutes three or four times a day.
• Medications: Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen and naproxen, will reduce pain and inflammation. Not everyone can take NSAIDs, so it’s a good idea to check with your healthcare provider before use.
• Physical therapy: Physical therapy exercises can strengthen the tendon.
• Orthotics: Over-the-counter shoe inserts or braces can provide support for your tendon and arch. Your healthcare provider may prescribe a walking boot or cast, or custom orthotic brace specifically molded to your foot.

If your pain doesn’t improve or completely go away after at least six months of nonsurgical treatment, you may be referred to a foot and ankle surgeon. Surgical treatments vary according to where your foot or ankle hurt. Treatments also vary according to the amount of damage to the tendon.

How soon after treatment will I feel better?

PTTD is a painful injury, and it can take several months to heal. You may have to change the ways you approach your daily activities. Slowly and carefully ease yourself back into any activities or exercises that you participated in before your injury.

How can I reduce my risk?

You can reduce your risk of PTTD by:

• Wearing supportive footwear. You should choose a shoe that provides extra arch support. Avoid footwear that can increase your risk of injury, including high heels, platform shoes and flip-flops.
• Stretching your lower leg. Standing calf stretches are a great way to stretch the tendon and the muscles that surround it. A foam roller can also loosen your calf muscles.
• Performing strengthening exercises. Resistance band exercises, single-limb heel rises and walking on your toes over a short distance can strengthen your foot and ankle and help prevent injuries.
• Not pushing through pain. Stop what you’re doing at the first sign of discomfort.

What can I expect if I have posterior tibial tendon dysfunction?

With proper diagnosis and treatment, the outlook for people with PTTD is good. Take care to follow your healthcare provider’s instructions about appropriate footwear options and your physical therapy routine.

What questions should I ask my healthcare provider?

• Why did this happen to me?
• What activities should I avoid? For how long?
• What can I do to manage my pain?
• What treatments do you recommend?
• Do you think I should have surgery?
• What kind of surgery do you recommend?

A note from Cleveland Clinic

PTTD is a common injury that affects the foot and ankle.

Injuries to your foot or ankle can be frustrating. If you’re not sure what’s caused the pain in your foot or ankle, or if you’re a woman or over the age of 40, stop any activity that increases the pain and contact your healthcare provider. Rest and over-the-counter or home remedies can treat PTTD in its earliest stages. In later stages, you may need to see a foot and ankle specialist. They’ll review more detailed treatment options with you, including any appropriate surgical procedures.