Over the past few weeks I have had a few questions regarding Posterior Tibialis Tendon Dysfunction (PTTD). Therefore, this blog post summarises the anatomy and function of tibialis posterior, the pathology of PTTD, management and treatment tips.
Please consider that this article is not aimed as a substitute for a detailed examination of a clinician.
Tibialis Posterior is a muscle that runs from the back of your shin bones (tibia and fibula), down to the inside of your calf and into your foot. The tendon runs along the inside of the bony bit of your ankle (medial malleolus). From here it extends into your foot where it attaches at different points, including the 2nd, 3rd and 4th metatarsals.
The main function of Tibialist Posterior is to invert the foot (turning the foot inwards). Tibialis Posterior also assists in plantarflexion (pointing the toes down) as well as maintaining the medial arch. Everyday functions that utilises the tibialis posterior include walking on your tip toes or pushing down a car pedal.
Posterior Tibialis Tendon Dysfunction (PTTD)
PTTD can be inflammatory in nature. However, this is a secondary response to an inflammatory systemic disease such as lupus or rheumatoid arthritis. FOveruse is frequently an issue. This can be through running without sufficient recovery time or by overloading into the medial structures. PTTD frequently also occurs amongst middle aged obese wome. A combination of increased biomechanical loading and pronation causes increased medial loading of the foot. PTTD develops in a similar way to a tendinopathy and the way the tendon passes along the inside of the ankle into the foot makes it more susceptible to tendinopathic changes. If left untreated PTTD can become a degenerative process and it is the leading cause of being flat-footed.
Furthermore, other risk factors include laxity of ligaments, diabetes, high blood pressure and a history of corticiosteriod therapy.
4 Stages of PTTD
- You might observe some mild swelling and complain of pain on the inside of your ankle. You should be able to complete a heel raise, but it might cause discomfort. There is no changes in foot position.
- In this stage we start to see the foot adapting a more flat footed appearance, but the foot is still flexible. You won’t be able to complete a single leg heel raise at this stage.
- Here the foot has adapted a rigid flatfoot deformity.
- Finally, this stage is characterised by early degenerative changes impacting the ankle joint as a whole.
First thing you want to do is reducing the aggravating activity. Continued overload is going to progress the pathology. Therefore it is a good idea to see a physiotherapist (or similar) to establish the cause and address this trough a bespoke program.
The literature suggests to go down the route of orthoses. Although, the evidence underpinning this claim is at times questionable. It seems more appropriately applied as a personal preference.
I have included rehabilitation program for PTTD below addressing weakness of tibias posterior. The research underpinning conservative treatment for PTTD are few and far between. The papers I did find had small sample sizes and utilised equipment which is not readily available. However, following papers on tendon rehabilitation, we know that progressive loading has shown good results.
- Heel raises squeezing a ball between your heels. Lift as high up on your toes as you can and then slowly return back down. Make this a slow exercise – lifting for 3, holding for 2 and lowering for 3.
- Inversion with theraband. Turn the foot inwards pushing against the resistance of the theraband. Make sure the movement originates from the ankle and not the knee or hip in order to isolate the correct muscle.
- Eccentric inversion exercise. Start with the foot inverted and push against the theraband until you return to a neutral position.
- Toe walking. Walking on tip toes. This can be made harder through a increasing speed, changing direction or combining with high marching.
Additionally, I would suggest to consider strengthening your glutes. Consequently I would direct you to this post for more information of how to target your glutes.
Bowring B, Chockalingam N. A clinical guideline for the conservative management of tibialis posterior tendon dysfunction. Foot (Edinb). 2009;19:211–7.
Kulig, K., Lee, S. P., Reischl, S. F., & Noceti-DeWit, L. (2015). Effect of posterior tibial tendon dysfunction on unipedal standing balance test. Foot & ankle international, 36(1), 83-89.
Kulig, K., Reischl, S. F., Pomrantz, A. B., Burnfield, J. M., Mais-Requejo, S., Thordarson, D. B., & Smith, R. W. (2009). Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Physical Therapy, 89(1), 26-37.