Posterior Tibialis Tendon Dysfunction | Diagnosis & Treatment for Physios

Posterior tibialis tendon dysfunction, abbreviated as PTTD, is the major cause of an adult acquired flatfoot deformity and medial ankle pain. It is caused by chronic overuse and subsequent tendon inflammation which may impede tendon degeneration in later stages. The prevalence of stage I and II posterior tibialis tendon dysfunction were reported to be 3.3%-10% in women over 40. This prevalence increases with age.

An inflammatory process in or around the posterior tibialis tendon (tendinitis or tenosynovitis) usually lies at the base of symptoms. Repetitive microtrauma due to for example overpronation of the foot has been described to lie at the base of the condition.

This leads to loss of function of the posterior tibialis tendon and collapse of the medial longitudinal arch. This increases strain on the medial foot and ankle ligaments. Gradually, the medial ligaments (deltoid ligament and calcaneonavicular ligament) become elongated and flatfoot deformity is acquired. It may gradually become chronic and can be accompanied by degenerative changes in the tendon. Acute trauma is rarely the cause of PTTD.

4 stages have been defined:

• Stage 1 presents with swelling and tenderness behind the medial malleolus along the course of the posterior tibialis tendon. The foot is flexible and the medial longitudinal arch is maintained. In this stage, a slight weakness and pain with inversion of the foot may be present.
• Stage 2 presents with less swelling, but a collapse of the medial longitudinal foot arch becomes evident. In this stage, the foot is flexible and the flatfoot may be corrected. It becomes gradually difficult or almost impossible to invert and plantarflex the foot and single-leg heel raise may be affected.
• In stage 3, fatigue, aching in the leg together with a reduced walking capacity becomes evident. The flatfoot deformity becomes rigid and cannot be corrected. Loss of ability to invert and plantarflex the foot is the hallmark sign.
• With stage 4, alongside the fixed flatfoot deformity, lateral ankle pain may develop due to fibular impingement against the sinus tarsi. Instability and limping may be present.

Clinical Presentation & Examination

Signs & Symptoms

The following signs & symptoms can be indicative of posterior tibialis tendon dysfunction:

• Gradual onset of pain and swelling of the medial hindfoot and along the course of the tendon, often present for months or years before patients seek help
• Patients can acquire a flattening of the foot arch in later stages
• Commonly the foot is hurting upon longer walks and walking capacity is impaired
• Participation in sports becomes almost impossible
• Lateral ankle pain may be present as well due to the impingement of the fibula on the sinus tarsi in later stages

Examination

The foot shows signs of swelling behind the medial malleolus. Palpation of the tendon reveals tenderness along its course behind the medial malleolus and insertion on the navicular tuberosity. In later stages, flattening of the medial longitudinal arch may be observed as the “too many toes sign” is apparent.

The active examination may reveal the following:

• Difficulty standing on toes
• Pain and difficulty to invert and plantar flex the foot
• A positive navicular drop test

Mobility of the ankle and subtalar joint can be assessed to determine if the flatfoot is flexible or rigid.

Treatment

Ross et al., 2018 showed a paucity of high-quality research for the conservative management of posterior tibial tendon dysfunction. Nonetheless, the following principles can be used.

Progressive resistance exercises to strengthen the weakened tibialis posterior and improve the medial longitudinal foot arch are recommended in early stages to prevent further progression of the condition.

Slow and heavy resistance training to (re)gain calf strength and to promote tendon adaptation.

Stretch-shorten cycle exercises to reintroduce the patient to more demanding activities

Tibialis anterior strengthening to support the tibialis posterior in maintaining the medial longitudinal arch. The foot arch may be further supported passively with orthoses. Talocrural, subtalar, and midfoot joint mobilizations to avoid the development of a rigid foot.

References

Kohls-Gatzoulis J, Woods B, Angel JC, Singh D. The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England. Foot Ankle Surg. 2009;15(2):75-81. doi: 10.1016/j.fas.2008.08.003. Epub 2008 Oct 1. PMID: 19410173.

Kohls-Gatzoulis J, Angel JC, Singh D, Haddad F, Livingstone J, Berry G. Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot. BMJ. 2004 Dec 4;329(7478):1328-33. doi: 10.1136/bmj.329.7478.1328. PMID: 15576744; PMCID: PMC534847.

Yao K, Yang TX, Yew WP. Posterior Tibialis Tendon Dysfunction: Overview of Evaluation and Management. Orthopedics. 2015 Jun;38(6):385-91. doi: 10.3928/01477447-20150603-06. PMID: 26091214.

Ling SK, Lui TH. Posterior Tibial Tendon Dysfunction: An Overview. Open Orthop J. 2017 Jul 31;11:714-723. doi: 10.2174/1874325001711010714. PMID: 28979585; PMCID: PMC5620404.

Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, Smith RW. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther. 2009 Jan;89(1):26-37. doi: 10.2522/ptj.20070242. Epub 2008 Nov 20. PMID: 19022863.

Kulig K, Lederhaus ES, Reischl S, Arya S, Bashford G. Effect of eccentric exercise program for early tibialis posterior tendinopathy. Foot Ankle Int. 2009 Sep;30(9):877-85. doi: 10.3113/FAI.2009.0877. PMID: 19755073.

Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006 Jan;27(1):2-8. doi: 10.1177/107110070602700102. PMID: 16442022.

Rabbito M, Pohl MB, Humble N, Ferber R. Biomechanical and clinical factors related to stage I posterior tibial tendon dysfunction. J Orthop Sports Phys Ther. 2011 Oct;41(10):776-84. doi: 10.2519/jospt.2011.3545. Epub 2011 Jul 12. PMID: 21765219.

Ross MH, Smith MD, Mellor R, Vicenzino B. Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines. BMJ Open Sport Exerc Med. 2018 Sep 19;4(1):e000430. doi: 10.1136/bmjsem-2018-000430. PMID: 30271611; PMCID: PMC6157513.

Gluck GS, Heckman DS, Parekh SG. Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon. Am J Sports Med. 2010 Oct;38(10):2133-44. doi: 10.1177/0363546509359492. Epub 2010 Mar 29. PMID: 20351200.