Tibialis Posterior Tendon Dysfunction (PTTD) is a common condition causing pain along the inside of the ankle and foot. It relates to the tibialis posterior tendon which has a major role in supporting the arch of your foot and supporting your ankle when you stand/walk/run.
PTTD is a term that encompasses a spectrum of the condition from pain solely being caused from the tibialis posterior tendon alone to further pain caused by the same tendon affecting the joints of the foot and ankle. The reason as to why the joints of the foot and ankle become involved is because as they are no longer supported by the tendon, causing the joints collapse, and become compressed. This then causes excess load to distribute through these joints which can lead to irritation and if left untreated, degeneration.
Symptoms
- Pain along the inside of the ankle with/without swelling
- Usually only one limb is affected (rarely does this condition happen on both legs)
- History of trauma to the ankle or overload (increased running/walking activity)
- Aggravated by walking/running particularly on uneven surfaces
- Flat feet or feet that roll in
- Pain when standing on tiptoes
Causes
Research suggests the most common cause for this condition relates to overload to the tibialis posterior tendon. This usually involves a rapid increase in standing, walking, or running activities.
PTTD can also be caused by direct trauma to the tibialis posterior tendon such as a direct blow to the inside of the ankle, or ankle/foot surgery.
Risk factors associated with this condition include:
- Greater then 55 years old
- High blood pressure
- Diabetes
- Obesity
Treatment
The severity of the condition greatly dictates whether conservative or surgical treatment is necessary. If the condition is severely affecting the joints of the foot/ankle and is greatly impacting on a person’s ability to function, a specialist opinion is advised to determine if surgery is necessary. However, should you catch this condition in the early stages, this condition can be successfully managed with conservative treatment. It is always important to seek expert advice regarding this condition to ensure an accurate diagnosis and appropriate treatment plan is made. Your physiotherapist will be able to determine the stage of this condition and determine whether conservative therapy or a surgical opinion is necessary. Generally, stages I and II of the condition can often be successfully managed where stages III and IV may require surgical intervention. Below are some common treatment options your physiotherapist may use to help manage PTTD.
Load Management
One of the primary pillars of recovery is managing the overall load that the tibialis posterior tendon is subject to. Because tissue has less capacity to tolerate load when injured, it is important to taper load appropriately to avoid further injury. This is done in conjunction with maintaining your overall function and improving the tendon strength and condition with exercises. This allows the tendon to recover while it becomes stronger and therefore, able to tolerate more load. This can be a fine line to walk between under-loading and overloading the tendon, however with the guidance of your physiotherapist, they can advise you as how you can manage tendon loading either with activity modification or complimentary devices such as taping, orthotics and footwear or if necessary, mobility aids.
Manual Therapy
Manual therapy can be used to assist with maintaining or improving joint and tissue mobility. This can include joint mobilisations, soft tissue massage and dry needling. These techniques are extremely useful when treating this condition as there is a strong relationship with calf tightness and ankle/foot joint stiffness associated with this condition. Improving muscle flexibility and joint mobility allows your foot and ankle to move in a more mechanically efficient way, therefore reducing the load through your tibialis posterior tendon.
Exercise Therapy
To improve tendon strength and functional capacity, exercise is key. There are specific tendon loading principles that guide treatment of PTTD that allows the tendon to strengthen without irritation (which may further injure the tendon). Another importance factor to consider is the length and function of the muscles around the joint to ensure their condition in maintained or improved. As previously mentioned, calf tightness is often associated with this condition, and stretching the calf muscle WITHOUT stretching the tibialis posterior tendon aids in PTTD recovery. It’s also important to consider the patient as a whole and if they are unable to participate in their normal cardiovascular activities such as walking or running, we can substitute these activities with swimming and cycling during recovery.
Orthotic Devices
One major role of the tibialis posterior tendon is to support the arch of the foot when standing, walking, and running. When the tendon is irritated, supporting the arch with either tape, foot orthotics or specific ankle braces will help unload the tendon during these activities. There is no one specific device that is appropriate for all individuals with this condition, therefore discussing and trialling them is extremely important to do under the guidance of your physiotherapist to avoid further injury. At times if the condition is extremely aggravated a CAM boot may be suggested to completely unload the tendon and allow you to walk comfortably.
Surgery
Unfortunately, there are times where conservative therapy may not be appropriate as the tendon and joint integrity may be lost due to the disease progression. When this occurs seeking further advice from an ankle/foot specialist will be helpful to determine whether surgery is necessary. As previously mentioned, it’s important to treat people as a whole, rather than focusing solely on their injury. While your wait for surgery, your physiotherapist will be able to develop and appropriate program for you to maintain or improve your cardiovascular fitness and general condition, without compromising your PTTD.
References
- Abousayed, M.M., et al. Classifications in Brief: Johnson and Strom Classification of Adult-acquired Flatfoot Deformity. Clin Orthop Relat Res 474, 588–593 (2016).
- Durrant, B., et al. (2015). Posterior Tibial Tendon Dysfunction: What does the single heel raise test mean in assessment? Foot and Ankle Online Journal, 8(2), 1-7.
- Myerson MS, at al. Classification and Nomenclature: Progressive Collapsing Foot Deformity. Foot Ankle Int. 2020 Oct;41(10):1271-1276.
- Houck J, et al. Randomized Controlled Trial Comparing Orthosis Augmented by Either Stretching or Stretching and Strengthening for Stage II Tibialis Posterior Tendon Dysfunction. Foot Ankle Int. 2015 Sep;36(9):1006-16.
- Kulig K, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther. 2009 Jan;89(1):26-37.
- Durrant B, et al. Posterior tibial tendon dysfunction: a review. J Am Podiatr Med Assoc. 2011 Mar-Apr;101(2):176-86.
- Geideman WM, Johnson JE. Posterior tibial tendon dysfunction. J Orthop Sports Phys Ther. 2000 Feb;30(2):68-77.
- Ross, M. H. (2020). Exploring the clinical presentation of tibialis posterior tendinopathy.
- BMJ Open Sport & Exercise Medicine 2018;4:e000430. doi: 10.1136/bmjsem-2018-000430
- Gómez-Jurado I, et al. Orthotic treatment for stage I and II posterior tibial tendon dysfunction (flat foot): A systematic review. Clin Rehabil. 2021 Feb;35(2):159-168.