Posterior Tibial Tendonitis Causes, Symptoms & Treatment

Overview

Tendons are strong, cord-like tissues that connect muscles to bones. The posterior tibial tendon runs from the calf, along the inside of the ankle, and attaches to the bones of the foot. It helps support the arch and is important for everyday walking.

When this tendon becomes inflamed or torn, the condition is known as posterior tibial tendon dysfunction. It often causes the arch to flatten, leading to a flatfoot deformity gradually. The arch collapses as the tendon becomes more damaged or completely ruptures.

Clinicians often classify posterior tibial tendon dysfunction (PTTD) into four progressive stages, with stage IV representing complete tendon failure.

What causes Posterior Tibial Tendonitis?

Posterior tibial tendonitis most often develops from repetitive strain or overuse of the tendon. Athletes and dancers involved in high-impact or repetitive foot movements are particularly at risk. In some cases, a single traumatic event, such as a fall or collision, can cause a partial or complete tear of the tendon.

• How the Injury Occurs: The condition results from repetitive stress, sudden trauma, or a combination of both. These forces lead to inflammation, tendon degeneration, and eventual weakening of the tendon’s ability to support the foot arch.
• Common Everyday Causes: Posterior tibial tendonitis is not limited to athletes. It is also common among individuals with flatfoot, obesity, or occupations that involve prolonged standing or walking, all of which place continuous strain on the tendon.

Posterior tibial tendon dysfunction is most common in these activities:

• Dancing: Repetitive jumping and pointe work place excessive load on the tendon, leading to inflammation and small tears.
• Tennis: Quick lateral movements and abrupt stops create significant stress on the tendon.
• Basketball: High-impact landings and rapid directional changes challenge tendon stability and function.
• Soccer: Continuous running, cutting, and pivoting motions contribute to chronic overuse and tendon irritation.

Symptoms

The main symptom of posterior tibial tendon dysfunction (PTTD) is pain along the inside (medial) aspect of the ankle, following the path of the tendon from the calf to the foot. As the condition progresses, additional signs and functional limitations may appear.

• Swelling: Localized inflammation and tenderness along the tendon, often accompanied by warmth around the affected area.
• Difficulty walking or running: Reduced tendon strength and stability make walking, running, or standing painful for long periods.
• Gradual flattening of the arch: The medial arch of the foot lowers over time as the tendon weakens.
• Advanced cases: The heel may shift outward (hindfoot valgus), and pain may develop along the outer side of the foot due to altered alignment and compensatory loading.

Non-operative treatment

Non-surgical management is often effective in the early stages of posterior tibial tendon dysfunction. The main objectives are reducing pain, controlling inflammation, and supporting tendon healing. Limiting activities that cause discomfort or repetitive strain on the foot is essential for recovery.

Common conservative treatments include:

• Physical therapy: Focused exercises to strengthen the posterior tibial tendon, improve flexibility, and restore proper foot alignment.
• Use of crutches: Recommended when walking is painful to minimize stress on the affected tendon.
• Immobilization: A cast, walking boot, or orthotic inserts with arch support may stabilize the foot and allow the tendon to heal.
• Anti-inflammatory medication: Helps manage pain and decrease localized swelling.
• Cortisone injection: In select cases, corticosteroid injections may be administered to control severe inflammation, though they are used cautiously to avoid tendon weakening.

For guided rehabilitation, specific posterior tibial tendonitis exercises can help strengthen the tendon and restore normal function.

A detailed Exercise Program is available in the PDF linked below:

Posterior Tibial Tendonitis Exercise Program (PDF)

Posterior Tibial Tendonitis

Surgical Treatment

Surgery is considered when conservative management fails after approximately six months or in advanced stages of posterior tibial tendon dysfunction. The specific procedure depends on the extent of tendon damage and structural deformity.

• Tendon debridement: Removing inflamed or degenerated tissue in the early stages may relieve symptoms and restore partial tendon function.
• Tendon transfer: When the posterior tibial tendon is severely damaged, a nearby healthy tendon may be transferred to assume its role and restore foot support.
• Osteotomy: For patients with significant arch collapse, surgical realignment through precise cutting and repositioning of the foot bones helps reconstruct the arch and correct deformity.
• Joint fusion (arthrodesis): In severe or end-stage cases, fusing affected joints with screws or plates stabilizes the foot, alleviates pain, and prevents further collapse.

Postoperative rehabilitation typically includes immobilization, gradual weight-bearing, and targeted physical therapy to restore mobility and strength.