Posterior Tibial Tendonitis

Posterior tibial tendon dysfunction (PTTD) is an overstretching of the posterior tibial tendon in the foot which generally occurs after long term overuse related inflammation and degeneration of the tendon, Posterior Tibial Tendonitis/tendonosis. Tibialis posterior muscle/tendon has a major role in supporting the medial arch of the foot and therefore its dysfunction can lead to over pronation in adults. Is it for this reason that PTTD is often called adult aquired flatfoot (AAF).

The tibialis posterior muscle is the key dynamic support of the medial longitudinal arch of the foot. When it fails progressively, the arch slowly collapses, the heel drifts into valgus, and the forefoot gradually abducts, resulting in painful acquired flatfoot. Tibialis posterior dysfunction is often misdiagnosed as a chronic ankle sprain, osteoarthritis, or collapsed arch as a result of ageing or obesity, and it leaves the patient debilitated.

Prompt diagnosis prevents frustration for the patient and allows treatment to be started at an earlier, more easily managed stage. The diagnosis of tibialis posterior tendon dysfunction is largely a clinical one. An increased awareness of the existence of tibialis posterior should serve to help patients with earlier referral and treatment and by limiting the amount of disability they experience.

Conservative treatment is indicated for nearly all patients initially before surgical management is considered. The key factors in determining appropriate treatment are whether acute inflammation and whether the foot deformity is flexible or fixed. However, the ultimate treatment is often determined by the patients, most of whom are women aged 40 or older. Compliance can be a problem, especially in stages I and II. It helps to emphasise to the patients that tibialis posterior dysfunction is a progressive and chronic condition and that several fittings and a trial of several different orthoses or treatments are often needed before a tolerable treatment is found.

Stages I and II: the flexible foot

Any acute inflammation surrounding the sheath of the tibialis posterior tendon should be dealt with before the chronic aspect of the condition is treated. A period of four to eight weeks of immobilisation in a plaster cast below the knee or a removable boot may be required to control accompanying inflammation. In conjunction, RICE (rest, ice, compression, and elevation) and anti-inflammatories can be used.

Stage III and IV: the rigid flatfoot

Overall, inflammation tends to be a less common feature of presentation with the rigid acquired flatfoot. Treatment revolves around accommodating the deformity (rather than attempting to correct it) with customised moulded rigid orthoses, used in conjunction with appropriate footwear (often custom made), as the foot deformity worsens.

Footwear has an important role, and patients should be encouraged to wear flat lace-up shoes, or even lace-up boots, which accommodate orthoses. The various casted, semirigid orthoses support the medial longitudinal arch of the foot and either hold the heel in a neutral alignment (stage I) or correct the outward bent heel to a neutral alignment (stage II). This approach is meant to serve several functions: to alleviate stress on the tibialis posterior; to make gait more efficient by holding the hindfoot fixed; and thirdly, to prevent progression of deformity.

Immediate, appropriate treatment in patients with Posterior Tibial Tendonitis is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times. If you ever wish to discuss our treatment protocols, or co-management of patients, please do not hesitate to contact this clinic. We would welcome the opportunity to dialogue with you.