Tibialis Posterior Tendinopathy

Your posterior tibial tendon is a crucial tendon when it comes to healthy foot and leg function, supporting the structure of your foot and arch as well as facilitating optimal and pain-free movement every time you take a step. The posterior tibial tendon originates at the back of the calf muscle, travelling down the side of our lower leg, crossing the inside of our ankle, and attaching to the underside of the foot. When the tendon is damaged or irritated, this is known as tibialis posterior tendinopathy, or more commonly posterior tibial tendon dysfunction (PTTD).

You may suspect that your posterior tibial tendon has been damaged if you’re experiencing pain along the inside of your foot or ankle (with or without swelling) that worsens with physical activity. A common exercise we ask you to do in our clinic to assess the severity of your tendon dysfunction is called a single raise heel test. To perform the test, hold onto the wall or a chair, beginning in a standing position and lift the unaffected foot up off the ground. Now, attempt to lift onto the toes of the affected foot. If you find this difficult or painful, it’s time to book in with your podiatrist.

The symptoms of posterior tibial tendon dysfunction progressively worsen, and as such, it is characterised into four stages of progression:

• Stage one is often missed because it comes with little or no symptoms. Medical imaging will also not reveal anything abnormal. However, you may have some mild inflammation of the tissue surrounding the tendon, and some mild pain, which may be your first signs. You will still be able to perform a single heel raise test without any issues.
• Stage two means that there is a tear in the tendon that affects its regular function. You may notice that your foot has started to become flatter. A radiological investigation will reveal the start of an arch collapse deformity. During physical examination, you will no longer be able to complete the single-leg heel raise test.
• Stage three is characterised by significant degeneration and deformation at the ankle, which is rigid, meaning it cannot be corrected by hand. Physical examination at this stage will reveal severe sinus tarsi pain while a radiological exam will reveal subtalar arthritis and arch collapse deformity. You cannot complete a single heel raise test.
• Stage four means that the deltoid ligament is compromised and there are degenerative changes at the ankle joint. The flatfoot deformity is worse and rigid throughout the foot. A physical examination will reveal ankle pain and severe sinus tarsi pain. As for radiography, it will show an arch collapse deformity, subtalar arthritis, and a talar tilt.

PTTD is an overuse condition, meaning that it is caused by repetitively overloading and straining the tendon past what it can safely handle, resulting in damage, inflammation and ultimately the inability of the tendon to carry out its role. Contributing factors to the development of PTTD can include:

• Going too hard too fast and placing too high of a load on the tendon repetitively, often seen during sports
• Having a naturally flat foot type (pronation)
• Other biomechanical issues in the feet, like weak calves and intrinsic foot muscles, tight hamstrings or calves, and poor control at the hip and knee
• Wearing flat, unsupportive footwear which results in tendon overloading
• Regular physical activity such as running, long-distance walking, hiking and climbing stairs
• Increased weight, which increases the demand on the tendon
• Conditions such as diabetes and hypertension
• Previous injury to the ankle or the tendon

We often see tibialis posterior tendinopathy in older adults, middle-aged women, and young athletes. In older women, this is linked to age-related changes in their collagen structure, which leads to reduced support and reinforcement in the arch, which can lead to a flatter foot and greater strain on the posterior tibial tendon. 

Before you get in to see your podiatrist, there are several things you can do to ease your foot and ankle pain:

• When swelling and pain are present, rest your foot and apply ice to the area for no more than 20 minutes at a time.
• Consider taking non-steroidal anti-inflammatory medication to give you temporary relief from some of your pain and symptoms.
• Keep your feet supported in good shoes both indoors and outdoors. Ideally, this will involve a supportive sports shoe with in-built arch support (if you need recommendations on a new shoe that will be best for your feet, our podiatrists will gladly help and give you names and styles during your appointment).
• Avoid being in bare feet, as this is when your posterior tibial tendon will have to work hardest
• Opt for low impact activities such as swimming or cycling throughout your recovery, as opposed to higher impact activities like running. It’s very important to many of our patients’ lifestyles and personal goals to be able to stay active during their recoveries, and this is one way to help make this possible.

All of the above suggestions are designed to help give you relief from your pain, but it’s important to note that they are not designed to ‘fix’ the problem. Fixing the problem means understanding why your posterior tibial tendon has become damaged and overloaded, and addressing these causes so that they don’t continue to worsen and cause you pain. Our in-depth knowledge in these fields is why our team is trusted to care for feet affected by posterior tibial tendon dysfunction, and how we produce results that last.

Here at Matt Raden Podiatry, our trusted and experienced podiatrists treat posterior tibial tendinopathy regularly, utilising a range of evidence-based and proven methods combined with getting to know your goals, your lifestyle and your preferences.

Every appointment starts with a biomechanical assessment to uncover the true causes of your problem in a structured and measurable way. Your assessment involves a physical exam, testing the range of motion at your joints and the strength in your feet and legs, assessing your foot posture, and performing a video gait analysis. If we suspect you may have a partial tear in your posterior tibial tendon, we’ll refer you for medical imaging. Your treatment with us may involve:

• Orthotics (insoles): using the measurements and results of your biomechanical exam, our podiatrists can prescribe custom foot orthotics that work to keep your posterior tibial tendon, foot and arch best supported with every step, creating an ideal environment for healing and repair. Orthotics should be as unique for your feet as prescription glasses are for your eyes, which is why it’s important to have them professionally prescribed by a podiatrist..
• Footwear recommendations: your footwear plays a vital role in supporting your recovery, housing your orthotics, keeping your feet comfortable, and preventing injury. This is why we make custom footwear recommendations and take the time to assess your footwear and answer all of your footwear-related questions.
• Personalised stretching and strengthening programme: for those where weak or tight muscles and tendons have contributed to the development of your posterior tibial tendon, we will design a tailored exercise program to help address these causes, support your recovery, and help prevent your pain from recurring in the future. We know it can be difficult to remember your exercise program, which is why we email you a video tutorial of every exercise we prescribe.
• Temporary activity modification: in some cases, we may need to make some adjustments to your regular training and activities, to best support your recovery.
• Where injury to the tendon is severe, such as a significant tear, a brace or cast may be required to completely off-load the tendon

In very severe cases of posterior tibial tendon dysfunction, a referral to explore surgical options may be necessary.