Posterior Tibial Tendon Dysfunction (PTTD)

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What is Posterior Tibial Tendon Dysfunction?

The Tibialis Posterior tendon travels around the back and inside of the leg, foot and ankle making it one of the major supporting structures of the foot.

This tendon can become strained resulting in pain, inflammation and stretching and over time causes the arch along the inside of the foot to become flatter.  This is known as Posterior Tibial Tendon Dysfunction.

Signs and Symptoms

You may notice:-

• Ankle stiffness
• Pain and swelling along the inside of the ankle which can range from mild to severe 
• Pain and swelling may increase with prolonged walking and activity or at the end of the day
• Foot and ankle weakness as though there is a loss of strength when you lift your heel off the ground walking
• Inability to raise up on to tip toe
• You may notice your ankles roll inwards and your foot becomes flatter
• Pain on the outside of your ankle as the foot becomes flatter and its position changes
• You may suffer tingling, shooting, burning or stabbing as a result of inflammation of the nerve inside the tarsal tunnel which travels beside the tendon.

Causes/risk factors 

Anybody can suffer with this condition however it is common in:

• Females aged over 40 years old.
• Occupations involving prolonged standing
• Acute injuries such as falls and ankle injuries
• Previous ankle injuries can cause inflammation and tears to the tendon
• Having flat feet places a greater strain on the tendon.
• Overuse of the tendon, altered foot mechanics and pressure distribution due to the shape of the foot or joint changes can also cause this overuse  
• Obesity increases the weight placed on your feet and therefore additional strain on the tendon
• Aging causes tendons to lose their elasticity and ability to glide as smoothly increasing the risk of dysfunction
• Systemic conditions such as high blood pressure, diabetes and rheumatoid arthritis can weaken tendons
• Tendons in this region have a poor blood supply so can take a long time to heal.
• Footwear - Wearing slip on, backless (flip flops) or soft heel counter footwear causes an increased strain on the tendon
• Repetitive heavy impact on the feet for example during sports and dancing has also been known to cause them.

Treatment

PTTD is a chronic progressive condition so is easier treated in the early stages preventing the need for surgery.

Cryotherapy

Resting the tendon by reducing your walking, standing and high impact activity and apply an ice pack (frozen vegetables covered with a towel to prevent ice burns) for 10 minutes, 4 times a day can reduce pain and inflammation.

Lifestyle

If you are overweight losing weight will reduce the load going through your feet when you are standing or walking.

Footwear

Keep pressure off the affected joint by:

• wearing comfortable shoes, trainers or hiking boots which have a high and firm heel counter and give the most support.  
• Avoid slip-on or backless shoes as they usually have a soft and low heel counter and therefore increase strain on the ankle and tendon.

This will also allow space for any orthoses you may need.

In advanced stages of this condition you may be required to wear specially made orthotic shoes or boots to help with your pain.

Please see our footwear leaflets for further advice.

Medication

Taking pain killers such as paracetamol and ibuprofen when needed to reduce pain and inflammation.

Activity

Make changes to/reduce any activity that regularly stresses the ankle.

Tendon strengthening exercises are prescribed to improve mobility, flexibility, reduce pain and reduce the risk of re-occurrence. 

Try this heavy slow resistance training:

1. Long sitting with arm support. Feet resting against a wall.
2. Push your toes into the wall, as if to try and push the wall away. Feel the muscles of your calf tightening.
3. Repeat 15 times and perform 3 repetitions with a 2 minute rest after each set.
4. Perform once per day for 12 weeks or until advised to stop.

Try this double leg heel raise:

1. Stand holding onto a wall or supportive surface such as the back of a chair.
2. Ensure your feet are hip distance apart and toes facing forward.
3. Push up onto the balls of your feet by lifting the heels from the ground over a count of 3 seconds.
4. Slowly lower yourself to the ground over a count of 3 seconds.
5. Repeat 40 times and perform 2 repetitions with a 2 minute rest after each set
6. Perform am/pm for 12 weeks or until advised to stop
7. Once you have seen a clinician you may be asked to perform this exercise using only one foot at a time (single leg heel raise).

Orthoses

Wearing orthoses can reduce forces around this area, allowing time for the tendon to heal and relieving pain. 

Offloading Boots

Short term immobilisation with a boot or cast will allow resting of the tendon.

Surgery

Surgery may be offered if other treatment options fail.  The type of surgery depends on the severity of the condition, ranging from a tendon repair to an ankle reconstruction.  Recovery is prolonged and requires at least 3 months off work depending on your job and 18 months to feel the full benefit of surgery.

Diagnosis

Diagnosis and clinical findings are initially based on observations.

Sometimes in later stages and where surgery is indicated imaging such as MRI scans may be ordered to confirm the diagnosis and check the extent of the injury. 

Blood tests may also be required if a systemic condition is thought to be the cause.