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Posterior Tibial Tendon Dysfunction

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Other Names

  • Tibialis Posterior Tendinopathy
  • Posterior Tibial Tendon Dysfunction (PTTD)
  • Posterior Tibialis Tendon Insufficiency
  • Tibialis Posterior Tendon Rupture
  • Tibialis Posterior Tendonitis
  • Tibialis Posterior Dysfunction
  • Peroneal Tendon Instability


  • This page refers to both acute and chronic injuries of the Tibialis Posterior tendon
    • Generally, this refers to posterior tibial tendon dysfunction (PTTD)
    • Other tendinopathies of the tibialis posterior are also discussed here



  • Epidemiology is poorly described in the literature
  • Typically unilateral, bilateral disease is uncommon[1]
  • Prevalence
    • Estimated to be between 3.3% and 10% of the population (need citation)


  • General
  • Posterior Tibial Tendon Dysfunction (PTTD)
    • Progressive, degenerative condition of the tibialis posterior tendon
    • Typically occurs in obese, middle-aged women
    • Results in progressive pes planus, hindfoot valgus and dysfunction of the posterior foot
    • This can cause limitations in mobility, significant pain and weakness


  • Acute/Traumatic
    • Inflammation of tendon can be seen after an acute injury such as ankle fracture, direct trauma to tendon[2]
  • Tendinitis/ Tendonosis
    • Repetitive microtrauma leading to tendinopathy is more common than an acute traumatic injury
    • Tends to occur in hypovascular region along the medial malleolus
  • Chronic
    • Degeneration of tendon can be seen with overuse or chronic tendinopathies that are untreated
    • Once the tendon becomes inflamed or torn, or loses function, the medial longitudinal arch of the foot begins to collapse
    • The patient will develop relative internal rotation of tibia and talus[3]
    • Eversion of subtalar joint, heel moves into valgus alignment, abduction of talonavicular joint
    • Contracture of the Achilles tendon can occur with a lateral shift of the normal axis[4]
  • Anatomic contributions may include
    • Sharp turn behind the medial malleolus taken by the tibialis posterior
    • The Flexor Retinaculum
    • Abnormal anatomy of the talus
    • Degenerative changes associated with osteoarthritis
    • Pre-existing Pes Planus (as opposed to acquired pes planus from PTTD)

Associated Conditions


  • Posterior Tibialis
    • Originates in the Deep Posterior Compartment of the Leg
    • Attaches along plantar surface of multiple tarsal, metatarsal bones
    • Aids in plantarflexion, inversion and supports medial arch of foot
  • Pathology
    • Hypovascular area prone to degeneration is approx. 0.6 to 2.2 cm proximal to the medial malleolus[5]

Risk Factors

Differential Diagnosis

Clinical Features

Clinical demonstration of 'too many toes' sign on right side. Note the hindfoot valgus.[7]
  • History
    • Typically insidious without an acute cause
    • Pain most commonly located posterior to the medial malleolus, medial hind foot
    • May have medial longitudinal arch pain
    • Pain worse with activity, especially push off phase during gait
    • Trouble walking on uneven surfaces, up or down stairs
    • In more chronic patients, they may have hind foot pain
    • Abnormal shoe wear pattern
  • Physical Exam: Physical Exam Foot And Ankle
    • Tenderness with palpation of the tibialis posterior tendon, especially posterior to the medial malleolus
    • Pain and/or weakness with resisted inversion and plantarflexion of the ankle
    • Medial ankle pain with standing heel raise
    • May have overpronated foot and/or planovalgus foot deformity
    • Valgus hindfoot, equinus contracture may be present
  • Special Tests


Lateral foot radiograph demonstrating severe pes planus with plantar facing talus, reduced calcaneal inclination angle consistent with PTTD[8]


  • Standard Radiographs Ankle, Standard Radiographs Feet
    • Should be weight bearing
  • Findings
    • May be normal early on
    • Collapse of medial longitudinal arch
    • Joint degeneration
    • Increased talonavicular uncoverage
    • Increased talo-first metatarsal angle (or Simmons angle)


  • Findings
    • Tendon changes (early)
    • Degeneration (later)


  • Can evaluate
    • Tendon size
    • Degree of degeneration
    • Presence of fluid


US of the posterior tibialis tendon showing hypoechoic areas within the tendon and peritendinous fluid consistent with tendonosis and tenosynovitis[8]

Johnson and Strom Classification

  • I: Inflamed, intact tendon without clinical deformity[3]
    • Able to perform single leg heel rise
    • Mild tenosynovitis
  • IIA: Ruptured or non-functional tendon with planovalgus deformity
    • Arch collapse on a radiograph
    • Unable to perform single-heel raise
  • IIB: Ruptured or non-functional tendon with planovalgus deformity
    • Arch collapse and talonavicular uncoverage (over 40%) on a radiograph
    • Unable to perform single heel raise
    • Flexible flatfoot deformity
    • Characteristic forefoot abduction
    • “too many toes” sign
    • Flexible flatfoot deformity
  • III: Advanced foot deformity with subtalar joint osteoarthritis
    • Subtalar arthritis on a radiograph
    • Unable to perform single heel raise
    • Flatfoot deformity with rigid forefoot abduction, hindfoot valgus
  • IV: Ankle joint involvement with tibio-talar degeneration
    • Valgus deformity of talus in the ankle mortise visualized on AP radiograph of the ankle
    • Talar tilt due to deltoid ligament compromise
    • Subtalar arthritis on radiographs
    • Unable to perform single heel raise,
    • Flatfoot deformity with rigid forefoot abduction and hindfoot valgus



  • PTTD
    • Progressive degenerative process which will get worse if left untreated
    • Stage I/II patients due well with orthosis and physical therapy, most patients returned to full strength at 4 months[9]
    • Surgical outcomes in more severe cases produce less predictable results (need citation)


  • Indications
    • Most PTTD Stage I, some stage II
    • Most forms of tendonitis or tendinosis
    • Patients who are mostly sedentary or poor surgical candidate
  • Activity modification
  • Immobilization with Tall Walking Boot
    • Duration 3-4 weeks (followed by PT)
  • Orthotics including Shoe Inserts, Ankle Foot Orthosis
  • Physical Therapy
    • Emphasis on stretching Achilles tendon, strengthen tibialis posterior
    • Eccentric exercises


  • Indications
    • Some PTTD stage II, most stage III/IV
    • Failure of conservative management after 3-4 months
  • Technique
    • II: calcaneal osteotomy, posterior tibial tendon excision, flexor digitorum longus transfer, and achilles tendon lengthening
    • III: triple arthrodesis (calcaneocuboid, talonavicular and subtalar joints)
    • IV: Ankle arthrodesis

Rehab and Return to Play


  • Post surgical
    • Non-weight bearing cast or splint for around 6 to 8 weeks

Return to Play

  • Needs to be updated


  • Posterior tibialis tendon rupture
  • Acquired Pes Planus
    • Most common cause of acquired flat foot deformity in elderly patients
  • Hindfoot Valgus

See Also


  1. Geideman WM, Johnson JE. Posterior tibial tendon dysfunction. J Orthop Sports Phys Ther. 2000;30:68–77
  2. Monto RR, Moorman CT, 3rd, Mallon WJ, Nunley JA., 3rd Rupture of the posterior tibial tendon associated with closed ankle fracture. Foot Ankle. 1991;11:400–3
  3. 3.0 3.1 Myerson M, Solomon G, Shereff M. Posterior tibial tendon dysfunction: Its association with seronegative inflammatory disease. Foot Ankle. 1989;9:219–25
  4. Mann RA. Acquired flatfoot in adults. Clin Orthop Relat Res. 1983:46–51.
  5. Manske MC, McKeon KE, Johnson JE, McCormick JJ, Klein SE. Arterial anatomy of the tibialis posterior tendon. Foot Ankle Int. 2015 Apr;36(4):436-43.
  6. Henceroth WD, 2nd, Deyerle WM. The acquired unilateral flatfoot in the adult: Some causative factors. Foot Ankle. 1982;2:304–8.
  7. Sung, Ki-Sun, and In-Sang Yu. "Acquired Adult Flatfoot: Pathophysiology, Diagnosis, and Nonoperative Treatment." Journal of Korean Foot & Ankle Society 18.3 (2014).
  8. 8.0 8.1 https://radiopaedia.org/cases/tibialis-posterior-tendon-dysfunction?lang=us
  9. Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006 Jan;27(1):2-8.
Created by:
John Kiel on 26 June 2019 22:06:18
Last edited:
4 October 2022 12:38:54