Posterior Tibial Tendon Dysfunction (PTTD)

May 15, 2019

Do you ever experience pain on the inner aspect of your ankle while running but don’t recall ever spraining or injuring yourself?

The pain may only ever present at the beginning or after a run, or sometimes you may even think it is just a niggle and can push past it, guess again! This little niggle that you may have been neglecting for the past few runs could potentially be the first stage of Posterior Tibial Tendon Dysfunction (PTTD), and is likely to become a lot more painful and debilitating!

The Tibialis Posterior muscle is located in the deep posterior compartment of the lower leg, and is a key muscle and tendon when it comes to stabilisation, as well as aiding in plantarflexion and inversion of the foot and ankle. Whilst the muscle belly helps to make up the calf muscles, the tendon extends down the inner aspect of the lower leg, passing behind the bony protuberance (medial malleolus) and inserting on to several midfoot bones (navicular and medial cuneiform) helping to maintain the arch of the foot.

PTTD, which is often called ‘adult acquired flat foot’ is a condition that is caused by changes in the Tibialis Posterior tendon, impairing its ability to support the arch. It is often caused by overuse, which is why PTTD is common amongst runners and athletes. Symptoms generally include pain at the medial ankle, swelling and flattening of the arch, however as the condition progresses the symptoms will change.

PTTD is progressive and disabling, and according to Johnson and Storm occurs in 4 stages:
Stage 1 – The Posterior Tibial tendon is inflamed however fibres are still intact. There may be swelling evident, but there is no structural deformity. You are still able to perform a single heel rise
Stage 2 – The tendon is dysfunctional and some deformity is present (starting to acquire a flat foot), however this is still correctable. There is difficulty performing a single heel rise
Stage 3 – There is degenerative changes in foot joints. Deformity is fixed and you cannot perform a single heel rise
Stage 4 – There is tilt of one of the main stabilising bones in the foot (talus) leading to lateral tibiotalar degeneration. Definitely cannot perform a single heel rise!

The first two stages of PTTD can be treated and managed nonoperatively. Depending on the severity of the condition, treatment usually begins with orthotic intervention, footwear modifications, strapping or immobilisation (CAM boot) in conjunction with physical therapy. Another treatment modality that we are able to utilise within our clinics in Extracorporeal Shock Wave Therapy (ESWT) that can assist with improving vascularization and stimulating cellular repair of the tendon promoting new cell growth and eliminating pain.

The most effective way to address the causative risk factors while complimenting other treatment options is through the use of an orthotic. An orthotic device is able to correct any biomechanical abnormalities, by supporting the arch and reducing the load on the tibialis posterior tendon.

If you are currently experiencing any form of ankle pain, or any other lower limb pain associated with overuse or running, book an appointment with one of our podiatrists today so they can conduct a full biomechanical assessment. Don’t let an injury get in the way of your training!

Steph Kreskas 



Johnson, K. A., & Storm, D. E. (1989). Tibialis posterior tendon dysfunction. Clinical Orthopaedics and Related Research, 239, 196-206.