Ankle > Posterior Tibial Tendon Disorder

What is the Posterior Tibial Tendon?

The posterior tibial tendon originates at the top of the calf muscle on the back of your leg. It travels down the inside of your ankle, right behind the bony bump on the inside of your ankle (medial malleolus), and connects to a bone, called the navicular, on the inside of your foot. The height of the navicular bone is responsible for the height of your foot’s arch. Your arch height is maintained by the posterior tibial tendon and navicular attachment. The tendon also is responsible for turning your foot inward (inversion) and helping you rise up on your toes.

Commonly an overuse injury, a disorder in your posterior tibial tendon can range from mild to severe. It can start with simple tendinitis, as the tendon may become tender when an injury causes swelling. Over the course of weeks or months, the tendon pain can become chronic and interfere with activities. Active people with posterior tibial tendon disorders typically develop microtears within the tendon itself. The tendon tends to become weak and you may have difficulty lifting the inside of your foot, or inverting your foot. As a result, your navicular bone may shift toward the bottom of your foot, and you can lose arch height. These flatfoot deformities in your foot can be painful and debilitating.

Posterior tibial tendon disorders are more common in middle-aged patients, as their tendons may become insufficient and incapable of doing their job, and tendon damage is more often the result of overuse than of a specific injury. Though the exact cause in athletes is not clear, long distance runners tend to have the highest risk of developing posterior tendon disorders. Adults over age 50 may be at an increased risk of straining their posterior tibial tendon if they rapidly increase their activity level. Less commonly, a posterior tibial tendon disorder can be caused by a traumatic injury, such as a laceration that cuts into the tendon.

Considerations

If left untreated, patients over 50 who have a posterior tibial tendon disorder tend to continue to lose the height of their arch, which can lead to a progressive foot deformity. Younger patients don't normally have noticeable arch deformities, but they put themselves at risk of foot problems later in life if they do not seek treatment. A posterior tibial tendon disorder can become very painful as the foot loses its arch and becomes more deformed. A different alignment of bones in your foot can cause debilitating pain and interfere with your gait and stride. Early treatment is the best way to avoid long-term foot pain. If your tendon is not torn and you have minimal damage, physicians generally prescribe conservative treatment, which includes bracing or casting, and then orthotic inserts for your shoes. Patients commonly receive four to six weeks of conservative treatment before they become candidates for surgery. Minor posterior tibial tendon damage may be treated with debridement surgery. If there is a tear in the tendon and the flatfoot deformity has started, surgical treatment typically is aggressive to stop the progression of the disease. Surgery for torn tendons usually involves transferring another tendon that is next to the posterior tibial tendon and realigning the heel bone to properly balance the foot.

Though many people with mild or moderate ankle pain feel they can treat themselves at home, you should have your ankle evaluated by a physician, who can check for complications and decide on a specific treatment program for your ankle. There usually are three parts to an orthopedic evaluation: medical history, a physical examination, and tests that your doctor may order.

MEDICAL HISTORY

Your physician likely will ask about your activities, which may have caused your posterior tibial tendon disorder, and about when the soreness or pain began. If you have had any prior ankle injuries, your physician will ask about the treatments you have tried in the past. You should reveal any history of ankle surgeries at this time. Your physician may suspect a posterior tibial tendon disorder if you have a history of pain along the inside of your ankle that increases with activity, and any history of long distance running or a recent increase in activity. You also may be asked about other conditions, such as diabetes and allergies, and medications currently being taken, and about your physical and athletic goals – information that will help decide what treatment might be best for you in achieving those goals.

During the physical exam, your physician typically looks for swelling along the inside of your ankle. Physicians usually use their fingers to press areas all around your ankle to pinpoint your pain. Your ankle may be moved up or down, side-to-side, and rotated to see if any positions are more painful. Patients with posterior tibial tendon disorders usually feel tenderness along the tendon, in the area behind the bony bump (medial malleolus) on the inside of your ankle. Your physician may ask you to turn your ankle inward against resistance. You also may have trouble rising up on your toes while standing on the injured ankle. Your physician usually compares the arch height and bone structure in both your feet to check for deformity. Your physician also examines the position of your forefoot and ankle while you stand. When you stand straight with your feet flat on the floor, a posterior tibial disorder commonly causes the pinky toe side of your forefoot to move outward (laterally) away from the uninjured foot.

TESTS

Studies include standing X-rays to see if there is any loss of arch height when comparing the normal side to the injured side. MRI (magnetic resonance imaging) may be taken to evaluate the tendon sheath and the tendon itself, to see if there are any tears. Your physician may notice tendon damage without the tests, but MRI commonly is taken to provide a clear diagnosis.

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