Physical Therapy for Posterior Tibial Tendon Dysfunction

Posterior tibial tendon dysfunction (PTDD) is one of the most common problems of the foot and ankle that occurs when the posterior tibial tendon is inflamed or torn, leading to an acquired flat foot. PTDD most often results from overuse due to repetitive loading on the tendon that causes microtrauma, inflammation, and eventually a tear of the posterior tibial tendon. Physical therapy can restore flexibility and strength in the foot and ankle, alleviate pain, and help patients return to the highest level of function. Because of the progressive nature of PTTD, early treatment with physical therapy and orthotics is essential in order to relieve symptoms and restore function without the need for surgery.

What is the Posterior Tibial Tendon?

The posterior tibial tendon is one of the most important tendons of the leg, attaching the calf muscle to the bones on the inside of the foot. The posterior tibial tendon plays a key role in supporting the foot and the arch of the foot when walking.

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What is PTDD [Posterior Tibial Tendon Dysfunction]?

Posterior tibial tendon dysfunction, or PTDD, is the most common cause of acquired flat foot and is a condition that causes pain in the arch of the foot. PTDD is also one of the most common problems of the foot and ankle that occurs when the posterior tibial tendon is inflamed or torn. When the tendon is inflamed or torn, it cannot provide support and stability to the arch of the foot, resulting in a flat foot.

PTDD most often results from overuse due to repetitive loading on the tendon that causes microtrauma, inflammation, and eventually a tear of the posterior tibial tendon. Risk factors that heighten the possibility of PTDD include hypertension, obesity, diabetes, previous trauma to the foot or ankle, and steroid exposure. The posterior tibial tendon can also break down with age. While the tendon can tear during an acute injury like a fall, it is more common in high-impact sports like basketball, tennis, or soccer where repetitive movements can inflame and tear the tendon.

Common symptoms of PTDD include:

• Pain on the inside of the foot along the posterior tibial tendon when used or touched

• A collapsed arch, or flat foot

• Pain in the inside of the foot or weakness when rising onto your toes during a single leg heel raise

• Pain when using the arch of the foot

• Pain that worsens with activity, especially high-intensity or high-impact activities like running

• Pain on the outside of the ankle (when the foot collapses, the heel bone can shift to a new position outward which puts pressure on the outside of the ankle bone)

There are four stages of PTDD:

1. Stage 1: Tendon becomes inflamed, but the foot arch remains intact. However, the individual may not be able to tolerate as much activity as usual.

2. Stage 2: The tendon becomes painful and stretched out and may even rupture, which causes the arch to collapse. The foot can become deformed.

3. Stage 3: The ankle joint is now affected as well as the arch of the foot. Individuals may also develop arthritic symptoms like pain and stiffness in the ankle. The foot becomes significantly deformed and degenerative changes occur in the connective tissue in the back of the foot.

4. Stage 4: Arthritic pain, stiffness, and degenerative changes are present in one or more of the three joints in the ankle as well as a total collapse of the arch of the foot.

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Physical Therapy for Posterior Tibial Tendon Dysfunction

Physical therapy can restore flexibility and strength in the foot and ankle, alleviate pain, and help patients return to the highest level of function. Because of the progressive nature of PTTD, early treatment is essential in order to relieve symptoms and restore function without the need for surgery. If left untreated, PTTD can progress to a point that the patient has extremely flat feet, arthritis in the foot and ankle, and increasing limits on the ability to run and walk.

During the initial evaluation, the physical therapist conducts a series of tests to assess the extent of PTDD. The therapist assesses swelling along the posterior tibial tendon in the ankle and foot and the range of motion, tenderness, and pain that occurs when moving the foot or ankle. The therapist also views the foot from behind to check for changes in structure or shape, e.g. heel pointing outward or the inner arch resting flat on the ground. If the foot looks like it has “too many toes,” this means that more toes are visible on the outside of the foot and is likely caused by PTDD; normally, just the pinky toe and part of the fourth toe are visible when viewed from behind.

The single-limb heel test is a key test to determine the health of the posterior tibial tendon. During this test, the patient must raise the healthy foot off the ground and attempt to lift onto the toes of the affected foot. Someone with PTTD can’t do one heel raise, whereas someone with a healthy foot can do 8-10 heel raises.

Physical therapy treatment for PTDD can include:

• Activity modification to minimize stress on the foot, ankle, and tendon and recommendations for safe progression to return to activity

• Pain and swelling management using ice and hands-on massage

• Manual therapy hands-on techniques to soft tissue and joints in the foot and ankle complex to help regain normal foot range of motion

• Balance and gait training to improve walking pattern

• Flexibility training and stretching of the foot and ankle

• Use of orthotics to improve symptoms and support the arch of the foot and the tendon

• Targeted strengthening of the foot, ankle, and leg

Conservative treatment with physical therapy and orthotics treats the majority of PTDD cases and can last for about 3-4 months. Surgery is only done if physical therapy does not resolve symptoms within six months or in severe cases of PTDD. Post-surgery rehabilitation is essential to regain function and strength in the foot.

A recent study found that 89% of patients with stage 1 and 2 PTDD responded to orthotics and physical therapy. Nearly all of these patients were back to full strength by four months. In contrast, analyses of surgical treatment outcomes revealed results that are much less predictable, and a return to the pre-disease state is not guaranteed after surgery.

Posterior tibial tendon dysfunction can be debilitating and limit your function. Work with a physical therapist to regain function and strength in your foot and the activities you love!