Posterior Tibial Tendon Dysfunction (PTTD)

The Posterior Tibial Tendon is one of the most important structures supporting the arch of the foot. When this tendon becomes inflamed, stretched or torn, the arch gradually collapses, resulting in a condition known as Posterior Tibial Tendon Dysfunction (PTTD) or Adult Acquired Flatfoot Deformity.

Without timely treatment, the condition may progress from mild tendon pain to severe flatfoot, arthritis and long-term disability.

At the Foot & Ankle Centre, Dr Anand Jadhav provides comprehensive evaluation and stage-specific treatment for PTTD, ranging from physiotherapy and orthotics to advanced tendon reconstruction and corrective foot surgery.

What is the Posterior Tibial Tendon?

The posterior tibial tendon runs behind the inner side of the ankle and attaches to the bones of the midfoot. It plays a vital role in:

• Supporting the arch of the foot
• Stabilising the ankle while walking
• Controlling foot movement
• Helping the foot push off during walking and running

When this tendon weakens or tears, the arch gradually collapses and the foot begins to roll inwards, resulting in progressive flatfoot deformity.

What Causes Posterior Tibial Tendon Dysfunction?

PTTD usually develops gradually due to degeneration of the tendon, although it may also occur after an injury. Common causes and risk factors include:

• Age-related tendon degeneration
• Previous ankle or foot injuries
• Obesity
• Diabetes
• Hypertension
• Long-term corticosteroid use
• Inflammatory arthritis
• Repetitive overuse
• Progressive weakening of the tendon

The condition is more commonly seen in women over the age of 50, but it can affect active individuals of any age.

Symptoms

Symptoms usually develop gradually and may worsen over time. Common symptoms include:

• Pain along the inner side of the ankle
• Swelling behind the inner ankle bone
• Pain while walking or standing
• Difficulty walking long distances
• Painful limp
• Progressive flattening of the foot
• Loss of the foot arch
• Difficulty standing on tiptoes
• Pain on the outer side of the foot in advanced stages
• Reduced balance and walking endurance

As the condition progresses, the deformity may become rigid and arthritis can develop in the surrounding joints.

Stages of Posterior Tibial Tendon Dysfunction

PTTD is a progressive condition and is commonly classified into stages:

Stage I – Tendon Inflammation

• Pain and swelling
• Tendon remains intact
• Foot shape is normal

Stage II – Flexible Flatfoot

• Tendon weakens
• Arch begins to collapse
• Flatfoot remains flexible
• Walking becomes more difficult

Stage III – Rigid Flatfoot

• Permanent flattening of the foot
• Stiff deformity
• Arthritis develops in the hindfoot joints

Stage IV – Advanced Deformity

• Ankle joint becomes involved
• Significant deformity
• Progressive arthritis and instability

Early diagnosis offers the best opportunity to preserve the foot and avoid major reconstructive surgery.

Diagnosis

A detailed assessment includes a comprehensive medical history, clinical examination, gait analysis, assessment of foot alignment, the single-leg heel raise test and evaluation of tendon strength and flexibility.

Investigations may include:

• Weight-bearing X-rays
• MRI Scan
• Ultrasound Scan

These investigations help assess tendon damage, foot alignment and any associated arthritis.

Non-Surgical Treatment

Early-stage PTTD often responds well to conservative treatment.

Activity Modification

Reducing high-impact activities allows the tendon to recover while maintaining overall fitness.

Supportive Footwear & Orthotics

Custom-made arch supports and supportive footwear reduce strain on the tendon and improve foot alignment.

Walking Boot

In more painful cases, a removable walking boot may be recommended for a short period to allow the tendon to settle.

Physiotherapy

A structured rehabilitation programme focuses on strengthening the posterior tibial tendon, calf stretching, balance training, gait correction and progressive functional exercises.

Platelet-Rich Plasma (PRP)

PRP therapy may be considered in selected patients with chronic tendon degeneration to support tendon healing.

When is Surgery Recommended?

Surgery may be advised when:

• Symptoms persist despite comprehensive conservative treatment
• The tendon has ruptured
• The flatfoot deformity continues to worsen
• Walking becomes increasingly difficult
• Arthritis develops in the foot joints

The choice of surgery depends on the stage of the condition and the degree of deformity.

Surgical Treatment

Modern surgical treatment is tailored to each patient's condition and may include:

Tendon Repair or Reconstruction

In early disease, the damaged tendon may be repaired or reinforced using a tendon transfer, most commonly the Flexor Digitorum Longus (FDL) tendon.

Calcaneal Osteotomy

The heel bone is repositioned to improve foot alignment and restore the arch.

Ligament Reconstruction

Supporting ligaments are repaired or reconstructed to improve long-term stability.

Triple Fusion

In advanced stages with arthritis and a rigid deformity, three joints in the hindfoot may be fused to relieve pain and restore alignment.

Recovery

Recovery depends on the procedure performed. Most patients can expect:

• Immobilisation in a cast or protective boot
• Non-weight-bearing with crutches for approximately 6 weeks
• Progressive weight-bearing as healing allows
• Structured physiotherapy
• Strengthening and gait retraining
• Return to normal activities over several months

Regular follow-up and imaging help ensure satisfactory healing and restoration of foot alignment.

Can Posterior Tibial Tendon Dysfunction Be Prevented?

Although not every case is preventable, the risk can be reduced by:

• Maintaining a healthy body weight
• Wearing supportive footwear
• Strengthening the foot and calf muscles
• Managing diabetes and inflammatory arthritis
• Treating ankle injuries promptly
• Seeking early medical attention for persistent pain on the inner side of the ankle

Why Choose Dr Anand Jadhav?

With over 30 years of orthopaedic experience and 12 years of specialist practice in the NHS, United Kingdom, Dr Anand Jadhav offers comprehensive treatment for foot and ankle disorders using the latest evidence-based techniques. His expertise includes:

• Posterior Tibial Tendon Dysfunction
• Adult Acquired Flatfoot
• Foot & Ankle Reconstruction
• Tendon Repair & Tendon Transfer
• Calcaneal Osteotomy
• Foot & Ankle Sports Injuries
• Comprehensive Rehabilitation

Every patient receives an individualised treatment plan aimed at preserving the foot whenever possible, relieving pain and restoring comfortable, confident walking.

Frequently Asked Questions (FAQs)

Can Posterior Tibial Tendon Dysfunction heal without surgery?

Yes. Early-stage PTTD often responds well to physiotherapy, orthotics, supportive footwear and activity modification. Surgery is generally reserved for progressive tendon damage, persistent pain or advanced deformity.

Is PTTD the same as flat feet?

Not exactly. PTTD is one of the most common causes of adult acquired flatfoot. As the tendon weakens, it loses its ability to support the arch, leading to progressive flattening of the foot.

What happens if PTTD is left untreated?

Without treatment, the tendon may continue to weaken, causing worsening flatfoot, arthritis, increasing pain and reduced mobility. Early diagnosis offers the best chance of preserving normal foot function.