Tibialis Posterior Tendinopathy
1. Introduction
The tibialis posterior muscle attaches the calf muscle to the bones on the inside of the foot. The action of the muscle is to plantar flex (point foot downwards), to invert the ankle (turn the foot inwards) and elevate the medial longitudinal arch (inner foot arch). Tibialis posterior tendinopathy or posterior tibial tendon dysfunction (PTTD) is an injury to the tendon of this muscle.
The tibialis posterior tendon supplies power for controlling acceleration and deceleration in walking and running. Due to the important and repetitive role in foot mechanics, acute and chronic injury can happen in athletes (8).
When the tendon is injured and becomes inflamed this is called tendinitis, or tendinopathy. Historically, tendinopathies were referred to as ‘tendinitis’ based on the belief that the condition was caused predominately by inflammation. However, our understanding has improved, and it is now accepted that persistent tendinopathies are caused by tendinosis (tendon degeneration) (5).
Currently, the best evidence for treating tendinopathy is based on progressive and appropriate loading of the tendon. Avoidance of activities that aggravate the problem is important to allow healing to take place. Orthotics (splints and bracing) and analgesics can be effective in relieving symptoms (2). Most tendinopathies will respond well to gradual strengthening. A surgical procedure can be considered on an individual basis if all other treatment options have been exhausted (1).
Frequently Asked Questions
- This is a condition involving injury to the tendon found around the bone at the inner side of the ankle.
- It is a common condition of the ankle and foot.
- It is estimated that the prevalence is anywhere from 3.3% to 10%, depending on age and gender (1).
- Chronic problems are common in middle-aged to elderly athletes and acute tendinopathies are more common in the younger athlete (8).
- No.
- There is no serious pathology linked to posterior tibial tendinopathies.
- Due to the progressive nature of the condition, prompt treatment is advised. If treated early enough, your symptoms can resolve more quickly.
- It can lead to flat foot deformity in the athlete/general population if the problem persists (1, 9).
- More common in women.
- Age – as you get older changes occur in tendons which can lead to tendinopathy.
- Being overweight – puts more pressure on the tendon.
- People that have diabetes or high blood pressure.
- Common in runners and other athletes.
- In can be caused by tendon overuse, abnormal foot mechanics and trauma (1, 2).
- Pain on the inner side of the foot and ankle (along the course of the tendon).
- Swelling.
- Flattening of the arch.
- Inward rolling of the ankle.
- There are four stages to the condition ranging from acute inflammation of the tendon, which in later stages can lead to flat foot deformity (1, 6).
- Treatment options for posterior tibial tendinopathy are decided based on whether there is an acute inflammation and whether there is foot deformity (2).
- Options include physiotherapy exercises, ice/heat therapy, avoidance of activities that aggravate your symptoms, orthotic devices (splints or bracing), immobilisation, medications and shoe modifications (1, 2).
- This will depend upon several factors including, but not limited to, medical/lifestyle factors, stage of injury, your ability to follow your rehabilitation, etc.
- Posterior tibial tendinopathy can take between 4-6 weeks to improve and early/too strenuous activity on a healing tendon can result in a setback in recovery.
- Patients with a more persistent problem can still be effectively treated non-operatively and can heal in 4 months (2).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
The symptoms of tibialis posterior tendinopathy include:
- Pain and swelling on the inner side of the foot and ankle.
- Pain that increases with activity, such as with running or walking, and in later stages there can be pain on the outside of the ankle.
- These symptoms may cause the arch of the foot to become flat over time.
- Tendon pain is ‘dose-dependent’, which means the pain will be aggravated based on the amount of load placed on it (6). This means that loading the tendon excessively by exposing it to strong forces, or by performing repetitive movements in a relatively short period of time, can result in the tendon not being able to adapt quickly enough. The tendon may begin to break down, leading to pain and developing a tendinopathy.
3. Causes
In tibialis posterior tendinopathy there can be inflammation and/or degeneration. It is credited to repetitive loading causing microtrauma (a very slight injury) and progressive failure of the tendon (3). This can occur in athletes due to the repetitive forces placed on the tendon during sports (8). Also, a lack of blood supply to this region can occur and may contribute to developing the condition (4).
The structure and location of the tendon can also be seen as a factor in developing tibialis posterior tendinopathy. This is due to the tendon wrapping around the medial malleolus (inner side bone of the ankle) which can put stress on the tendon during muscle contraction. The other tendons in this region do not take this sharp turn around the ankle, so are therefore less likely to become injured (1).
Another cause has been attributed to pressure placed on the tendon by structures in the region, such as the flexor retinaculum, abnormalities of the talus bone, structural changes due to osteoarthritis and a pre-existing flat foot (3).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing tibialis posterior tendinopathy. It does not mean everyone with these risk factors will develop symptoms (1, 2, 8).
- In athletes, over-training or sudden increase in activity can be a risk factor in developing this condition.
- Acute (quick onset) tendinopathy is more common in younger athletes.
- Chronic (long term) commonly occurs in middle-aged to elderly athletes.
- Inappropriate footwear.
- Diabetes, high blood pressure and obesity are also a risk factor.
- Steroid use, either orally or by local injection, can also increase its risk, therefore steroid injections are no longer recommended for this problem.
- Prior surgery or trauma can also lead to this condition.
5. Prevalence
Tibialis posterior tendinopathy is a common condition of the ankle and foot. The true prevalence is unknown as no large studies have been undertaken but it is believed that the prevalence is anywhere from 3.3% to 10% depending on age and gender (1). Persistent tendinopathies are more common in the middle-aged to elderly athletes. In younger athletes, acute tendinopathies are more common but persistent problems can also occur (8).
6. Assessment & Diagnosis
Your musculoskeletal physiotherapist can provide you with an accurate diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other conditions and gain a greater understanding of your physical abilities.
Your physiotherapist will ask how your condition affects you day-to-day so that treatment can be tailored to your needs. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment. Images like X-ray, magnetic resonance imaging (MRI) or ultrasound are usually not needed to achieve a working diagnosis but, in some cases, they may be needed to confirm tendinopathy.
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your tibialis posterior tendinopathy. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
Research is clear that changing the load on the tendon is the key element which stimulates recovery. This involves avoiding any activities that aggravate your symptoms, whilst progressively loading the tendon to improve its tensile strength. Recovery can take some time, as the speed of tendon regeneration is much slower than other structures in the body (5).
Your musculoskeletal physiotherapist will give guidance on the progression of your exercises to gradually increase the load being put through the tendon. For patients wanting to return to sports or achieve a high level of function, more demanding exercises will be introduced at the correct time to help this.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing posterior tibial tendinopathy. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Tibialis Posterior Tendinopathy
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme begins the process of loading the tendon in a gentle way to avoid aggravating the condition. Pain should not exceed 5/10 on your self-perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
At this stage, the exercises become more challenging to try and put more stress on the tendon and stimulate it to recover. Pain should not exceed 5/10 on your self-perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a progression of the previous stage with more functional exercises and again a greater amount of stress on the tendon with the aim of returning to normal activities. Pain should not exceed 5/10 on your self-perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to sport, a rehabilitation programme should incorporate plyometric based exercises; this might include things like jumping and running exercises (5, 7).
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from further assessment to ensure you are making progress and to establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reccurrence.
11. Other Treatment Options
- Orthotic devices or bracing – to give your arch the support it needs. Your foot and ankle surgeon may provide you with an ankle brace or a custom orthotic device that fits into the shoe.
- Immobilisation – sometimes a short-leg cast or boot is worn to immobilise the foot and allow the tendon to heal, or you may need to completely avoid all weight-bearing for a while.
- Physiotherapy – adjuncts to exercise may be used by your therapist to relieve symptoms.
- Medications – nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
- Surgery – for some advanced cases, surgery may be the only choice. Your foot and ankle surgeon will decide the best approach for you.
References
- Knapp PW, Constant D. Posterior Tibial Tendon Dysfunction. [Updated 2020 Jun 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542160/
- Alvarez, R.G., Marini, A., Schmitt, C. & Saltzman, C.L. (2006). Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot & ankle international, 27(1), 2-8.
- Manske, M.C., McKeon, K.E., Johnson, J.E., McCormick, J.J. & Klein, S.E. (2015). Arterial anatomy of the tibialis posterior tendon. Foot & ankle international, 36(4), 436-443.
- Lin, T. W., Cardenas, L. & Soslowsky, L. J. (2004). Biomechanics of tendon injury and repair. Journal of biomechanics, 37(6), 865-877.
- Johnson, K.A. & Strom, D.E. (1989). Tibialis posterior tendon dysfunction. Clinical orthopaedics and related research, (239), 196-206.
- Geideman, W.M. & Johnson, J.E. (2000). Posterior tibial tendon dysfunction. Journal of Orthopaedic & Sports Physical Therapy, 30(2), 68-77.
- Kohls-Gatzoulis, J., Angel, J.C., Singh, D., Haddad, F., Livingstone, J. & Berry, G. (2004). Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot. Bmj, 329(7478), 1328-1333.
- Aurichio, T.R., Rebelatto, J.R. & De Castro, A.P. (2011). The relationship between the body mass index (BMI) and foot posture in elderly people. Archives of gerontology and geriatrics, 52(2), 89-92.
Other Conditions in
Lower Legs, Ankles
Low Back Pain and Sciatica
Sciatica is a symptom describing pain and/or pins and needles down the back of the leg.
Baker’s Cyst
Swelling in the popliteal space (space behind the knee) that causes a visible lump.
Adolescent Shin Pain
A common complaint in adolescent athletes affecting those aged between 12-18.