Topics discussed on this
Posterior Tibial Tendon (PTT)
Tibialis Posterior Tendon
Posterior Tibial Tendon Dysfunction (PTTD)
What is the Posterior Tibial
Tibial Tendon (PTT), also
known as the Tibialis Posterior Tendon,
is the attachment for a major muscle on the back of the tibia
and fibula, (the lower leg bones). It comes down
the back of the leg, passing behind the
(the bump on the inside of the ankle), and
attaches to the foot at the
on the medial (inside) border of the foot.
The tendon is very strong and very important
in gait. The tendon's primary function is to supinate
the foot--to raise the arch, lock bones into a stable position
and help push you off from the ground.
Because it is used so much in gait, the PTT undergoes
a great deal of stress. For this reason, the tendon is vulnerable
to injury, particularly when certain other conditions are present.
When the Posterior Tibial Tendon is injured, several
things may occur. First, if the injury is not severe, the tendon
may simply become inflamed, a condition known as
If the injury is chronic, the tendon may be gradually become attenuated,
or stretched out. In this case, the tendon no longer able to
function as it once did, and the foot becomes non-functional (discussed
below). This is known as "Posterior
Tibial Tendon Dysfunction" or PTTD. Finally,
if the injury is severe enough, the tendon may completely rupture, a
problem that usually requires surgical intervention.
What conditions predispose someone
There are many predisposing factors to developing
posterior tibial tendon problems:
(Females get problems more than males.)
(This appears to be the single most common factor in patients with
(Steroids weaken tendon, and this is one reason why steroids like
cortisone should not be used to treat this condition.)
Excessive weight (It's obvious, perhaps, but the
more force applied to the tendon, the more stress it's under, and
the more likely it is to fail.)
Age (Except for acute tendon rupture, which is
usually seen in younger patients), most PTTD patients are over 60.)
Smoking (Smoking disrupts circulation and weakens
Rheumatological (arthritic) conditions (Certain
types of arthritis tend to also weaken the tendon and may create
deposition within the tendon)
A history of injury (This may mean sudden trauma or
chronic, reptetitive, low-grade trauma.)
A fracture of the navicular (This is the bone where
the tendon attaches.)
Biomechanical abnormalities such as:
Foot type (A pronated foot is one that flattens too much).
A leg-length difference.
Calcaneal Valgus (This is a condition where the
heel bone is no longer straight, but rolls inwards relative to the
Forefoot Varus (This is a condition where the
front of the foot--the metatarsals and toes, e.g.--is positioned
inverted relative to the heel).
The presence of an
Tibiale Externum, or OTE. (The OTE is a small, extra bone near
What kind of problems does the patient
experience with PTTD?
Stage One describes the
condition when the patient has some sort of biomechanical or
predisposing factor before symptoms develop.
point when the tendon begins to develop some symptoms (tendinitis) along
the course of the tendon or in the calf (shin splints). There may
be a mild weakness of the tendon.
is the stage
when the tendon begins to become attenuated or stretched out
(tendinosis) and functions poorly. It may be hard for the patient
to stand on his toes.
describes the point where the foot begins to collapse, causing
instability in the foot and arthritis in the joints of the
Arthritis develops, and the pain usually
worsens. To the right is a good example of a foot
where the arch has collapsed as a result of posterior tibial
How is PTTD diagnosed?
While it's not usually hard to
diagnose PTTD once you know to look for it, the condition is very much
under-diagnosed and overlooked. The condition is also fairly
common. In our office we see the condition once every week or so.
In most cases the diagnosis can be
made by history and physical alone. Pain along the course of the
tendon, muscle weakness on one side over the other, and a collapsing
arch are all possible indicators.
Tendons don't typically show up on
but radiographs may be of some use when calcification of the tendon, a
fractured navicular, a collapsing arch or degenerative changes in the
join are suspected clinically. A physician with a good
biomechanical background will also be able to see many associated
biomechanical abnormalities on film.
CT may also be of some use, but
MRI is generally more useful, as it images tendons and other soft tissues
better, and it is highly sensitive and specific for this injury. A
tenogram, (a test where dye is injected into the tendon sheath) is still
another alternative, though its invasive nature means other diagnostic
tests are more frequently considered.
How is PTT treated?
This condition may be rapidly progressing, so
treatment should be aggressive.
acute cases, the
primary direction of treatment is based upon stabilizing the joint and
calming the tissue.
To stabilize the joint, treatment may range from
taping and padding for mild injuries to complete immobilization with a
soft or hard cast.
The tissues may be calmed down with conservative care
like ice, compression, anti-inflammatories, and ultrasound. Steroid
injections are not suggested, as they tend to weaken tendons.
Extra-corporeal Shockwave Therapy (ESWT)
is another treatment option. This is a technology
analogous to lithotripsy, the technique that uses sound waves to
break up kidney stones instead of surgery. ESWT promotes
healing of bone and tendon and ligaments where they attach to
bone. It stimulates healing at the cellular level and can
offer fairly quick relief, depending upon the location of the
PTTD injury. However, even when ESWT is successful, most
cases of PTTD still require that long-term biomechanical
abnormalities still need to be addressed.
(We are please to offer
the newest ESWT technology available anywhere, piezoelectric
ESWT. For more information, visit the website of our
partners in ESWT,
aggressive functional orthoses is useful for most patients, even many
severe ones. New advances in
therapy, such as
Richie Braces or inverted orthoses, are particularly helpful and may frequently postpone surgery.
In fact, with the newer types of orthotic therapy, we find that less
than 10% of PTTD patients end up requiring surgery.
If orthoses do not adequately resolve the complaint,
surgical intervention may be indicated. Procedures range from
repair of the degenerative portions of the tendon and performing tendon
transfers to stabilizing or fusing one or a combination of joints in the
mid and rearfoot. The procedure chosen is variable from patient to