Home Print this page Email this page Small font size Default font size Increase font size
Users Online: 5267
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents 
Year : 2015  |  Volume : 4  |  Issue : 1  |  Page : 26-29  

Posterior tibial tendon dysfunction: An overlooked cause of foot deformity

Mona Vale Hospital, 1 Coronation Drive, Mona Vale NSW, Australia

Date of Web Publication27-Feb-2015

Correspondence Address:
David Carmody
Mona Vale Hospital, 1 Coronation Drive, Mona Vale NSW
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-4863.152245

Rights and Permissions

Posterior tibial tendon dysfunction is the most common cause of adult acquired flatfoot. Degenerative changes in this tendon, lead to pain and weakness and if not identified and treated will progress to deformity of the foot and degenerative changes in the surrounding joints. Patients will complain of medial foot pain, weakness, and a slowly progressive foot deformity. A "too many toes" sign may be present and patients will be unable to perform a single heal raise test. Investigations such X-ray, ultrasound and magnetic resonance imaging will help stage the disease and decide on management. The optimal manage may change based on the progression of deformity and stage of disease. Early identification and prompt initiation of treatment can halt progression of the disease. The purpose of this article is to examine the causes, signs, symptoms, examinations, investigations and treatment options for posterior tibial tendon dysfunction.

Keywords: Adult acquired flatfoot, pes planovalgus, posterior tibial tendon

How to cite this article:
Bubra PS, Keighley GS, Rateesh S, Carmody D. Posterior tibial tendon dysfunction: An overlooked cause of foot deformity. J Family Med Prim Care 2015;4:26-9

How to cite this URL:
Bubra PS, Keighley GS, Rateesh S, Carmody D. Posterior tibial tendon dysfunction: An overlooked cause of foot deformity. J Family Med Prim Care [serial online] 2015 [cited 2021 Sep 24];4:26-9. Available from: https://www.jfmpc.com/text.asp?2015/4/1/26/152245

  Introduction Top

Posterior tibial tendon dysfunction is the most common cause of adult acquired flatfoot disease. The changes of advanced disease are obvious and have significant morbidity associated with it. Tendon degeneration, however, begins far before clinical disease is apparent. [1] By detecting early posterior tibial tendon disease, progression may be halted with nonoperative means; if left to progress, surgical reconstruction with osteotomy and arthrodesis becomes necessary. [2] The purpose of this article is to review the pathphysiology, clinical stages, investigations and treatment options for posterior tibial tendon dysfunction, so that general practitioners can easily identify early disease and initiate treatment before deformity sets  [Table 1].
Table 1: Posterior tibial tendon dysfunction-overview

Click here to view

  Anatomy Top

Tibialis posterior originates from the posterolateral tibia, posteromedial fibula and interosseous membrane. It runs through the deep posterior compartment of the leg and its tendon passes behind the medial malleolus. Blood supply to the tendon is poorest in this area and is the most common site for rupture. [3]

Close to its insertion site the tendon splits into a main, plantar and recurrent components, with the main component inserting onto the navicular tuberosity, the plantar portion onto the second, third, fourth metatarsals, second and third cuneiforms and cuboid. The recurrent component attaches to the sustentaculum tali of the calcaneus. [4]

Tibialis posterior acts as the primary dynamic stabilizer of the medial longitudinal arch and main inverter of the midfoot. [5],[6] Its contraction also elevates the medial longitudinal arch, causing the hind foot and midfoot to become a rigid structure. This allows the gastrocnemius to act with greater efficiency during the gait cycle. [5]

  Pathophysiology Top

Acute/traumatic rupture of the posterior tibial tendon is the cause of acquired flatfoot and may result from ankle fractures or direct trauma to the tendon. [7],[8] A complete rupture of the tendon is not required for development of adult flatfoot; due to the short excursion of the tendon, lesser damage may render it ineffective. The more usual cause is tendinosis from repeated microtrauma. As the tendon degenerates, it is replaced with ineffective fibrotic tissue. [9] This may occur in a zone of hypovascularity in the region of the medial malleolus. [3],[10]

As the tendon loses function, the medial longitudinal arch of the foot collapses, which causes a relative internal rotation of the tibia and talus. [11] There is eversion of the subtalar joint, which forces the heel into valgus alignment, and abduction at the talonavicular joint. Varus alignment of the heel causes a lateral shift in the normal axis of the achilles tendon, which in time will lead to a contracture. [12],[13] As the deformity gets worse, the distal fibula comes into contact with the lateral calcaneus, causing lateral hindfoot pain. [5]

  Epidemiology Top

Posterior tibial tendon dysfunction typically occurs in obese, middle-aged women [5],[14],[15],[16],[17] with up to 10% prevalence in this group. [18] Conditions such as diabetes, hypertension, obesity, previous surgery, foot/ankle trauma and steroid use is found in up to 60% of patients. [4] Seronegative spondylarthropathies have also been identified as risk factors, [11] as have local steroid injections. [4],[19] Though many of these risk factors are generalized medical conditions, only one side is typically affected; bilateral disease is rare [Table 2]. [20]
Table 2: Risk factors for posterior tibial tendon dysfunction

Click here to view

  Classification Top

Johnson and Strom developed a classification scheme in 1989 to describe the stages of posterior tibial tendon dysfunction. [15] Originally three stages were described, with Stage I having an intact tendon with inflammation, but no clinical deformity. Treatment at this stage is conservative, with tenosynovectomy and debridement for severe cases. [10],[21] In Stage II the tendon is ruptured or otherwise nonfunctional, resulting in a planovalgus deformity which is passively correctable. In Stage III the foot deformity is no longer correctable and osteoarthritis is seen in the subtalar joint. A fourth stage, added by Myerson, describes patients with a valgus tilt of the talus in the ankle joint with tibiotalar degeneration. [5],[15] Surgical correction of Stage III and IV involves fusion of one or more joints, including the subtalar, calcaneocuboid, talonavicular and ankle joints [Table 3].
Table 3: Posterior tibial tendon dysfunction-stages

Click here to view

  History Top

Most patients report a slow, insidious onset of unilateral flatfoot deformity. [15],[18] A history of trauma may be present in up to 50% of cases. [22] Patients will describe the pain and swelling along the medial aspect of the foot and ankle, which may be exacerbated with activity. Standing on their toes may be painful and difficult, as may walk up or down stairs or on uneven surfaces. In addition, patients may complain of an exacerbation of a preexisting limp. As the medial longitudinal arch collapses, the deformity of the foot increases; in this instance patients may describe abnormal wear on their shoes. In severe cases of deformity the distal fibula will come into contact with the calcaneus, and pain will move to the lateral aspect of the foot; patients at this stage may describe the feeling of walking on the medial ankle. [23]

  Examination Top

In Stage, I posterior tibial tendon dysfunction there is swelling and tenderness along the course of the tendon, typically behind and below the medial malleolus [1],[5] accompanied by weakness with inversion of the foot. [5],[23] As the dysfunction progresses, patients may have less swelling and pain but this alludes to a complete rupture of the posterior tibial tendon and impending flatfoot deformity.

Inspecting the patient from behind will show a valgus position of the heel and flattening of the medial longitudinal arch with compensatory forefoot abduction. A "too many toes sign" will be present where more than one to two toes are seen along the lateral aspect of the affected foot. [1],[5]

One of the most sensitive tests for posterior tibial tendon dysfunction is the single limb heel rise. To perform this test, the patient uses their arms to balance themselves against the wall. The patient will then lift the opposite foot off the ground and attempt to rise onto the toes of the affected foot.

When performing a single heel raise patients may have difficulty performing a single heel raise or weakness after multiple heel attempts. [1],[5] Patients with a fully functional tendon can complete 8-10 repetitions, but by Stage II, the vast majority of patients are unable to perform a single unsupported heel rise (or may only be able to complete a few).

An attempt to correct any valgus deformity of the hind foot should be made by grasping the heel. In Stage II the deformity will still be correctable but by Stage III and IV it will not be reducible.

  Investigations Top

Weight bearing anteroposterior and lateral views of both feet, in addition to bilateral weight bearing ankle views, should be obtained. Changes may not be apparent on X-ray in the early stages but as the disease progresses, collapse of the medial longitudinal arch and joint degeneration may become evident. [15],[24],[25]

Ultrasound is a quick, readily available, low-cost investigation which gives information about tendon size, degeneration and presence of fluid. Quality of results, however, can be ultrasonographer dependent. [25],[26],[27]

Magnetic resonance imaging (MRI) is useful in detecting early changes within the tendon and for assessing joint degeneration in later disease. [25],[28],[29],[30] Detecting early tendon changes and prompt initiation of nonoperative treatment may avert the need for surgery. MRI is also useful in more advanced stages of the disease, where precise delineation of joint degeneration plays a part in preoperative planning.

  Treatment Top

Management of posterior tibial tendon dysfunction relies upon accurate staging of the disease, as both nonoperative and operative treatment options change with each disease stage. Aims of treatment are to relieve pain, improve function, restore alignment by correction of any deformity, and to halt or slow progression of the disease. We recommend early referral to an orthopedic surgeon.

Stage I disease

A walking cast or CAM boot can be used to immobilize the foot. If this brings relief, the patient can have shoe inserts or modifications, orthotics or an ankle-foot orthosis (AFO) fitted. Options for custom orthotics include the University of California Biomechanics Laboratory Orthosis, an AFO, or a removable boot. Orthotics aims to provide arch support and correct the flexible component of the deformity. [31],[25] Physiotherapy for achilles tendon stretching and tibialis posterior strengthening along with nonsteroidal anti-inflammatories can also help. [32],[33],[34] Up to 4 months of nonoperative treatment should be trialed; if there is no improvement after this period, a tendon synovectomy or debridement may be indicated. [2]

Stage II disease

Nonoperative methods can still be trialed at this stage and include walking cast, CAM boots, or orthotics. These interventions often prove to be ineffective and surgical treatment is typically carried out in Stage II of the disease. This is because the deformity is still correctable and joint degeneration has not occurred, allowing for better joint alignment and possibly avoiding joint fusion. A variety of methods have been described, and these normally include bony procedures along with soft tissue reconstruction and tendon transfers. [12],[13],[16] Traditionally, this would consist of a combination of calcaneal osteotomy, posterior tibial tendon excision, flexor digitorum longus transfer, and achilles tendon lengthening. These aim to correct the flexible deformity and dynamically stabilize the medial arch. [16],[21],[22],[33]

Stage III and stage IV

At Stage III the deformity is rigid and at Stage IV there is ankle joint involvement. [5] Nonoperative treatment at this stage consists of specialized shoes, orthotics, AFO, and inserts that accommodate the deformity. The collective primary aim is analgesia; secondarily they may serve to slow progression of the disease. Surgical intervention at these stages will involve multiple bony procedures such as osteotomies and arthrodesis. In Stage III typically a triple arthrodesis (fusion) of the calcaneocuboid, talonavicular and subtalar joints is undertaken, whereas in Stage IV an ankle joint fusion is performed, in addition to a triple arthrodesis. [5],[12],[16],[35],[36]

  Conclusion Top

Posterior tibial tendon dysfunction characteristically is a slow onset condition mainly affecting middle-aged, obese women. Risk factors include obesity, hypertension, diabetes, steroid use and seronegative arthropathies. Patients may complain of pain and swelling around the medial ankle, difficulty mobilizing or exacerbation of an existing limp. Examination may show tenderness along the course of the tendon, difficulty performing a single heel raise or "too many toes" when feet are viewed standing from behind. X-ray and MRI can confirm diagnosis, help stage disease and assist in preoperative planning. The disease as an entity is under-recognized, and early stages of the disease can be misdiagnosed, but prompt treatment can prevent deformity and need for surgery.

  References Top

Johnson KA. Tibialis posterior tendon rupture. Clin Orthop Relat Res 1983;140-7.  Back to cited text no. 1
Arangio GA, Salathe EP. A biomechanical analysis of posterior tibial tendon dysfunction, medial displacement calcaneal osteotomy and flexor digitorum longus transfer in adult acquired flat foot. Clin Biomech 2009;24:385-90  Back to cited text no. 2
Deland JT, de Asla RJ, Sung IH, Ernberg LA, Potter HG. Posterior tibial tendon insufficiency: Which ligaments are involved? Foot Ankle Int 2005;26:427-35.  Back to cited text no. 3
Kohls-Gatzoulis J, Angel JC, Singh D, Haddad F, Livingstone J, Berry G. Tibialis posterior dysfunction: A common and treatable cause of adult acquired flatfoot. BMJ 2004;329:1328-33.  Back to cited text no. 4
Myerson MS. Adult acquired flat foot deformity. J Bone Joint Surg 1996;78A: 780-92.  Back to cited text no. 5
Gluck GS, Heckman DS, Parekh SG. Tendon disorders of the foot and ankle, part 3: The posterior tibial tendon. Am J Sports Med 2010;38:2133-44.  Back to cited text no. 6
Kettelkamp DB, Alexander HH. Spontaneous rupture of the posterior tibial tendon. J Bone Joint Surg Am 1969;51:759-64.  Back to cited text no. 7
Monto RR, Moorman CT 3 rd , Mallon WJ, Nunley JA 3 rd . Rupture of the posterior tibial tendon associated with closed ankle fracture. Foot Ankle 1991;11:400-3.  Back to cited text no. 8
Mosier SM, Lucas DR, Pomeroy G, Manoli A 2 nd . Pathology of the posterior tibial tendon in posterior tibial tendon insufficiency. Foot Ankle Int 1998;19:520-4.  Back to cited text no. 9
Khazen G, Khazen C. Tendoscopy in stage I posterior tibial tendon dysfunction. Foot Ankle Clin 2012;17:399-406.  Back to cited text no. 10
Myerson M, Solomon G, Shereff M. Posterior tibial tendon dysfunction: Its association with seronegative inflammatory disease. Foot Ankle 1989;9:219-25.  Back to cited text no. 11
Mann RA. Acquired flatfoot in adults. Clin Orthop Relat Res 1983;46-51.  Back to cited text no. 12
Deland JT. Adult-acquired flatfoot deformity. J Am Acad Orthop Surg 2008;16:399-406.  Back to cited text no. 13
Kohls-Gatzoulis J, Woods B, Angel JC, Singh D. The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England. J Foot Ankle Surg 2009;15:75-81.  Back to cited text no. 14
Fuhrmann RA, Trommer T, Venbrocks RA. The acquired buckling-flatfoot. A foot deformity due to obesity? Orthopade 2005;34:682-9.  Back to cited text no. 15
Mann RA, Thompson FM. Rupture of the posterior tibial tendon causing flat foot. Surgical treatment. J Bone Joint Surg Am 1985;67:556-61.  Back to cited text no. 16
Funk DA, Cass JR, Johnson KA. Acquired adult flat foot secondary to posterior tibial-tendon pathology. J Bone Joint Surg Am 1986;68:95-102.  Back to cited text no. 17
Kohls-Gatzoulis JA, Singh D. Tibialis posterior dysfunction as a cause of flatfeet in elderly patients. Foot 2004;14:207-9.  Back to cited text no. 18
Henceroth WD 2 nd , Deyerle WM. The acquired unilateral flatfoot in the adult: Some causative factors. Foot Ankle 1982;2:304-8.  Back to cited text no. 19
Geideman WM, Johnson JE. Posterior tibial tendon dysfunction. J Orthop Sports Phys Ther 2000;30:68-77.  Back to cited text no. 20
Shereff MJ. Treatment of ruptured posterior tibial tendon with direct repair and FDL tenodesis. Foot Ankle Clin 1997;2:281-96.  Back to cited text no. 21
Mann RA. Flatfoot in adults. In: Mann RA, Coughlin MJ, editors. Surgery of the Foot and Ankle. 6 th ed., Vol. 1. St. Louis, Mo: The CV Mosby Co.; 1 993. p. 757-84.  Back to cited text no. 22
Pomeroy GC, Pike RH, Beals TC, Manoli A 2 nd . Acquired flatfoot in adults due to dysfunction of the posterior tibial tendon. J Bone Joint Surg Am 1999;81:1173-82.  Back to cited text no. 23
Pedowitz WJ, Kovatis P. Flatfoot in the Adult. J Am Acad Orthop Surg 1995;3:293-302.  Back to cited text no. 24
Kong A, Van Der Vliet A. Imaging of tibialis posterior dysfunction. Br J Radiol 2008;81:826-36.  Back to cited text no. 25
Miller SD, Van Holsbeeck M, Boruta PM, Wu KK, Katcherian DA. Ultrasound in the diagnosis of posterior tibial tendon pathology. Foot Ankle Int 1996;17:555-8.  Back to cited text no. 26
Nazarian LN, Rawool NM, Martin CE, Schweitzer ME. Synovial fluid in the hindfoot and ankle: Detection of amount and distribution with US. Radiology 1995;197:275-8.  Back to cited text no. 27
Mink JH. Tendons. In: Deutsch AL, Mink JH, Kerr R, editors. MRI of the Foot and Ankle. Vol. 72. New York: Raven Press; 1992. p. 135-1.  Back to cited text no. 28
Alexander IJ, Johnson KA, Berquist TH. Magnetic resonance imaging in the diagnosis of disruption of the posterior tibial tendon. Foot Ankle 1987;8:144-7.  Back to cited text no. 29
Conti SF. Posterior tibial tendon problems in athletes. Orthop Clin North Am 1994;25:109-21.  Back to cited text no. 30
Burns J, Landorf KB, Ryan MM, Crosbie J, Ouvrier RA. Interventions for the prevention and treatment of pes cavus. Cochrane Database Syst Rev. 2007;4:CD006154.  Back to cited text no. 31
Williams R. Chronic non-specific tendovaginitis of tibialis posterior. J Bone Joint Surg Br 1963;45:542-5.  Back to cited text no. 32
Wacker JT, Hennessy MS, Saxby TS. Calcaneal osteotomy and transfer of the tendon of flexor digitorum longus for stage-II dysfunction of tibialis posterior. Three- to five-year results. J Bone Joint Surg Br 2002;84:54-8.  Back to cited text no. 33
Miniaci-Coxhead SL, Flemister AS Jr. Office-based management of adult-acquired flatfoot deformity. Med Clin North Am 2014;98:291-9  Back to cited text no. 34
Mehta SK, Kellum RB, Robertson GH, Moore AR, Wingerter SA, Tarquinio TA. Radiographic correction of stage III posterior tibial tendon dysfunction with a modified triple arthrodesis. Foot Ankle Int 2013;34:1355-63.  Back to cited text no. 35
Zaw H, Calder JD. Operative management options for symptomatic flexible adult acquired flatfoot deformity: A review. Knee Surg Sports Traumatol Arthrosc 2010;18:135-42.  Back to cited text no. 36


  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 The Prevalence Disability resulting from adult acquired Foot Flat Deformity among Middle aged population
Sowmya M. V,Rajeswari. V
Research Journal of Pharmacy and Technology. 2021; : 4329
[Pubmed] | [DOI]
2 Impact of a dynamic ankle orthosis on acute pain and function in patients with mechanical foot and ankle pain
Chloe L. Chung,Max R. Paquette,Denis J. DiAngelo
Clinical Biomechanics. 2021; : 105281
[Pubmed] | [DOI]
3 Adult flatfoot
Chris Yuk Kwan Tang,Ka Ho Ng,Joyce Lai
BMJ. 2020; : m295
[Pubmed] | [DOI]
4 Surgical Management of Symptomatic Adult Pes Planovalgus Secondary to Stage 2B Posterior Tibial Tendon Dysfunction: A Comparison of Two Different Surgical Treatments
Christopher Fang Junxian,Remesh Kunnasegaran,Gowreeson Thevendran
Indian Journal of Orthopaedics. 2020; 54(1): 22
[Pubmed] | [DOI]
5 The awareness of hindfoot malalignment on non-weight-bearing ankle MRI
Syed Ehtasham Junaid,Anil Haldar,Raul Colta,Karan Malhotra,Kar Ho Brian Lee,Matthew Welck,Asif Saifuddin
Skeletal Radiology. 2020;
[Pubmed] | [DOI]
6 T2* mapping and subregion analysis of the tibialis posterior tendon using 3 Tesla magnetic resonance imaging
Carly Anne Lockard,Angela Chang,Thomas O Clanton,Charles P Ho
The British Journal of Radiology. 2019; : 20190221
[Pubmed] | [DOI]
7 Chronic Lower Leg Pain in Athletes: Overview of Presentation and Management
Neil Mohile,Jose Perez,Michael Rizzo,Christopher P. Emerson,Greg Foremny,Paul Allegra,Harry G. Greditzer,Jean Jose
HSS Journal ®. 2019;
[Pubmed] | [DOI]
8 A proposal for a new classification for the tendon of insertion of tibialis posterior
Lukasz Olewnik
Clinical Anatomy. 2019;
[Pubmed] | [DOI]
9 Surgical Considerations: Repair of Long Segment Defect Posterior Tibial Tendon Using Fresh Frozen Tibial Tendon Allograft
Raymond Cavaliere,Danielle M. Mercado
The Journal of Foot and Ankle Surgery. 2019;
[Pubmed] | [DOI]
10 Ultrasonographic features of tibialis posterior tendon in rheumatoid arthritis patients with pes planovalgus
Hamdy Khamis Koraym,Wafaa S. El-Emary,Sherine M. Elsherif,Ahmed H. Afifi,Samar A. S. M. Olibah
Egyptian Rheumatology and Rehabilitation. 2019; 46(2): 113
[Pubmed] | [DOI]
11 Age-related decrease in collagen proton fraction in tibial tendons estimated by magnetization transfer modeling of ultrashort echo time magnetic resonance imaging (UTE-MRI)
Saeed Jerban,Yajun Ma,Behnam Namiranian,Aria Ashir,Hoda Shirazian,Zhao Wei,Nicole Le,Mei Wu,Zhenyu Cai,Jiang Du,Eric Y. Chang
Scientific Reports. 2019; 9(1)
[Pubmed] | [DOI]
12 Sonographic and radiographic findings of posterior tibial tendon dysfunction: a practical step forward
Steven B. Soliman,Paul J. Spicer,Marnix T. van Holsbeeck
Skeletal Radiology. 2018;
[Pubmed] | [DOI]
13 Ultrasound evaluation of adult-acquired flatfoot deformity: Emphasis on the involvement of spring ligament
Quanson Sirlyn
Australasian Journal of Ultrasound in Medicine. 2017; 20(2): 83
[Pubmed] | [DOI]
14 Finite element simulation on posterior tibial tendinopathy: Load transfer alteration and implications to the onset of pes planus
Duo Wai-Chi Wong,Yan Wang,Aaron Kam-Lun Leung,Ming Yang,Ming Zhang
Clinical Biomechanics. 2017;
[Pubmed] | [DOI]
15 Coordination among the rearfoot, midfoot, and forefoot during walking
Tomoya Takabayashi,Mutsuaki Edama,Emi Nakamura,Erika Yokoyama,Chiaki Kanaya,Masayoshi Kubo
Journal of Foot and Ankle Research. 2017; 10(1)
[Pubmed] | [DOI]
16 Reported selection criteria for adult acquired flatfoot deformity and posterior tibial tendon dysfunction: Are they one and the same? A systematic review
Megan H. Ross,Michelle D. Smith,Bill Vicenzino,Yih-Kuen Jan
PLOS ONE. 2017; 12(12): e0187201
[Pubmed] | [DOI]
17 Structural damage in rheumatoid arthritis: comparison between tendon damage evaluated by ultrasound and radiographic damage
Iustina Janta,Denisa Stanciu,Michelle Hinojosa,Juan Carlos Nieto-González,Lara Valor,Natalia Bello,Belen Serrano,Carmen Mata-Martínez,Julia Martínez-Barrio,Juan Gabriel Ovalles-Bonilla,Carlos Manuel González,Francisco Javier López-Longo,Indalecio Monteagudo,Esperanza Naredo,Luis Carreño
Rheumatology. 2016; 55(6): 1042
[Pubmed] | [DOI]
18 Acute tear of tibialis posterior: case report
Edward Sellon,A Daghir
Journal of the Royal Army Medical Corps. 2016; 162(5): 393
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Tables

 Article Access Statistics
    PDF Downloaded1095    
    Comments [Add]    
    Cited by others 18    

Recommend this journal