Posterior Tibial Tendonitis Signs and Treatment

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Posterior tibial tendonitis is a common problem. It occurs when one of the tendons on the inner side of the ankle becomes damaged, which then can lead to other issues.

This article explains what this condition is, how it occurs, the symptoms to watch out for, and how to treat it.

Symptoms of posterior tibial tendonitis
Verywell / Cindy Chung

Ankle Anatomy

A review of your anatomy is helpful to understand how this occurs. The posterior tibial muscle attaches to the back of the shin bone. The posterior tibial tendon connects this muscle to the bones of the foot. A tendon is a thick cord of tissue that attaches a muscle to a bone.

The posterior tibial tendon passes down the back of the leg, not far from the Achilles tendon. It then turns under the inner side of the ankle. Here, it attaches to the bone of the inner side of the foot, just next to the arch of the foot.

Posterior tibial tendon problems usually occur just underneath the inner side of the ankle, called the medial malleolus. The medial malleolus is the end of the shin bone (the tibia). It's the big bump you feel on the inside of your ankle. The posterior tibial tendon wraps just underneath the medial malleolus.

This area of the tendon is particularly prone to problems—it exists in a "watershed zone," where the blood supply is weakest. So when the tendon becomes injured from trauma or overuse, the body has trouble delivering the proper nutrients for healing.

Posterior Tibial Tendonitis Symptoms

Most commonly, people with posterior tibial tendonitis feel pain on the inner side of the foot and ankle. They may also occasionally have an unsteady gait, or trouble maintaining stability while walking.

Many people with this condition report having had a recent ankle sprain. However, some will have had no recent injury. The tendon can also be damaged from overuse.

As the condition gets worse, the foot's arch can flatten, and the toes begin to point outwards. This is the result of the posterior tibial tendon not doing its job to support the arch of the foot.

Adult-Acquired Flatfoot Deformity

When left untreated, posterior tibial tendonitis can gradually bring on a problem called adult-acquired flatfoot deformity (AAFD), also known as a "fallen arch." This condition typically begins with pain and weakness of the tendon.

As AAFD advances, the ligaments of the foot are affected. At that point, the foot joints might no longer line up correctly and may become set in the wrong position. For this reason, most physicians prefer early treatment before the later stages of AAFD.

Recap

Symptoms of posterior tibial tendonitis include:

  • Pain on the inner side of the foot and ankle
  • Instability while walking
  • Flattened foot arch
  • Toes begin to point outward

Diagnosis

Physicians diagnose posterior tibial tendonitis by physical examination. People with the condition have tenderness and swelling along the posterior tibial tendon.

Usually, they also have weakness when trying to point their toes inward. In addition, they have trouble standing on their toes on the affected side.

If the examination is unclear or your doctor is considering surgical repair, they may order a magnetic resonance imaging (MRI) scan. The MRI can determine whether the tendon has ruptured, and where. It can also show inflammation surrounding the tendon.

Stages

Posterior tibial tendonitis is classified according to the stage of the condition. Stage 1 through stage 4 indicate increasing deformity (abnormal shape) of the foot as the condition progresses:

  • Stage 1: The earliest stage is having pain and swelling along the tendon. The foot may appear completely normal. On the other hand, some people may notice their foot has a mild flatfoot deformity. This may be something they feel they have always had.
  • Stage 2: As the condition progresses, the arch of the foot begins to collapse. When they stand, the foot appears flat along its inner side. At this stage, it may be possible to correct the flattened arch.
  • Stage 3: In stage 3 of the condition, called a rigid flatfoot deformity, a doctor cannot easily correct the foot.
  • Stage 4: In stage 4, not only is the foot involved, but the adjacent ankle joint also is affected by the condition.

As these stages progress, more extensive treatments are needed to correct the problem.

Nonsurgical treatment can be used at any stage. However, the chances of success with these options decrease as the condition progresses.

Treatment

Treatment varies depending on the stage of the tendonitis. In the early stage, it mostly involves rest. Later, it may require surgery.

Early Treatment

The initial treatment of posterior tibial tendonitis is rest so that the tendon can heal. Unfortunately, even normal walking may get in the way of allowing the tendon to heal adequately. In these cases, you must stop using the ankle to allow it to rest.

Options for early treatment include:

By providing a stiff platform for the foot, shoe inserts and walking boots prevent motion between the middle and back of the foot. Preventing this motion should decrease the inflammation associated with posterior tibial tendonitis.

Casts are more bothersome. But they are probably the safest method to ensure the tendon is adequately rested. Anti-inflammatory medication and limited mobility can help control the inflammation around the tendon.

Physical therapy, including stretching and strengthening exercises, also may help relieve pain and help you get back to your normal activities.

Surgical Options

Surgical treatment of posterior tibial tendonitis is controversial. Surgical options vary depending on the extent of the condition and include:

  • Debridement: In the early stage, some surgeons may recommend a procedure to clean up the inflammation. During debridement, the inflamed tissue and abnormal tendon are removed. This allows for the healing of the damaged tendon.
  • Reconstruction: In more advanced stages, the arch of the foot collapses. At this stage, a simple tendon debridement may not be enough to correct the problem, and your doctor may surgically reconstruct the area instead. This involves using a neighboring tendon, called the flexor digitorum longus, to replace the damaged posterior tibial tendon. Bones in the foot may be cut and reshaped to create a new arch, as well.
  • Fusion: Finally, in the most advanced cases, when the foot's arch has become rigid, doctors often prefer a fusion procedure, where the bones and joints in the foot are fixed in place to restore the arch.

Recap

Treatment options depend on the stage of the posterior tibial tendonitis.

In the early stages, you may be able to heal the tendon by resting the foot and ankle.

As the condition progresses, you will likely require surgery. Debridement, reconstruction, and fusion are all surgeries used for posterior tibial tendonitis. Which surgery is best for you will depend on how severe your condition is.

Summary

Posterior tibial tendonitis is a condition that results in pain on the inner side of the foot and ankle. It may cause instability while walking.

Over time, the condition can lead to the arches becoming flattened, a condition called adult-acquired flatfoot deformity (AAFD).

Diagnosis is made by physical examination. Sometimes an MRI may be used. The condition is categorized in stages (1-4) according to severity.

Treatment depends on how advanced the condition is. In the early stages, it can be treated by immobilization and rest. In later stages, it requires surgery.

A Word From Verywell

Posterior tibial tendonitis and adult-acquired flatfoot deformity can be frustrating problems. Often, people feel their discomfort and instability are ignored by a doctor who may not recognize the problem.

However, it's best to treat the condition early, before it gets worse. So, it's important to find a doctor who will listen to you and take your symptoms seriously.

Once in the later stages, surgery is usually needed, and you may lose some function in your foot. For these reasons, early treatments such as wearing a cast, boot, or brace and getting physical therapy are important.

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