Posterior Tibial Tendonitis Signs and Treatment

Posterior tibial tendonitis is a common problem that occurs when one of the tendons on the inner side of the ankle becomes damaged. This can lead to foot and ankle pain, as well as other issues.

Treatment varies depending on the severity of the condition and may include rest, immobilization, medication, and surgery.

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

Posterior Tibial Tendon Anatomy

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.

Posterior Tibial Tendonitis Symptoms

Most commonly, people with posterior tibial tendonitis feel:

• Pain, tenderness, or swelling over the back, inside part of the ankle
• Pain with standing on the ball of the foot or when the foot is flexed
• Pain with ankle motion, especially when pushing off or pushing down with the front of the foot
• A cracking sound when the tendon is moved or touched

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. The foot joints may no longer line up correctly and may become set in the wrong position. For this reason, early treatment is important before the later stages of AAFD.

Diagnosing Posterior Tibial Tendonitis

A podiatrist, or doctor who specializes in foot and ankle problems, can diagnose posterior tibial tendonitis by physical examination. People with the condition have:

• Tenderness and swelling along the posterior tibial tendon
• Weakness when trying to point their toes inward
• 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. People may experience it as simply a feeling of weakness in the arch. 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, the deformity has progressed to the extent where the foot becomes fixed (rigid) in its deformed position.
• Stage 4: In this most severe stage, not only is the foot involved, but the adjacent ankle joint also is affected by the condition. The deltoid ligament on the inside of the ankle fails, resulting in a deformity in the ankle as well as a deformity in the foot. Over time, this can lead to arthritis of the ankle.

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

Posterior Tibial Tendonitis Treatment

How to fix posterior tibial tendonitis depends 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. Even normal walking should be avoided because it may aggravate the tendonitis or prevent healing.

Options for early treatment include:

• Shoe inserts and arch supports, which prevent motion between the middle and back of the foot and decrease inflammation
• Walking boots, which can help decrease inflammation
• Casts, which are the safest method to ensure the tendon is adequately rested
• Anti-inflammatory medications, which help reduce inflammation around the tendon
• Limiting activity, which can help the tendon rest and reduce inflammation around it
• Cortisone shots, which may be injected around the posterior tibial tendon to reduce inflammation and pain
• Physical therapy, which may include stretching and strengthening exercises, as well as massage
  

Research suggests that taping may help reduce improper movement of a functional posterior tibial tendon and slightly increase muscle activity for the first 15 minutes of running.

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 and your doctor may surgically reconstruct the area. This involves grafting a healthy tendon or portion of a tendon from another part of the body to replace the damaged posterior tibial tendon. Bones in the foot or heel may be broken and reshaped to correct the deformity, called calcaneal osteotomy.
• 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.

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).

Your doctor will diagnose this condition based on a physical examination and imaging techniques. It's best to treat the condition early. Treatment depends on how advanced the condition is. Once in the later stages, surgery is usually needed, and you may lose some function in your foot.