Posterior tibialis tendon dysfunction (PTTD)

Oct 12, 2026

Posterior tibialis tendon dysfunction (PTTD) is a muscle–tendon condition that usually affects one foot, involving inflammation and degeneration. When untreated, the tendon can rupture and may require surgery. PTTD is a major cause of adult-acquired flatfoot, where the arch progressively flattens, leading to deformity and osteoarthritis. The text explains anatomy, typical symptoms near the inner ankle/instep, risk factors, warning signs, diagnosis approach, and the four-stage progression that guides treatment choices.

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CategoryGeneral

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What is posterior tibialis tendon dysfunction?

Anatomy

Symptoms and characteristics of PTTD

PTTD-risk factors and causes

Warning

How is PTTD diagnosed?

Progression of PTTD

Stage 1

Stage 2

Stage 3

Stage 4

Posterior tibialis tendon dysfunction (PTTD) What is posterior tibialis tendon dysfunction? Posterior tibialis tendon dysfunction (PTTD) is a muscle tendon issue usually affecting one foot involving inflammation and degeneration. If left untreated, the tendon can rupture and require surgery. PTTD can occur acutely from specific tendon injury but tends to develop over time and is sometimes called an ‘overuse’ injury or tendon ‘insufficiency’. PTTD is a major cause of developing adult acquired flat foot deformity showing a change in foot shape as the arch flattens over time resulting in bone deformity and osteoarthritis. Anatomy The posterior tibialis muscle is long and deep , originating in the lower leg between the tibia and fibula bones and forms the posterior tibialis tendon behind the inside ankle bone. The tendon attaches the muscle to bones in the arch and sole of the foot. By storing and releasing energy, it supports and stabilizes the arch of the foot, enables you to rise on tiptoes and point your foot inwards. Activities such as walking, running or standing on tiptoes depend upon a healthy functional posterior tibialis tendon. Symptoms and characteristics of PTTD • Pain, ache, inflammation (warmth, swelling and/or redness), stiffness behind or under your inner ankle or along your instep. You may be tender when you touch along the course of the tendon. • Difficulty standing, walking, or running – discomfort is usually worse on standing and for the first steps but can become constant and for prolonged time as the injury progresses. • Weakness, pain and inability to stand on tiptoes on the affected foot. • Heel rolling inward, ‘duck-footed’ or ‘too many toes’ sign (A) and change in foot shape as it becomes flatter through time (B) • The change in foot shape creates increased stress on other foot structures and possibly pain on the outside of the ankle or foot and the knee. PTTD-risk factors and causes Excessive strain/abnormal load – already having flat feet or over-pronating (feet roll inwards) , being hypermobile , being overweight, exercise intensity or duration change (especially sudden change) , shoe or equipment change and stiff or weak calf muscles can each present excessive stress and micro tears to the tendon. Age – the risk of developing PTTD increases with age as ageing naturally leads to degenerative changes in tendons, ligaments, and muscles. It is most common in women aged 40 and above. Conditions – certain conditions such as diabetes, hypertension, steroid use, or inflammatory arthritis can also contribute to a higher risk of developing PTTD. Trauma – specific injury to the tendon from high impact or excessive force. Warning If your symptoms are a result of a sudden trauma , your foot is persistently painful or keeping you awake at night , you have a high temperature or you feel hot and shivery it is recommended you contact your GP or attend an emergency department to receive medical attention. People with diabetes experiencing redness, swelling or warmth on their foot should also attend an emergency department. We strongly recommend that you do not weight bear on the foot until a full examination by a medical professional, to prevent further damage. How is PTTD diagnosed? Your doctor or health professional will consider your medical history, ask questions regarding your symptoms and perform a seated and standing physical examination. Progression of PTTD There are four stages of PTTD indicated by increasing symptoms and physical deformity. Treatment options depend on stage. Without treatment the condition progresses with rigid flatfoot and osteoarthritis developing. Stage 1 • Tendon is inflamed and pain and/or swelling is felt at the inside of ankle and/or arch. • Little or no change to foot shape and able perform a one leg heel raise. • Treatment options include rest from activity which overloads the tendon, progressive loading exercises and for pain reductio

FAQs

What is posterior tibialis tendon dysfunction (PTTD)?

PTTD is inflammation and degeneration of the posterior tibialis tendon, often affecting one foot. If left untreated, it can rupture and may require surgery.

What symptoms and physical signs are typical of PTTD?

Common symptoms include pain, warmth, swelling, redness, and stiffness behind or under the inner ankle/along the instep. Progression can cause arch flattening and signs such as the heel rolling inward and a “too many toes” appearance.

How is PTTD diagnosed and how does it progress?

Diagnosis involves reviewing medical history, asking about symptoms, and performing seated and standing physical examinations. The condition progresses through four stages with increasing deformity, guiding treatment from rest and supportive care to orthoses, rehabilitation, and possible surgery.

Oct 12, 2026

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