Posterior Tibialis Tendon Dysfunction (PTTD) is a common issue that occurs amongst many athletes, especially runners.
The posterior tibialis muscle originates exactly where its name suggests, posterior meaning “behind”. It arises from the back of the tibia or shinbone and runs down the leg, inserting onto the navicular bone, cuboid, cuneiform bones and the 2nd, 3rd and 4th metatarsals.
This means it attaches to the bones that comprise the arch and inner side of your foot. The posterior tibialis helps to point your foot downwards and also bring the foot inwards when non-weight bearing.
When weight bearing, it helps to distribute weight across the foot and maintain balance.
The true cause of PTTD is still unknown, but research has been able to pinpoint specific factors in biomechanics and tissue integrity when analyzing patients with the condition.
Generally, most complaints of symptoms are directed towards the region located behind the medial malleolus, which is the bone that is prominent on the inside of the ankle.
Pain can also run from the arch of the foot where the tendon inserts on the navicular bone and travel up to the medial tibia, which is right behind the shinbone.
Reports of pain will be during the loading phase when walking while the foot absorbs most of the weight of the body. Pain can also be reported during the push-off phase when the toes push into the ground upon finishing a step.
With PTTD there is also difficulty performing a single-sided heel raise while standing on the affected leg due to pain with the noted inability to achieve the same height off the ground compared to the non-involved side.
Aside from pain with this condition, mechanical and structural deficits are also noted with the presence of a significant medial arch drop on the affected side with the foot appearing “flat”.
The muscle belly can be felt right between the bulk of the gastroc/soleus tissue and the tibia. The tendon can be felt right behind the medial malleolus.
Since the posterior tibialis runs across multiple joints, aggravation to the tendon can occur easily. The ankle is a pretty mobile joint in that it allows for adjustment to dynamic surfaces.
The talocrural joint generally allows movement of the foot up and down and the subtalar joint allows for movement of the foot inward and outward but also separate movement between the forefoot and the heel. This is how the foot adjusts to uneven terrain.
Currently, research has revealed that alterations in heel eversion and forefoot abduction are the primary deficits with PTTD. This means that the heel and the forefoot both have excessive outward movement moments.
Contrary to the initial thought process of just supporting the medial arch with orthotics, controlling the heel AND forefoot have been found to be most effective.
There are two extremes of foot positions, pes plantus and pes cavus. There are mixed thought processes amongst specialists on how to address proper control of foot position.
Some specialists believe in using orthotics or bracing and others believe in training the neuromuscular control while some are a blend of both interventions.
It really depends on the individual, severity of mobility deficits, motor control and tissue integrity.
Activity and sports engagement are also factors contributing to intervention types.
An individual with a “flat” foot doesn’t’ always have a predisposition towards PTTD. There are many cases of individuals with a pes plantus foot position that demonstrate good neuromuscular control.
Applying an orthotic, taping or brace to support the arch isn’t always the answer for “flat feet”. The same applies to someone with pes cavus or a high arch.
If the foot is very rigid and lacks the ability to properly conform and absorb impact, then bracing or orthotics may be appropriate. If the person has a foot that demonstrates a good balance of mobility and stability, then bracing may not be required.
There some specific exercises for PTTD but generally they are focused on medial arch control, heel position, and single leg stance stability.
Research has seen some benefits of engaging in reactive neuromuscular training while wearing a form of support. This means engaging in stability exercises while wearing a brace or taping.
I personally implement a form of taping for my patients while they begin basic coordination and stability exercises. The tape acts as a crutch while they learn to teach their body how to properly stabilize their foot and activate the appropriate muscles in various positions.
The goal is to try to wean them off of the tape in an attempt to see if they can demonstrate good neuromuscular control without the external support.
Soft tissue work such as Graston and active tissue release may also be implemented to the tendon and the muscle belly in an attempt to restore normal tissue properties for the ability to accept and produce normal loads and forces again.
Improving and maintaining mobility in the soft tissue and joints of the foot and ankle are also important components of the rehab protocol.
Once the individual has demonstrated improvement with their mobility and stability, implementing appropriate footwear is the final step.
The take-home message with this condition is that the human foot and ankle should consist of a balance of good mobility and neuromuscular control.
A flexible foot that lacks proper control is just as bad as a rigid foot lacking proper control.
There can be genetic components that play a factor, as some individuals are born with feet that are on one end of either extreme.
Sometimes a form of external support is required such as shoe with more support.
Regardless of these factors, ensuring the proper balance of the right interventions for the individual is the best way to return them back to pain-free limitless function.
About The Author
Michael St. George, PT, DPT (@icore_stgeorge on Instagram) is a physical therapist who works for Excel Physical Therapy and Fitness which is a private practice that is based around the greater Philadelphia region and suburbs. He is FMS, SFMA, Y Balance and Motor Control Test Certified with 8 years of experience in outpatient orthopedics and sports medicine. His training consists of experience working with physicians and surgeons from the Rothman Institute and therapists in his field specializing in various manual techniques and advanced treatment procedures.