Posterior Tibial Tendon Dysfunction and Painful Flat Feet

The posterior tibialis is a very important but often overlooked calf muscle. It is one of the main supports for the arch, it inverts the heel and assists with plantarflexion, and it is a key dynamic stabilizer of the foot and ankle complex. Because of its location underneath that gastroc and soleus, the posterior tibialis gets can easily gets overshadowed by these larger muscles. 

The strength and health of the posterior tibialis is vital in maintaining the medial arch. Before discussing different ways to strengthen the muscle to help with pronation and flat feet I wanted to discuss a condition called Tibialis Posterior Tendon Dysfunction (PTTD). Not too long ago I wrote about Achilles tendon ruptures and how they are a result of a degenerative process of the tendon tissue. PTTD has a lot in common with Achilles tendinopathy, except applied to women. Whereas Achilles tendon ruptures typically occur in men, usually in their 30s and 40s, PTTD mostly happens to women after the age of 40.

Posterior Tibialis

Comparison to Achilles tendon problems

The posterior tibialis tendon runs along the inside of the ankle and attaches to the arch and underside of the foot.  Weakening of the tendon leads to a progressive collapse of the arch. Similar to Achilles tendinopathy, the exact cause of PTTD is not well understood. Previously, the problem would often be mistaken for similar conditions like ankle sprains or Achilles tendinosis. Recent investigation into the nature of the problem is starting to shed some light into this tendon dysfunction, thought many unanswered questions still remain.

Research has shown the dysfunction is not the result of an inflammatory process as once thought, but rather a degeneration of the quality of the tissue that comprises the tendon. What causes the tendon to deteriorate still remains a mystery. There is some evidence that systemic diseases (e.g. rheumatoid arthritis) may affect of subset of people who develop the problem but when PTTD occurs as an isolated incidence, in the absence of other tendon problems throughout the body, the dysfunction is thought to be caused by mechanical stress or overuse. 

Faulty Mechanics 

Regarding the mechanical theory of PTTD there is also some debate about what came first: the tendon insufficiency of the flat foot? One studied examine radiographs of the non-involved leg in people presenting with PTTD. The researchers in that study concluded that a pre-existing flexible flat foot was often present and is a likely contributed to the development of the problem.

This is supported by other studies that have shown increased EMG activity in the posterior tibialis muscle in people PTTD and flat feet, which could predispose the tendon to overuse. When the posterior tibialis tendon completely stretches out or ruptures there would likely be a further collapse of the arch due to  the increased strain transfered to other structures. 

If the origin of the problem is mechanical issue, than a prevention strategy could be devised aimed at reducing abnormal stress on the posterior tibialis and performing exercises that strengthen the muscle and tendon. In order to relieve the stress there are two basic options. Orthotics or a program to correct the mechanical problems causing flat feet.

There is some evidence that orthotic inserts can prevent the muscle from being overworked. In my view this is more of a way to compensate for the problem than it is a method to solve it. Adopting the orthotic approach means being chained to using the insert. Wearing an orthotic may mask the symptoms, but the bad biomechanics will still exist and will likely recur whenever the person is not using the device. 

Prevention and Management

A better option would be focusing on all the contributing factors causing the muscle to be strained, and this would include most of the biomechanical faults that are associated with flat feet: limited ankle mobility, calf inflexibility, weak arch supporting muscles, poor posture and hip strength. A recent study in the Journal of Orthopedic and Sports Physical Therapy showed that women with PTTD had not only weak ankles but weak hip muscles as well. 

For individuals in the early states of PTTD there is mounting evidence the a program involving posterior tibialis strengthening exercises, and in particular eccentric type exercises, is effective in reducing symptoms and improving function. This makes since, given the similarities of this problem with Achilles tendinopathy, as eccentric strengthening is currently the gold standard intervention for treating the Achilles tendon. I would propose that PTTD and Achilles tendon problems are very closely related. The reason women get PPTD and men tear their Achilles may be be due to some yet unidentified variable that predisposes each gender to one and not the other. 

If you go through the archives you’ll see I’ve covered several of the different corrective exercises I’ve been implementing as a protocol for reversing flexible flat feet. I plan of introducing more information on specific exercises in the near future but in the meantime here are two videos that are helpful demonstrating the basic concepts on home to target the posterior tibialis effectively.

For more specifics about the PPTD risk factors and symptoms you can visit its stand alone page on in the injury section of the site found here

References

Myerson M, Solomon G, Shereff M. Posterior tibial tendon dysfunction: its association with seronegative inflammatory disease. Foot Ankle. 1989 Apr;9(5):219-25.

Dyal CM, Feder J, Deland JT, Thompson FM. Pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic foot. Foot Ankle Int. 1997 Feb;18(2):85-8.

Ringleb SI, Kavros SJ, Kotajarvi BR, Hansen DK, Kitaoka HB, Kaufman KR. Changes in gait associated with acute stage II posterior tibial tendon dysfunction. Gait Posture. 2007 Apr;25(4):555-64. 

Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, Smith RW. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther. 2009 Jan;89(1):26-37. 

Ruth Semple R, Murley G, Woodburn J, Turner D. Tibialis posterior in health and disease: a review of structure and function with specific reference to electromyographic studies. J Foot Ankle Res. 2009, 2:24 

Murley G, Landorf K, Bird A, Menz H. Do foot orthoses change lower limb muscle activity in people with flat-arched feet towards a pattern observed in those with normal-arched feet? J Foot Ankle Res. 2011; 4(Suppl 1): O33.

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