Posterior Tibial Tendinopathy (PTT) Rehab Guide

What is Posterior Tibial Tendinopathy?

Posterior tibial tendinopathy (PTT) is described as the degeneration of the tendon supporting the foot’s medial arch. The degeneration of the tendon can result in inflammation and dysfunction. The posterior tibial tendon plays a crucial role in supporting the arch of the foot and stabilizing the ankle during walking and standing.

PTT typically results from chronic inflammation and stress on the posterior tibial tendon, often due to increased sub-talar joint pronation during physical activity. Causes of PTT involve both intrinsic and extrinsic factors. Some common symptoms include: pain/swelling along inner ankle, flattened arch, and difficulty standing on toes.

It is crucial to recognize posterior tibial tendinopathy early on to allow for immediate treatment. If this condition is left untreated, it can lead to permanent flatfoot deformity and chronic pain.

The Anatomy of the Posterior Tibial Tendon

The key role of the posterior tibial tendon is to maintain medial arch stability during walking and running. The posterior tibial tendon is a dynamic stabilizer, which works with ligaments to maintain arch shape during movement.

The posterior tibial tendon originates from the posterior tibia, fibula, and interosseous membrane (deep calf). The tendon inserts into multiple foot bones such as the navicular, cuneiforms, metatarsals.

The insertion and origin of a tendon influence tendinopathy by determining stress concentration, vascular supply, and biomechanical load distribution, making certain areas (such as bony insertions or hypovascular zones) more prone to degeneration and injury.

Primary Functions of the Posterior Tibial Tendon:

1. Supports the Medial Arch Prevents excessive flattening of the foot.
2. Inverts the Foot (turns sole inward) for stability.
3. Controls Foot Pronation – Decelerates arch collapse during walking/running.

Importance of the Posterior Tibial Tendon

• Critical for balance, push-off strength, and shock absorption.
• Dysfunction → overpronation, flatfoot deformity, and gait abnormalities.

Causes and Risk Factors of Posterior Tibial Tendinopathy

Main Causes:

1. Overuse Injuries:  Repeated stress from running, jumping, or sudden increases in activity
2. Biomechanical Issues: Flat feet (pes planus) or excessive pronation overload the tendon
3. Trauma: Ankle sprains or fractures that damage the tendon
4. Age-Related Changes: Natural tendon degeneration after 40

Top Risk Factors:

1. Obesity: Extra weight increases strain on the tendon
2. Poor Footwear: Shoes lacking arch support or stability
3. Medical Conditions: Diabetes, hypertension, or inflammatory arthritis (RA) weaken tendons
4. Sudden Activity Changes: Rapidly increasing exercise intensity/duration

Who's Most at Risk?

🏃 Athletes – Runners, dancers, basketball/tennis players

👟 People with Flat Feet – Naturally higher stress on PTT

👵 Middle-Aged/Older Adults – Tendon strength declines with age

Importance of Early Intervention

Early intervention for flat feet or overpronation can significantly reduce an individual’s risk of developing PTT.

Why Physiotherapy is Critical

Physiotherapy doesn’t just treat pain, it addresses the root causes of posterior tibial tendon dysfunction by:

1. Rebuilding tendon strength
2. Correcting gait mechanics
3. Preventing permanent arch collapse

Key Interventions:

1. Eccentric Strengthening

• Slow, controlled lowering movements (e.g., heel drops off a step) to remodel tendon fibers
• The gold standard for rehabilitating tendinopathy

2. Gait Retraining

• Teaches proper foot strike and arch engagement during walking/running
• Prevents poor mechanical movements that can aggravate tendinopathy

3. Balance/Proprioception Drills

• Wobble board exercises to improve ankle stability

4. Arch Activation Techniques

• Short foot exercises to reactivate dormant foot muscles

5. Modalities for Pain Relief

• Ultrasound/electrotherapy to reduce inflammation in early stages

6. External Support

• Custom Orthotic Guidance: Helps transition from braces to supportive footwear long-term
• Low Dye Taping: Helps increase arch support

Rehabilitation Timeline

Starting physiotherapy early is crucial in promoting rehabilitation and possibly avoiding surgery. It is important to note that each individual has a different rehabilitation pathway.

Early Stage (1-2 weeks): Focus on reversing tendon damage

Late Stage (3+ weeks): Prevent further deformity pre-surgery

Can PTT Be Fully Reversed?

Early Stages: Yes, with aggressive rehab

• 3-6 months of dedicated physiotherapy often restores function
• 60-70% of patients avoid surgery with proper intervention

Advanced Cases: Damage may be irreversible

• Tendon elongation/tears often require:
  • Lifetime orthotics
  • Surgical reconstruction (tendon transfer + osteotomy)

Key Recovery Factors:

Stage at Diagnosis: Earlier treatment = better outcomes

Patient Compliance: Consistent rehab is critical

Biomechanics: Addressing flat feet/overpronation slows progression

Our Physiotherapy Treatment Plan

1. Biomechanical Assessment

• Analyze gait, foot posture, and hip/knee alignment.

2. Strengthening Exercises

• Heel Raises with Eversion
  • Lift heels while squeezing a ball between ankles.
• Resisted Ankle Eversion
  • Use resistance bands to target posterior tibialis.

3. Balance and Proprioception

• Wobble board drills to enhance foot stability.
• Single leg balance is crucial for PTT rehabilitation.

4. Manual Therapy

• Mobilize subtalar joint, calf/myofascial release.

5. Orthotics and Taping

• External support can help provide temporary relief
• Custom arch supports such as orthotics
• Athletic low dye taping for additional arch support

6. Gait Retraining

• Shorter strides, midfoot striking, avoiding overpronation
• Proper gait mechanics can help reduce the risk of re-injury

Prevention Strategies

To avoid posterior tibial tendon dysfunction, focus on strengthening, proper biomechanics, and smart training habits.

1. Footwear & Orthotics

Wearing proper footwear and orthotics is critical for arch support.

Choose Supportive Shoes:

• Motion control or stability shoes if you overpronate
• Avoid worn-out shoes
• Minimal heel-to-toe drop (4–8mm reduces tendon strain)

Consider Custom Orthotics if:

• You have flat feet or collapsing arches
• You stand/walk extensively

2. Strength & Stability Training

Ensuring strength and stability training is essential for long term resilience. It is important to avoid sudden increases in activity. Gradual progression is better for preventing re-injury!

A. Posterior Tibialis Strengthening

• Heel Raises with Eversion (squeeze a ball between ankles)
• Resisted Ankle Eversion (use a resistance band)
• Short-Foot Exercise (activate intrinsic foot muscles)

B. Hip & Core Stability

• Hip and core stability helps to reduce overpronation
• Clamshells (with band) to strengthen hip abductors
• Single-Leg Glute Bridges

C. Balance & Proprioception

• Single-Leg Stands (progress to unstable surfaces)
• Wobble Board Drills

FAQs

Can PTT Cause Arthritis?

Yes. Untreated PTT dysfunction can lead to midfoot/hindfoot arthritis due to:

• Chronic abnormal joint loading from arch collapse
• Late-stage deformity (e.g., rigid flatfoot)

Is Barefoot Walking Bad for PTT?

Generally yes, especially with:

• Existing flat feet
• Overpronation
• Early PTT symptoms

Note that short barefoot walking on soft surfaces may help strengthen foot intrinsics if pain-free.

Can Orthotics Cure PTT?

No, but they're essential for:

• Offloading the tendon (reducing pain)
• Slowing progression
• Supporting rehab

How Do I Know If I Need Surgery?

Red flags to look out for:

• Failed 6+ months of PT
• Inability to do a single heel raise
• Progressive arch collapse (visible deformity)
• Persistent pain at rest
• Arthritis on imaging

Ready to Overcome Posterior Tibial Tendinopathy?

Come see a posterior tibial tendon physiotherapist at Vaughan Physiotherapy Clinic today!

Our Specialized Approach to Rehab

Our comprehensive treatment programs include:

• Detailed biomechanical assessment of foot/ankle alignment, gait, and hip stability
• Customized strengthening plans for the posterior tibialis and foot arch support
• Manual therapy to improve ankle mobility and reduce tendon strain (e.g., calf release, joint mobilizations)
• Gait retraining to correct overpronation and reduce tendon load
• Progressive balance training (e.g., wobble boards, single-leg drills)
• Regular progress evaluations to adapt your rehab plan

Why Choose Our Clinic for PTT Treatment?

1. Evidence-Based Expertise
   • Latest protocols for tendon loading and foot biomechanics
   • Specialized training in lower limb rehabilitation
   • Experience with runners, dancers, and chronic flat foot cases
2. Personalized Care
   • Analysis of footwear, activity demands, and arch collapse patterns
   • Tailored plans combining orthotics (if needed) and strengthening
   • Focus on your specific goals (e.g., return to running, standing tolerance)
3. Holistic Recovery Support
   • Education on supportive footwear and activity pacing
   • Strategies to strengthen hips/core for better foot alignment
   • Long-term prevention of arch collapse and tendon degeneration

Take the First Step Toward Stronger Arches

Stop letting foot and ankle pain hold you back. Our team will help you walk, run, and stand with confidence.

Book Your Specialized Assessment Today:

• Phone: 905-669-1221
• Location: 398 Steeles Ave W #201, Thornhill, ON L4J 6X3
• Online Booking: www.vaughanphysiotherapy.com

Serving Thornhill, Langstaff, Newtonbrook, Willowdale, North York, Markham, Richmond Hill, Concord, and North Toronto.

Convenient Thornhill location with evening/weekend appointments available.

Your Path to Recovery Starts Here!

Whether you’re an athlete struggling with arch pain or someone battling daily discomfort, our proven methods can restore your foot function. Contact us today to begin your journey!

By: Tiffany Corpus

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