Posterior Tibial Tendon Dysfunction

Populations and Risk Factors

Adults over 40, especially women
Runners and athletes with overuse patterns
Obese individuals (increased load on the medial arch)
Those with biomechanical imbalances (overpronation) or running on uneven ground
Individuals with rheumatoid arthritis or other inflammatory conditions affecting tendons

Tendinosis predominance: Most cases involve chronic collagen degeneration (tendinosis) rather than acute inflammation (tendinitis). The tendon loses its organized parallel fiber structure and becomes thickened but mechanically weak
Progressive failure: Repetitive stress from running, walking, or obesity exceeds the tendon's repair capacity. As the tendon weakens, it elongates and loses its ability to dynamically support the medial arch
Hyperpronation cascade: Weak or inhibited tendon allows the foot to hyperponate, placing excessive weight medially. This creates a "whip-like force" during overpronation that accelerates collagen breakdown
Tenosynovitis component: The tendon's synovial sheath around the medial malleolus can become inflamed independently of the tendon itself
Tarsal tunnel connection: Swelling in the tendon sheath can compress the posterior tibial nerve within the tarsal tunnel, adding neurological symptoms (tingling, numbness in the sole)

Pain behind the medial malleolus or along the distal medial shin
Visible flattening of the medial arch with hindfoot valgus (heel angles outward)
Overpronation with decreased push-off during gait
Reduced inversion and plantarflexion strength
Palpable tendon thickening along the medial tibial border
"Too many toes" sign: when viewed from behind, more toes visible on the affected side than normal due to foot abduction
Red flags: Pain directly on bone (not tendon or muscle) requires referral to rule out stress fracture; sudden loss of arch with inability to single-heel-raise indicates complete tendon rupture — refer

CMTO Appendix category A1 (MSK conditions)
Key concept: PTTD is the primary cause of acquired flat foot in adults
Tarsal tunnel connection: tendon sheath swelling can compress the posterior tibial nerve
Single-heel-raise test: inability to rise on tiptoe on the affected side indicates significant tendon dysfunction
Safety trigger: pain directly on bone (not tendon/muscle) requires referral for stress fracture evaluation

Strategy: Release gastrocnemius and soleus first to reduce plantarflexion tension, then address the posterior tibialis directly — the calf muscles must be relaxed before the deep posterior compartment can be accessed effectively
Techniques: Myofascial release, deep longitudinal stripping along the medial tibial border, multidirectional friction for tendon adhesions
Access: Displace the relaxed soleus to reach the deep muscle belly of tibialis posterior around the medial tibia border
PIR application: Resist inversion, then apply deeper stretch to lengthen connective tissue adhesions
Functional distinction: If the client is hyperpronating, strengthen (not stretch) tibialis posterior. If hypertonic with excessive supination, lengthen through stretching
Tarsal tunnel awareness: If neurological symptoms (sole tingling/numbness) are present, focus on reducing swelling around the medial malleolus to decompress the posterior tibial nerve

PTTD is the leading cause of acquired flat foot in adults. Most cases are tendinosis (collagen breakdown) rather than acute inflammation
Treatment strategy: release gastrocnemius and soleus first to reduce plantarflexion tension, then address the posterior tibialis directly
If the client is hyperpronating, strengthen (not stretch) tibialis posterior. If hypertonic with excessive supination, lengthen through stretching
Tarsal tunnel connection: swelling in the tendon sheath can compress the posterior tibial nerve, adding neurological symptoms
Safety trigger: pain directly on bone (not tendon or muscle) requires referral to rule out stress fracture
"Too many toes" sign and inability to single-heel-raise are key clinical indicators