Issue: July 2012
July 03, 2012
3 min read

Posterior tibial tendon dysfunction is primary cause of medial ankle pain in the middle-aged patient

Tendon transfer surgery may fail, especially if not combined with a corrective osteotomy.

Issue: July 2012
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4 Questions with Dr. Jackson 

In this month’s 4 Questions, Carol C. Frey, MD, shares her extensive experience on posterior tibial tendon dysfunction. Orthopedic surgeons frequently see posterior tibial tendon dysfunction in patients older than 50 years. These patients often present after the tendon has ruptured and when they notice a new flat foot configuration. Additionally, some patients develop lateral ankle pain. Dr. Frey highlights the prevention of posterior tibial tendon dysfunction, as well as the current nonoperative and salvage surgical treatments.

Douglas W. Jackson, MD
Chief Medical Editor

Douglas W. Jackson, MD: How common is chronic posterior tibial tendon dysfunction and rupture in the population older than 40 years?

Carol C. Frey, MD: Posterior tibial tendon dysfunction is the primary cause of medial ankle pain in the middle-aged patient. A typical patient would be an overweight woman older than 55 years of age. Other risk factors include steroid injections, history of pes planus, diabetes mellitus, hypertension and previous injury to the foot. The posterior tibial tendon is thickened and shows degenerative changes in most cases. As a result, the posterior tibialis muscle is inefficient and its function of supporting the medial longitudinal arch is lost. Since the posterior tibial tendon is one of the most important supporting structures of the medial ankle and arch, a flatfoot develops. Initially the foot is flexible, but over time, the deformity becomes fixed and arthritic changes may occur in the hindfoot.

The differential diagnosis includes: congenital pes planus (bilateral, present since childhood); Lisfranc fracture-dislocation (history of trauma, pain in the midfoot); medial ankle laxity (rare, abnormal ankle radiographs); medial malleolus stress fracture (focal bony tenderness); and tarsal coalition (fixed deformity, onset as adolescent or young adult).

Jackson: Are there pre-rupture symptoms that can be treated to prevent the progression to the rupture of the tendon?

Frey: Pain and swelling on the medial aspect of the ankle are the most common early symptoms. The onset of symptoms is insidious, and there is usually no history of trauma. Although pain and tenderness initially occur along the medial aspect of the foot and ankle, lateral pain ultimately develops as the collapsed flatfoot abuts the fibula and causes impingement in the sinus tarsi. In more advanced cases, the patient will state that they have lost the arch and that the ankle rolls in.

Since posterior tibial tendon pathology is most often the result of hypovasuclarity and resultant degeneration of the tendon, posterior tibial tenondinois is progressive. However, with weight loss, orthotics and supportive shoes, the symptoms can be managed for years. The recommended orthotic device includes a medial longitudinal arch support with a medial internal heel wedge which decreases the excursion of the tendon. Tenosynovitits of the tendon, often the initial presentation, should be treated with a short leg cast or cast brace for 4 weeks. After the cast is removed, a molded ankle foot orthosis or semi-rigid ankle brace with a hind foot lock may be used as the tenosynovitis resolves.

Jackson: What is your approach to treatment once it progresses to a flat foot deformity?

Frey: Conservative treatment for posterior tibial tendon dysfunction with a flatfoot includes orthotic devices, supportive shoes with a firm medial heel counter, anti-inflammatory medications, weight loss if the patient is overweight, and a semi-rigid ankle brace with a hindfoot lock, such as the ASO. A flexible flatfoot may be managed with a University of California Biomechanics Laboratory orthotic device.

A progressive, painful flatfoot with gait disturbance is common. A severe flatfoot makes shoe wear or even bracing difficult. Once conservative treatment fails, surgery is considered the best option. If the deformity is flexible, a tendon transfer combined with a realignment osteotomy is usually recommended. However, once a rigid flatfoot develops, stabilization of the hindfoot by arthrodesis is the better alternative.

Jackson: Over the years, many of the surgical interventions I have seen in my patients for the deformities from a ruptured posterior tendon have not made the patients more functional. What do you tell your patients about outcomes from surgical intervention for the symptoms and deformity?

Frey: Tendon transfer surgery may fail, especially if not combined with a corrective osteotomy. A soft tissue procedure alone will not hold up over time. If the tendon transfer and realignment fail, then an arthrodesis may be necessary.

For more information:
  • Carol C. Frey, MD, is Orthopedics Today Section Editor, Foot & Ankle. She can be reached at West Coast Center for Orthopedic Surgery and Sports Medicine, 1200 Rosecrans Ave., Ste. 208, Manhattan Beach, CA 90266; email:
  • Frey has no relevant financial disclosures.