What is Posterior Tibial Tendon
When the Posterior Tibial Tendon
becomes irritated from overuse, the gliding motion of
becomes impaired, thus leading to Posterior Tibial Tendon
Dysfunction (PTTD). PTTD may be a slow
or abrupt progression resulting in inflammation, overstretching,
partial, or complete rupture of the
The Posterior Tibial Tendon begins in the calf, runs
along the medial aspect of the foot, and inserts into
the navicular bone and lesser tarsus (ie. metatarsal
bases, cuneiform, and cuboid) (2,3). The Posterior Tibial
Tendon not only stabilizes the medial arch of the foot,
it also plantar-flexes the foot which provides support
during the toe-off phase of gait (1,2,3). Symptoms of
PTTD may include pain, inflammation, an inward rolling
of the ankle, and hindfoot valgus with forefoot abduction
(a flattening of the medial arch of the foot) (1,2,3,4).
Posterior Tibial Tendon Dysfunction
is the leading contributor of Adult Acquired Flatfoot
(Pes Planus) (1,2,3,4,5). Additional contributing
factors to the onset of PTTD may include hypertension,
diabetes, peripheral neuropathy, smoking, or arthritis.
The demographic most associated with Posterior Tibial
Tendon Dysfunction and Adult Acquired Flatfoot are
women over 50 and athletes, who present with an
aggravated Posterior Tibial Tendon.
A common test to evaluate Posterior
Tibial Tendon Dysfunction is the too many
toes sign. The too many toes sign
measures abduction (deviation away from the midline
of the body) of the forefoot. With damage to the
Posterior Tibial Tendon, the forefoot will abduct
or move out in relation to the rest of the foot.
When the foot is viewed from behind in cases of
PTTD, the toes appear as too many on the outside
of the foot, also known as hindfoot valgus with
Several classifications have been
developed to describe and treat Posterior Tibial
Tendon Dysfunction (3,5). Treatment of PTTD is determined
based upon the clinical stage and health of the
patient (5). If PTTD is diagnosed and treated early,
non-surgical methods may be applied, such as biomechanical
orthotics or heel elevators, medications, and/or
casting (1). Such shoe gear will decrease the functioning
load of the Posterior Tibial Tendon by supporting
the arch of the foot and stabilizing the hindfoot.
In cases where Posterior Tibial Tendon
Dysfunction has significantly progressed, or in circumstances
where non-surgical applications have failed, surgical
treatment may be required to correct the damage to the
Posterior Tibial Tendon. Integra LifeSciences Corporation
offers innovative and comprehensive products, designed
for the surgical procedures associated with the treatment
of Posterior Tibial Tendon Dysfunction and Adult Acquired
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1. Kelly, Ian P, Mark E.
Easly, TREATMENT OF STAGE 3 ADULT ACQUIRED FLATFOOT
Foot and Ankle, Clin. Mar 2001: 153-166.
2. DiPaola M, Raikin SM, TENDON TRANSFERS AND REALIGNMENT
OSTEOTOMIES FOR TREATMENT OF STAGE II POSTERIOR
TIBIAL TENDON DYSFUNCTION, Foot Ankle Clin. 2007
June; 12(2): 273-85, vi.
3. Pomeroy GC, Pike RH, Beals TC, Manoli A 2nd.,
ACQUIRED FLATFOOT IN ADULTS DUE TO DYSFUNCTION OF
THE POSTERIOR TIBIAL TENDO,N J Bone Joint Surg Am.
1999 Aug; 81(8):1173-82.
4. Mann RA, Thompson FM, RUPTURE OF THE POSTERIOR
TIBIAL TENDON CAUSING FLAT FOOT. SURGICAL TREATMENT,
J Bone Joint Surg Am. 1985 Apr; 67(4): 556-61.
5. Bluman EM, Title CI, Myerson MS, POSTERIOR TIBIAL
TENDON RUPTURE: A REFINED CLASSIFICATION SYSTEM,
Foot Ankle Clin. 2007 June; 12(2):233-49,v.
6. Wacker JT, Hennessy MS, Saxby TS, CALCANEAL OSTEOTOMY
AND TRANSFER OF THE TENDON OF FLEXOR DIGITORUM LONGUS
FOR STAGE II DYSFUNCTION OF TIBIALIS POSTERIOR. THREE
TO FIVE YEAR RESULTS, J Bone Joint Surg Br. 2002 Jan;