Can PTTD affect both feet?

Yes — bilateral PTTD occurs, though one foot is usually more symptomatic than the other. Dr. Gunter evaluates both feet regardless of which side prompted the visit, because early-stage disease on the less symptomatic side benefits from intervention before it advances.

/ CONDITIONS / POSTERIOR TIBIAL TENDON DYSFUNCTION

Posterior Tibial Tendon Dysfunction

The most common cause of adult-acquired flatfoot — progressive inner ankle and arch pain that worsens over time without treatment. Early evaluation produces significantly better outcomes.

Andrew Gunter, DPM — San Antonio, TX.

Call (210) 581-9800

Posterior tibial tendon dysfunction and adult-acquired flatfoot treatment in San Antonio TX by Dr. Andrew Gunter DPM

What Is Posterior Tibial Tendon Dysfunction?

The posterior tibial tendon is one of the most important structural tendons in the foot. Running from the calf muscle down behind the inner ankle bone and attaching to several bones on the inner side of the midfoot, it is the primary dynamic supporter of the medial arch during walking and standing. When this tendon functions properly, it holds the arch up and controls inward rolling of the foot with every step.

Posterior tibial tendon dysfunction — PTTD — occurs when this tendon becomes inflamed, degenerates, or tears. As the tendon loses its ability to support the arch, the arch progressively collapses, the heel shifts outward, and the forefoot abducts — a pattern of deformity that is characteristic of adult-acquired flatfoot. Left untreated, the deformity progresses through predictable stages from flexible to rigid, and the treatment options become progressively more complex as it advances.

PTTD most commonly affects women over 40, though it is not exclusive to this demographic. Obesity, hypertension, diabetes, and prior steroid injections around the tendon are recognized risk factors. The condition develops gradually rather than from a single injury — which is why patients often attribute the early symptoms to a general ankle ache or mild flatfoot rather than recognizing the specific tendon problem.

The most common early symptoms are pain and swelling along the inner ankle and the inner edge of the foot — the course of the posterior tibial tendon. Standing on tiptoe on the affected foot is painful and may be impossible in more advanced cases. As the deformity progresses, the arch visibly collapses, the heel tilts outward, and the forefoot drifts away from the midline when the patient stands.

The critical clinical point about PTTD is that early-stage disease — when the tendon is inflamed but still intact — responds well to conservative treatment including custom orthotics and bracing. Advanced-stage disease — when the tendon has torn and the deformity has become rigid — typically requires surgical reconstruction. The window for effective conservative management is real but finite, and it is why Dr. Gunter emphasizes that inner ankle and arch pain in this pattern warrants prompt evaluation rather than watchful waiting.

COMMON SYMPTOMS:

Pain and swelling along the inner ankle
Arch aching that builds throughout the day
Pain along the inner edge of the foot
Difficulty standing on tiptoe on the affected foot
Visible flattening of the arch over time
Heel shifting outward when standing
Forefoot pointing outward — 'too many toes' sign
Increasing fatigue with walking and standing

PTTD IS MORE COMMON IN:

Women over 40 — the most commonly affected group
Patients who are overweight
Those with hypertension or diabetes
Patients with a history of steroid injections near the tendon
Adults with pre-existing flat feet or overpronation
Those who spend long periods on their feet

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Treatment Options for Posterior Tibial Tendon Dysfunction

Treatment is matched entirely to the stage of the condition at the time of evaluation. This is why prompt evaluation — before the condition advances — is so important for preserving conservative treatment options.

Custom orthotics & arch support

In early-stage PTTD, precision custom orthotics provide the arch support the weakening posterior tibial tendon can no longer reliably deliver. They slow or halt deformity progression and significantly reduce pain with activity. Dr. Gunter designs orthotics specifically for PTTD — addressing the hindfoot valgus and midfoot collapse pattern characteristic of the condition.

Bracing & immobilization

For more significant tendon involvement, an ankle-foot orthosis (AFO) or walking boot provides the level of support that orthotics alone cannot deliver. Immobilization allows the tendon to rest and reduce acute inflammation. Dr. Gunter determines the appropriate support level based on the stage and severity of the condition.

Tendon rehabilitation

A targeted physical therapy program strengthens the posterior tibial muscle and the supporting foot and ankle musculature — reducing the dynamic load on the compromised tendon and supporting functional arch mechanics. Rehabilitation is an essential component of conservative management in early to mid-stage disease.

Surgical reconstruction

For advanced or failed conservative management, surgical options range from tendon transfer and calcaneal osteotomy in flexible deformity to triple arthrodesis in rigid deformity. The specific procedure depends on the stage and individual anatomy — discussed thoroughly at your surgical consultation.

Related conditions: Arch pain & flat feet · Ankle sprains & instability · Custom orthotics

The Stages of Posterior Tibial Tendon Dysfunction

PTTD progresses through recognizable stages. Understanding the stage helps Dr. Gunter recommend the most appropriate treatment — and helps patients understand why earlier evaluation produces better outcomes.

Stage I — Tendon Inflammation

The tendon is inflamed and painful but still intact and functioning. The arch height is preserved. Pain along the inner ankle with activity. Conservative treatment — orthotics, bracing, physical therapy — is most effective at this stage.

Stage II — Flexible Flatfoot

The tendon has elongated or partially torn. The arch has collapsed but remains flexible — it can still be passively corrected. The heel shifts outward. Conservative treatment remains possible but is more demanding. Surgical options are discussed if conservative management fails.

Stage III — Rigid Flatfoot

The deformity has become rigid — the arch cannot be passively corrected. Arthritis has developed in the hindfoot and midfoot joints. Surgical reconstruction is typically required for meaningful improvement at this stage.

Stage IV — Ankle Involvement

The deformity has extended to the ankle joint with valgus tilting of the talus. The most advanced and complex stage. Surgical management is required and involves reconstruction of both the hindfoot and ankle.

Stages I and II are manageable with conservative treatment and — in stage II cases that don't respond — corrective surgery with good functional outcomes. Stages III and IV require more complex surgical reconstruction with longer recovery and less predictable results. The earlier PTTD is identified and treated, the better the outcome. If you recognize the symptoms of Stage I or early Stage II, this is the time to be evaluated.

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Frequently Asked Questions — Posterior Tibial Tendon Dysfunction

The distinction is important. Structural flat feet — pes planus — is a foot shape that has been present since childhood or early adulthood, is usually bilateral, and may or may not be symptomatic. PTTD is a progressive tendon condition that produces a change in foot shape over time — an arch that was previously higher and is now collapsing, with pain specifically along the posterior tibial tendon course on the inner ankle. The history of change is the key diagnostic clue. Flat feet that have always been flat are a different clinical entity from an arch that is progressively collapsing in an adult. Dr. Gunter's evaluation distinguishes between the two.

Yes — in early and mid-stage disease (Stages I and II), conservative treatment with custom orthotics, bracing, and rehabilitation is the primary approach and is effective for a significant proportion of patients. The earlier the condition is identified and treated conservatively, the better the outcomes. Advanced disease (Stages III and IV) typically requires surgical intervention because the deformity has become structural and rigid. Whether conservative treatment alone is sufficient depends on the stage of the condition at the time of evaluation — which is why early evaluation is important.

Posterior tibial tendinitis describes acute inflammation of the tendon — typically an early-stage presentation. PTTD is the broader term that encompasses the full spectrum from early tendon inflammation to complete tendon failure and progressive flatfoot deformity. Tendinitis is Stage I PTTD in clinical staging terms. The distinction matters because acute tendinitis that is recognized and treated early may not progress to the deformity stages — which is the best possible outcome.

PTTD progresses through its staging system without treatment — moving from flexible deformity to rigid deformity to ankle joint involvement. Each stage is more difficult to treat than the prior one. The window for conservative management closes as the deformity advances. The functional consequences of advanced PTTD — persistent pain, significant difficulty walking, and limited footwear options — are substantially more disabling than the early-stage condition. Early evaluation and treatment is the most effective way to prevent this progression.

Inner ankle pain or a changing arch? The sooner it's evaluated, the better the options.

Posterior tibial tendon dysfunction is one of the most important conditions to catch early. Dr. Andrew Gunter, DPM evaluates arch and ankle pain thoroughly — staging the condition accurately and recommending the most appropriate treatment before the window for conservative management closes. Serving San Antonio and surrounding communities. Same-day appointments available. Most insurance plans accepted.