Fixing Tibialis Posterior Tendon Dysfunction (PTTD)
Key insights: 60-second read
- PTTD may be more than a foot problem - The tibialis posterior tendon can become overloaded when the arch collapses, which can be influenced by restrictions and movement compensations higher up the leg.
- Treating symptoms alone may not address the whole problem - Orthotics and arch supports can provide support while they are being used, but they do not necessarily address why the leg and arch are collapsing.
- Try a "top-down" approach - You can actively lift your arch by externally rotating your leg from the hip. If your arch lifts when you "screw your feet" into the ground, it may indicate that the position and movement of the leg are contributing to the problem.
- Four-step protocol - 1) Symptom relief with tibialis posterior release, 2) address ankle restrictions, 3) address hip restrictions, and 4) reinforce the movement pattern with squats.
On this page
Is PTTD More Than a Foot Problem?
Posterior tibial tendon dysfunction (PTTD) is often associated with arch dysfunction and overloading of the tibialis posterior tendon. However, in my clinical experience, the arch dysfunction can sometimes be part of a broader movement problem involving the ankle and hip. For this reason, I believe it is worth looking beyond the foot when assessing and treating PTTD.
Key Takeaways for PTTD
PTTD May Be More Than a Foot Problem
The tibialis posterior tendon runs behind the inner ankle and plays an important role in supporting the arch. When the tendon is subjected to excessive strain, it can become irritated. A collapsing arch can contribute to this strain, but from my clinical perspective, it is also important to consider whether the position and movement of the entire leg are contributing to the arch collapse.
The Pitfall of Symptomatic-Only Treatment
Orthotics and arch supports can be useful for supporting the foot, particularly when symptoms are aggravated by loading. However, they do not necessarily address the underlying reason why the leg and arch are collapsing. Our broader aim should be to help the body develop better control and support of the arch rather than relying solely on external support.
The "Top-Down" Approach to Arch Support
You can actively lift your arch by externally rotating your entire leg from the hip. If your arch lifts when you "screw your feet" into the ground and rotate your knees out, this provides a useful indication that the position and movement of the leg may be contributing to the arch collapse.
Identify the Hidden Restrictions
Two important areas to consider are the ankle and hip:
- Ankle joint restrictions: A stiff ankle can limit the shin's ability to move forward properly, potentially contributing to the leg collapsing inward or the foot turning out.
- Hip restrictions: Tightness around the hip external rotators and hip flexors may make it more difficult to maintain a stable, externally rotated position of the leg.
A Four-Step PTTD Treatment Protocol
The video outlines a sequential four-part approach designed to address both symptoms and the movement factors that may be contributing to them.
Step 1: Symptom Relief - Tibialis Posterior Release
Goal: Reduce tension in the tibialis posterior muscle above the sore tendon.
How: Use a ball, such as a lacrosse ball, on the inside of your shin.
- Sit with your heel off the edge of a chair or on the floor.
- Find the shin bone and move behind it, searching for tight or tender areas along the inner calf.
- Apply pressure using techniques such as static pressure, shearing and tense-and-relax methods.
Step 2: Address Ankle Restrictions - Banded Ankle Stretch
Goal: Mobilise a stiff ankle to allow more appropriate forward movement.
How:
- Tie a resistance band to a sturdy object and loop it just above your ankle bones.
- Step forward to create tension, keeping the other foot in front.
- Lunge forward by bending your back knee while keeping your knee aligned over your foot.
- Focus on driving your knee forward and slightly outward.
- Hold for 30 seconds to 2 minutes, or gently oscillate in and out of the position.
Step 3: Address Hip Restrictions - Two Key Stretches
Goal: Improve hip mobility to allow more stable external rotation of the leg.
A. Hip External Rotation / Glute Stretch
- Sit tall and cross one ankle over the opposite knee in a figure-four position.
- Keep your back straight and hinge forward from the hips until you feel a stretch in your glutes.
- Use the "tense and relax" method by tensing the tight glute muscles for 5-10 seconds, then relaxing and gently sinking deeper.
B. Couch Stretch - Hip Flexor Stretch
- Place the shin of your back leg against a wall or couch, with your front foot on the floor in a lunge position.
- Keep your back straight and squeeze the glute of the back leg.
- Use the same "tense and relax" method for the hip flexors.
Step 4: Reinforce the New Movement Pattern
Goal: Integrate the new mobility into a functional movement pattern.
How: Practise bodyweight squats while focusing on your foot and knee position.
- Keep your feet relatively straight.
- As you squat down, consciously "screw your feet" into the ground to externally rotate your legs and lift your arches.
- Keep your knees tracking in line with your feet rather than allowing them to collapse inward.
Conclusion
The key to long-term relief from PTTD is to look beyond the sore tendon and consider the movement mechanics that may be contributing to its overload. By pairing symptomatic relief with mobility and strength work for the ankle and hip, then reinforcing the changes through functional movement, you can create an environment where the tibialis posterior tendon is better supported during movement and can recover.
I genuinely hope this article offers a fresh perspective - or at least one useful takeaway. If you have a different issue, or simply want to learn more about how your body moves, head over to the Your Wellness Nerd YouTube channel. Subscribe if you feel inclined, and let me know in the comments what you'd like me to cover next.
- Grant
Frequently Asked Questions About PTTD
What is Posterior Tibial Tendon Dysfunction (PTTD)?
PTTD involves irritation and dysfunction of the tibialis posterior tendon, which runs behind the inner ankle and plays an important role in supporting the foot's arch. In this clinical approach, excessive loading of the tendon is considered alongside the movement of the ankle, foot and entire leg.
Can orthotics fix PTTD permanently?
Orthotics can provide support while they are being worn, but they do not necessarily address why the leg and arch are collapsing. This approach therefore also considers the ankle and hip restrictions that may be contributing to the movement pattern.
What exercises help PTTD?
A four-step approach includes 1) tibialis posterior release with a ball, 2) a banded ankle stretch to address ankle mobility, 3) hip external rotation and couch stretches to address hip restrictions, and 4) bodyweight squats focusing on "screwing your feet" into the ground to reinforce the movement pattern.
How do I know if my ankle or hip is contributing to my PTTD?
If your arch visibly lifts when you externally rotate your leg from the hip by "screwing your feet" into the ground, this may provide a useful clue that the position of the leg is contributing to the arch collapse. Common restrictions considered in this approach include ankle stiffness and hip tightness that may limit stable external rotation.
One key insight from this post
"The tendon irritation is a symptom, not the root cause. By releasing the tibialis posterior, then addressing ankle and hip restrictions, you can stop the leg from collapsing inward and let the tendon heal."
Living With Persistent Pain?
If your pain has lasted longer than expected, feels disproportionate to injury, or hasn't responded to standard treatment, you may benefit from a broader approach. Learn more about our ankle pain physiotherapy services in Port Macquarie.
Want personalised guidance?
If you'd like help making sense of your aches, pains, or ongoing symptoms, you can book with Grant either in Port Macquarie or via an online telehealth consultation.
