Fallen Arch: Tibialis Posterior Tendon Dysfunction

The 26 Review

  • What is Tibialis Posterior Tendon Dysfunction The large tendon on the inside of the ankle stretches, tears, and/or is inflamed, causing the foot’s arch to lose support and flatten
  • Causes Trauma, chronic overuse, poor shoe gear, genetics
  • Who Individuals over 40, obesity, chronic use of unsupportive shoes
  • Symptoms Fallen arches, pain and/or swelling on the inside or outside of the ankle
  • Diagnosis Physical examination, X-rays, MRIs, and ultrasounds
  • Treatment Ankle bracing, custom orthotics, boot immobilization, physical therapy, icing, OTC pain medication, and surgery
26 Foot and Ankle Arthritis

Let’s take a closer look…

Posterior tibial tendon dysfunction better known as PTTD or acquired flat foot, is a condition that develops over time, typically due to an injury. This condition is the result of inflammation, tearing, and/or stretching of the posterior tibial tendon.

Once this tendon has become stretched or torn it no longer supports the foot’s arch as it should. This is because the posterior tibial tendon connects one of the calf muscles to the bones located on the inner foot.

In many cases, the large tendon on the inside of the ankle can also become degenerative and begin thickening. Due to the tendon no longer being in its proper position, it can be the source of pain, swelling, and/or redness. In addition, the foot becomes flatter; it can also cause pain during weight-bearing activities.

PTTD is different from congenital flatfoot, however, sometimes patients develop similar symptoms and require similar treatments. Continue reading on to learn more about PTTD (fallen arch condition).


The posterior tibial tendon can be injured in many different ways. Most commonly, this tendon is injured from a fall or direct contact during high-impact sports. Over time, however, overuse of the tendon can also cause injury.

Common activities that can cause an overuse injury include walking, hiking, running, climbing stairs, and high-impact sports. PTTD can be more likely to occur in specific demographics. Those demographics include females, people who are 40 or older, people with diabetes, people with hypertension, and people who are overweight or obese.


There are a multitude of symptoms that can directly point out a damaged tibialis posterior tendon. The key visible indicators would be a fallen arch and/or an inward rolling or collapsing ankle.

Pain is most likely to occur around the inside of the foot and ankle, however, pain and swelling can occur on the outside of the ankle as well. Other common symptoms include swelling, warmth, and redness along the inside of the foot and ankle.

Most patients with PTTD have reported that pain increases/worsens during weight-bearing activities, including walking and running. Patients may also observe the turning out of the toes and foot as a symptom as well.


If you or someone you know is experiencing any of the previously mentioned symptoms, it is highly encouraged to visit a podiatrist for diagnosis and treatment. During an office visit, patients can expect a few different things to occur.

First the medical professional will begin by examining the foot. They will be looking for swelling and redness along the posterior tibial tendon. The doctor will also test a patient’s range of motion by moving the foot from side to side and up and down.

PTTD, at times, can cause issues with side-to-side motion, as well as problems with moving the toes upward. The doctor will also look for a collapsed arch and a heel that has moved outward. At times, the doctor may also check how many toes they can see from behind a patient’s heel when standing.

PTTD can cause the toes to shift, making the 4th and 5th toes more visible. At times, all of the toes can be visible. Most individuals with PTTD can’t stand on their tiptoes, so this will also be tested.

Most podiatrists can diagnose PTTD solely with physical examination, but the medical professional may also order some imaging tests to be 100% sure. The podiatrist may order X-rays or CT scans to determine whether there is also arthritis in the foot and ankle. MRIs and ultrasound scans can confirm PTTD.


In most cases, fallen arch can be treated without surgery with non-invasive treatments. Initial treatment typically focuses on reducing pain and swelling, allowing the tendon to heal on its own. At this time, applying ice to the sore area and taking nonsteroidal anti-inflammatory medications can aid in reducing pain and swelling.

A doctor may also advise their patient to rest and avoid activities that cause pain, like running or other high-impact sports. Depending on the severity of the PTTD, the medical professional may also suggest some form of support for the foot and ankle.

Ankle braces can help take tension off the tendon and allow it to heal quicker. Custom orthotics can also help support the foot and restore the natural foot position. The foot and ankle may require immobilization in a walking boot if the fallen arch injury is more severe. Patients wearing a walking boot can expect to wear it for 6 to 8 weeks. Prolonged use of a walking boot can cause muscle atrophy or weakening of the muscles, so medical professionals only recommend them in severe cases.

Surgery may be necessary if the PTTD is severe and other non-invasive treatments have not been successful. Depending on a patient’s symptoms and the extent of the injury, different surgical options will be recommended. The determining factors for choosing a surgery include severity of deformity, flexibility of deformity, presence of underlying arthritis, and patient’s age, among other factors.

Patients with trouble moving their ankles may require a surgical procedure that lengthens the calf muscle. Other surgical options include removing damaged areas from the tendon or replacing the posterior tibial tendon with another tendon from the body.

In more serious cases, an osteotomy or surgery that fuses joints together may be necessary to correct a flatfoot. If you or someone you know is considering their treatment options for the fallen arch, make sure to speak with your podiatrist.

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