Posterior Tibial Tendon Dysfunction

(Adult Acquired Flatfoot Deformity)


Posterior tibial tendon dysfunction (or Adult Acquired Flatfoot Deformity) is commonly known as a flat foot or “collapsed arch.”  This loss of arch occurs because the large tendon on the inside of the ankle, the posterior tibial tendon, becomes stretched out and no longer supports the foot’s arch as it should.  In many cases the tendon also becomes degenerative and may become thickened.  Because the tendon is no longer normal, it can be a source of pain.  In addition, as the foot becomes more flat, this can also cause pain especially with activities.  This is different than people who have had flat feet for their entire life (or congenital flatfoot), though sometimes these patients develop similar symptoms and require similar treatments as those listed below.


  • “Fallen arches” or “ankle collapsing in”
  • Pain and/or swelling on inside of ankle
  • Pain on outside ankle
  • Symptoms  increase with weight bearing activity


During your office visit, you can expect the following to occur to better understand the extent of your discomfort.

  • X-rays:  X-rays of the foot and ankle will be taken to evaluate for bony alignment
  • Complete history and physical examination to access areas of discomfort, degree and flexibility of deformity and prior treatment interventions.
  • An MRI or ultrasound may be warranted to further assess the tendon; this will be determined on a patient to patient basis.


Both non-operative and operative treatments will be discussed.  A treatment plan will be formed based on prior interventions, current level of disability and presence of other medical conditions.

Non-Operative Treatment: Always first line of treatment, especially if no other interventions have been prescribed.  This can include:

  • Ankle bracing, either over the counter or custom
  • Custom orthotics
  • Boot immobilization
  • Physical therapy
  • Activity modifications, ice and anti-inflammatory medications

Operative Treatment:  If all appropriate conservative measures have failed, then surgery may be the next reasonable step.  The type of surgery indicated depends on many factors to include severity of deformity, flexibility of deformity, presence of underlying arthritis and patient’s age and other medical co-morbidities.

  • Flatfoot Reconstruction: indicated for a flexible flatfoot deformity
    • Involves cutting and shifting the calcaneus or heel bone into a more neutral position, transferring the tendon used to flex the lesser toes to augment the posterior tibial tendon, and lengthening the calf muscle. Other additional procedures that may also be considered include a lateral column lengthening or fusion of one of the midfoot joints.
    • Risks & Benefits
      • Excellent pain relief
      • Correction of deformity
      • Risk of bony non-union
      • Risk of continued pain
    • Surgical procedure
      • May be outpatient or inpatient
      • Involves general anesthesia with regional nerve block
    • Post-Operative Care
      • Patient will be non-weight bearing in a splint or cast for the first 6 weeks post-operatively
      • Sutures or staples are removed after 2 weeks
      • At 6 weeks post-operatively, patient is transitioned into a weight bearing surgical boot.
      • At 3 months post-operatively, patient is transitioned into a regular shoe with an ankle brace. Physical therapy is initiated at this time if needed.
      • Non-impact exercise activities can be initiated 3-6 months post-operatively.
    • Long Term Expectations
      • It can take a full year to reach maximal medical improvement
      • You may still require the use of a foot orthotic
  • Triple Arthrodesis: indicated for a rigid flatfoot deformity or evidence of underlying arthritis
    • Involves fusing, or making stiff, three joints in the back of the foot – subtalar, talonavicular and calcaneocuboid.
    • Risks & Benefits
      • Excellent pain relief
      • Correction of deformity
      • Side to side motion of the foot will be lost
      • Risk of bony non-union and continued pain
    • Post-Operative Care
      • Patient will be non-weight bearing in splint or cast for 6-8 weeks post-operatively
      • Sutures or staples will be removed after 2 weeks
      • At 6-8 weeks post-operatively, weight bearing in a boot will be initiated.
      • At approximately 3 months post-operatively, patient will be transitioned into a boot or shoe with an ankle brace
      • Usually no formal physical therapy is required
    • Long Term Expectations
      • It may take a full year to reach maximal medical improvement
      • Gait: Due to restricted side to side motion of the foot, uneven surfaces may be difficult to maneuver, however, should not be painful
      • Recreational Activities: It is expected that the patient will be able to return to non-impact activities comfortably such as walking, biking, and swimming.