Posterior tibialis tendon: a key player in foot biomechanics (2023)

Trevor Langforddiscusses the anatomy and biomechanics of the posterior tibia and outlines appropriate examination protocols and the treatment and management options for dysfunction

Posterior tibialis tendon: a key player in foot biomechanics (1)

The posterior tibial tendon (TPT) plays an important role in the optimal functioning of foot biomechanics, particularly as it provides stability to the medial longitudinal arch (MLA).(1). Dysfunctions not only show up as pain on the inside of the lower leg and ankle, but can also be a major cause of flat feet in the event of a tendon rupture – or vice versa, where flat feet inherently cause tendon overload(2). Many healthcare professionals are yet to fully appreciate the importance of the posterior tibialis tendon and its significant role in injury incidence, making it important to increase recognition of this condition(3).

Occurrence of malfunctions

A number of risk factors have been identified for the occurrence of posterior tibial tendonitis dysfunction. Obesity is a factor, with obese middle-aged women being diagnosed 10% of the time(2). Other factors include pes planus (flat feet), steroid injections around the tendon, high blood pressure, diabetes, and rheumatoid arthritis(3). Other causes of flat feet in adults include previous fractures, inflammatory arthropathy, osteoarthropathy, tear of the spring ligament (calcaneonavicular ligament), and anterior tibial rupture (although these are less common).(3).

Triathletes often suffer from this injury due to the repetitive stress in the three disciplines(4). The demands on this tendon when running are obvious; With poor biomechanics, it's easy to see how the tendon can become overloaded and collapse. When it comes to swimming, the requirements are not so obvious.

(Video) Posterior Tibial Tendonitis

However, placing the ankle in plantar flexion (by pointing the toes during freestyle swimming) increases muscle shortening at the calf complex. Added to this is the repeated push-off from the wall when swimming in the pool. In addition to poor foot biomechanics, some of the more common factors can cause tendon overload such as: B. rapid increase in volume/load, hill reps, improperly fitting shoes(4).

In the triathlon, the shortening of the calf muscles when swimming and the high build-up of strength when cycling are combined at the start of the run, which means that the run starts with calf muscles that are already heavily used and also tires you out. Therefore, effective training with proper recovery protocols is essential to prevent these types of injuries in triathletes.

anatomy and biomechanics

The tibialis posterior (also known as the posterior tibial tendon) arises on the posterior surface of the tibia on the outside, with a muscular insertion on the medial surface of the fibula and the interosseous membrane between the tibia and fibula(2). It runs along with the more dominant calf muscles of the gastrocnemius and soleus through the deep posterior compartment of the lower leg and passes behind the medial malleolus of the ankle. At this point (directly behind the inner malleolus) the blood supply is reduced(2).

At the distal insertion, the tibialis posterior divides into three segments, with the main section attaching to the tuber naviculare (bony prominence) on the inside of the foot(2). The plantar segment inserts at the second, third, and fourth metatarsal bones, at the second and third sphenoid bone, and at the cuboid bone. The third section, referred to as the recurring section, begins at the sustentaculum tali of the calcaneus (see Figures 1 and 2).

Due to the anatomical features of the posterior tibialis, it is the primary ankle inverter and also serves to maintain the dynamic stability of the foot's MLA and to assist the other calf muscles in plantar flexion(5). Because of its attachment sites to the navicular, calcaneus, and cuneiform bones, it is evident how the posterior tibialis plays a significant role in elevating the MLA to increase hindfoot and midfoot stiffness during stance. As a result, this provides an opportunity for the gastrocnemius to function with greater efficiency(2). It can therefore be argued that the tibialis posterior tendon is of great importance in foot biomechanics.

Figure 1: Posterior view showing the TPT behind the medial malleolus

Posterior tibialis tendon: a key player in foot biomechanics (2)

Figure 2: Medial aspect of the foot/ankle complex showing the posterior tibial tendon

Posterior tibialis tendon: a key player in foot biomechanics (3)

(Video) Dr. Evan Loewy, Posterior Tibial Tendon Dysfunction - Florida Orthopaedic Institute


Quite often, posterior tibial tendonitis develops over time—perhaps after an ankle fracture or a serious ankle sprain. Prolonged time in an Aircast boot or pot can result in tendon weakness and reduced MLA height. A complete rupture of the tendon at the base of the foot does not have to be necessary for a flatfoot deformity to develop. Therefore, a rehabilitation program should include foot inverter strengthening exercises. If this strength work is not performed, the posterior tibial tendon can become exposed and repeated microtrauma can cause tendinosis to occur.

As the tendon degenerates, it is replaced by fibrotic tissue, and this often occurs in areas of poor circulation in areas such as behind the medial malleolus(2). Bubra and colleagues have found that contracture of the Achilles tendon can occur due to the valgus changes of the hindfoot, leading to changes in the forces exerted on the hindfoot(2). These changes in applied forces can cause pain due to contact of the fibula and lateral calcaneus. Another biomechanical factor associated with changes in the hindfoot is contracture of the peroneus brevis, which causes mechanical force to be applied to the opposing posterior tibialis tendon. Therefore, soft tissue release should be considered not only for the posterior tibial fibers but also for the opposite peroneals.


It's important to establish a thorough investigation protocol if you suspect that posterior tibial tendinosis might be a possibility. The first thing to assess is swelling behind the medial malleolus (Figure 3), which in conjunction with changes in foot shape has 100% accuracy for diagnosing posterior tibial tendon dysfunction(3).

Patients with stage one tendon degeneration typically have vague medial foot pain on the inside of the foot and swelling behind the ankle(3). These patients have no history of trauma. Observe the lower leg from behind using the “too many toes” sign (Figure 4) which, when positive, indicates a hindfoot valgus deformity coinciding with MLA flattening and compensatory forefoot abduction(2).

Figure 3: Swelling of the tibialis posterior tendon behind the medial malleolus of the ankle

Posterior tibialis tendon: a key player in foot biomechanics (4)

Figure 4: Sign of too many toes

Posterior tibialis tendon: a key player in foot biomechanics (5)

Signs of too many toes as a result of foot abduction, where two extra toes can be observed on the outside of the foot.

(Video) Best Way To Treat Posterior Tibial Tendonitis

In the last stages there is less swelling and pain, but it is more noticeable due to the unilateral flatfoot deformity with a valgus force of the heel bone. This causes the "too many toes" sign to stand out. Ask the patient to stand on tiptoe with both feet; An inability to perform this exercise (usually causing the heel to rotate inward) is a key indicator of a tendon rupture(3).

One progression is to ask the patient to stand up on one leg; a patient with posterior tibial tendinosis is unable to do this. The one-leg raise is one of the most important functional tests for this condition. If function is normal, a person should be able to complete ten repetitions without pain. The strength of the musculoskeletal unit can be tested by resisting from a dorsiflexed/everted position into a plantar flexion inversion following actions that the muscle actively facilitates(3).

An X-ray of both lower extremities is used to observe the patient in a standing position. X-rays are best taken from the anterior and lateral aspect of the ankle to best demonstrate the presence or absence of degenerative changes in the subtalar and talocrural joints. Although a radiologist may request an MRI or ultrasound scan, researchers at the Royal National Orthopedic Hospital, UK, have argued that clinical testing for posterior tibial tendon pain is sufficient to make a diagnosis(3).

treatment and administration

Tendon degeneration can be divided into four different stages (Table 1) and the appropriate treatment at each stage therefore depends largely on the stage of the injury. Stages three and four are less commonly observed in athletes, but at the same time it is important to recognize the progression of tendon degeneration.

It is possible that the second stage tendon degeneration is reversible and corrects the abnormal foot biomechanics(3). However, the third stage is associated with irreversible subtalar joint degeneration with irreversible tendon changes. Stage four has been added to include degenerative changes within the ankle as well as the structures involved in stage three. It is important to functionally develop the strength of the tendon once the swelling has subsided and a heel lift can be performed. A simple exercise with a tennis ball between your heels (see Figure 5) helps improve hindfoot eversion and activation of the posterior tibialis.

Table 1: Staged presentation and conservative versus surgical treatment options(3)

Posterior tibialis tendon: a key player in foot biomechanics (6)

Figure 5: Bipedal heel lift while squeezing a tennis ball actively encourages hindfoot version correction.

Posterior tibialis tendon: a key player in foot biomechanics (7)

(Video) Posterior tibial tendon transfer (Dr. Edgardo Rodriguez-Collazo)

Case study triathlete

A 41-year-old male novice triathlete presented to a physical therapy clinic with acute right ankle pain three days after performing a flip turn during a pool training session(4). An hour into a session, he experienced extreme right calf pain without a pop or pop, followed by a cramping sensation. He immediately stopped training.

Pain was initially rated 8/10 (using a 0-10 pain rating scale) and presented as a dull ache. Aggravating activities included climbing stairs and driving. The patient had avoided putting weight on his right leg. He walked with a significant limp and was unable to perform a heel lift. The patient had previously had iliotibial band and gluteal muscle weakness on the same side and was still being treated but had resolved almost 100%.

Palpation of the posterior tibial tendon replicated the extreme pain, as did passive dorsiflexion with eversion and resistance to plantar flexion with inversion. There was minimal tenderness at the medial Achilles tendon and no tenderness in the calf muscles. In addition, all ankle band tests failed to reproduce pain. Swelling and discoloration was noted on the inside of the ankle with a circumference measurement of 29 cm on the affected limb compared to 25 cm on the unaffected limb.

Grade 1 posterior tibial strain was diagnosed with treatment consisting of acupuncture, active calf muscle relaxation techniques, and soft tissue relaxation using the Graston technique, followed by ice and elevation. Eight days after the initial examination, the circumference had reduced to 27 cm and the patient could walk with a normal gait without a compensatory limp. After the fourth treatment (13 days after the initial assessment), the pain score was two or three out of ten and he was able to climb stairs without pain. Resisting plantar flexion with inversion reproduced minimal pain.

The patient had returned to pool training, using a pullbuoy to reduce stress on the foot and refraining from pushing off the wall. The patient returned one month after the injury and had no further worsening of his symptoms. He continued to work on the bike and in the pool, plus specific tibialis posterior strength exercises with a tennis ball between his heels in a double-leg heel raise.

Six weeks after the initial injury, the patient was pain free and ready to return to walking. A treadmill gait analysis was performed which revealed that he ran with excessive forward leaning of the body with reduced hip and knee flexion. The patient also pronated at the ankle with marked outward toe movement with eversion. A single leg squat with increased tibial internal rotation was noted with increased standing pronation. There was also a low arch height on the right side as indicated by a gait scan. Calluses were also noted on the metatarsal heads of both feet. Orthoses were applied along with modifications to the patient's gait. After another month, the patient ran with increased cadence and longer distances, but remained pain-free.


Various diseases are considered risk factors for the occurrence of a dysfunction of the tibialis posterior tendon and should be considered during the examination. It is important to focus on the effective rehabilitation of ankle injuries, either acute or postoperative, to ensure that an earlier injury does not result in tendon dysfunction at a later date. Effective screening should take place within a sports team to ensure that no one is present with abnormal foot biomechanics that can lead to tendon degeneration.

(Video) Introduction to Posterior Tibial Tendon Dysfunction


  1. Blasimann – J Foot and Ankle Res, 2015, 8, 37
  2. Bubra – J Family Med Prim Care, 2015, Jan, 4, 1, 26-29
  3. Kohls-Gatzoulis-BMJ, 2004, 329, 1328-1333
  4. Howitt – JCCA, 2009, 53,1, 23–31
  5. Brocket - Ortho and Trauma, 2016, 30, 3, 232-238


What is the function of the posterior tibial tendon? ›

A tendon attaches muscles to bones, and the posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot. The main function of the tendon is to hold up the arch and support the foot when walking. The posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot.

What is the importance of the posterior side of the tibia? ›

The tibia is the site of attachment for many leg muscles. Roughly speaking, the lateral surface of the tibia provides attachment sites for the muscles of the anterior compartment of the leg, while the posterior surface provides attachment sites for the muscles of the posterior leg compartment.

Is tibialis posterior involved in plantar flexion? ›

Function. Tibialis posterior is involved in movements at two different joints, as follows: Plantar flexion of the foot at the talocrural (ankle) joint. Inversion of the foot at the subtalar joint.

What muscle does the posterior tibial tendon attach? ›

It is also attached to the interosseous membrane medially, which attaches to the tibia and fibula. The tendon of the tibialis posterior muscle (sometimes called the posterior tibial tendon) descends posterior to the medial malleolus. It terminates by dividing into plantar, main, and recurrent components.

Is posterior tibial tendon dysfunction? ›

Posterior tibial tendon dysfunction (PTTD) represents an acquired, progressive disease of the foot and ankle that is seen commonly in middle-aged patients. It is the most common cause of adult acquired flatfoot deformity. Treatments involve conservative and surgical options depending on the severity of the disease.

What is the antagonist to tibialis posterior? ›

Posterior Tibial Tendon Dysfunction

Its principal antagonist is the peroneus brevis, which normally everts the subtalar joint and abducts the forefoot.

Why is the tibialis important? ›

Function. Tibialis anterior dorsiflexes the foot at the talocrural joint and inverts it at the subtalar joint. It plays an important role in the activities of walking, hiking and kicking the ball by stabilizing the ankle joint as the foot hits the floor and pull it clear of the ground as the leg continues moving.

What are the 2 major actions of the muscles of the posterior compartment of the leg? ›

The posterior compartment musculature functions to plantarflex and invert the foot.

Is posterior tibial tendon a flexor? ›

Posterior Tibial Tendon (Box 16.3) The posterior tibial tendon is the largest of the three medial flexor tendons. It has an oval shape and is approximately twice as large as the adjacent round flexor digitorum and flexor hallucis longus tendons.

Which muscle is primarily responsible for plantar flexion? ›

Gastrocnemius: This muscle makes up half of your calf muscle. It runs down the back of your lower leg, from behind your knee to the Achilles tendon in your heel. It's one of the main muscles involved in plantar flexion. Soleus: The soleus muscle also plays a major role in plantar flexion.

What movement is the tibialis anterior responsible for? ›

The tibialis anterior acts primarily in dorsiflexion of the ankle and also as a strong inverter of the subtalar joint. It is active during the first phase of gait and contracts eccentrically from heel strike to toe-off.

What causes posterior tibial tendon dysfunction? ›

Overuse of the posterior tibial tendon is often the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking or climbing stairs.

Where does the posterior tibial tendon start? ›

The tibialis posterior tendon muscle originates on the tibia, the interosseous membrane, and the fibula. It descends within the posterior compartment of the leg, between the flexor digitorum longus (FDL) and the flexor hallucis longus (FHL).

What exercise works tibialis posterior? ›

Stand sideways on to a wall, on one foot, with your arch held in a good neutral position. Push up onto the ball of your foot, hold for1 second at the top of the movement, and return slowly to the starting position. Make sure that when your foot returns to the ground you do not allow your arch to collapse inwards.

Does stretching help posterior tibial tendonitis? ›

Mobility & stretching exercises

Stretching the calf muscles and tibialis posterior muscles at the back of the lower leg is important. Make sure you stretch the calf muscles with both the knee straight and the knee bent. This will ensure all muscles in the back of the lower leg are stretched thoroughly.

Does posterior tibial tendonitis improve? ›

PTTD is a painful injury, and it can take several months to heal. You may have to change the ways you approach your daily activities. Slowly and carefully ease yourself back into any activities or exercises that you participated in before your injury.

Is posterior tibial tendonitis permanent? ›

Degeneration of the posterior tibial tendon can lead to flat feet, so it is imperative that an injury is spotted and diagnosed in the beginning stages. Some of the damage that this condition incurs can be permanent if it is not diagnosed promptly.

Are plantar fasciitis and posterior tibial tendonitis related? ›

The posterior tibial tendon runs along the inside of the ankle and the foot. When there is post-tibial tendon disfunction, the tendon does not function to hold up the arch, resulting in flat feet. This can lead to heel pain, arch pain, plantar fasciitis and/or heel spurs.

What is the synergist muscle for tibialis posterior? ›

Synergist: Gastrocnemius, Flexor digitorum longus, Flexor hallucis longus, Peroneus longus and brevis, Soleus, Plantaris. Antagonist: Extensor hallucis longus, Extensor digitorum longus, Tibialis anterior, Peroneus tertius.

Where does posterior tibialis attach? ›

Medial portion of posterior, proximal half of fibula. Insertion: (distal attachments): Navicular tuberosity, cuneiforms, cuboid, 2-4 metatarsals, and sustentaculum tali of calcaneus.

Is the tibialis important for running? ›

Two important muscles of the lower extremity used during running are the gastrocnemius and the tibialis anterior. These muscles are responsible for the plantarflexion and dorsiflexion of the foot, respectively.

What does training your tibialis do? ›

A strong tibialis also helps to improve stopping power, vertical jumps, agility, balance, ankle mobility and reducing the impact the knees and ankles absorb during physical activity. Strengthening the tibialis can be done by following along to the exercises below.

Do tibialis raises increase ankle mobility? ›

Tibialis Anterior Raises

The Tibialis Anterior runs along the front of your shin and is one of the muscles responsible for the dorsiflexion of the foot as well as helps stabilize the ankle joint and knee joint. This is very important for walking or running as it helps lift the foot off the ground.

What are the functions of the main posterior muscles? ›

The posterior or back muscles perform a wide range of functions, including movement of the shoulder, head, and neck and assisting in respiration, posture, and balance.

What are the 2 movements produced by tibialis anterior? ›

The movements of tibialis anterior are dorsiflexion and inversion of the ankle.

What muscles cause inversion of the foot? ›

There are two muscles that produce inversion, tibialis anterior, which we've seen already, and tibialis posterior. The other muscle that can act as a foot invertor is tibialis anterior, which inserts so close to tibialis posterior that it has almost the same line of action.

Is the tibialis anterior a flexor or extensor? ›

Function. Tibialis anterior is the primary dorsiflexor of the ankle with synergistic action of extensor hallicus longus, extensor digitorium longus and peroneous tertius.

Is tibialis anterior a plantar flexor? ›

So it's not surprising that the muscles for plantar flexion are much larger than the ones for dorsiflexion. There's one muscle on the front of the leg for dorsiflexion, tibialis anterior. There are three on the back of the leg for plantar flexion, gastrocnemius, soleus, and plantaris. Here's tibialis anterior.

Which muscle is the strongest plantar flexor? ›

The gastrocnemius is one of the muscles that does most of the work in plantar flexion. This is a broad and strong muscle that also starts behind the knee and runs beneath the gastrocnemius.

What causes plantar flexion contractures? ›

ANKLE PLANTARFLEXION contractures are a common complication from central nervous system (CNS) injury or disease that results in spasticity of the triceps surae complex.

What is the main agonist for plantar flexion? ›

Plantar flexion takes place at the ankle (hinge joint). When the gastrocnemius relaxes and lengthens (antagonist) the tibialis anterior contracts and shortens (agonist).

What muscles cause dorsiflexion of the foot? ›

The foot and ankle dorsiflexors include the tibialis anterior, the extensor hallucis longus (EHL), and the extensor digitorum longus (EDL). These muscles help the body clear the foot during swing phase and control plantarflexion of the foot on heel strike.

Which muscle plantar flexes the foot? ›

The superficial muscles which are the main plantar flexors of the foot consist of the gastrocnemius, soleus and plantaris, the tendons of which converge to form the tendo calcaneus or Achilles' tendon (Figs 6.38, 6.39, 6.40).

How do you prevent posterior tibial tendon dysfunction? ›

Make Changes to Your Shoes and Use Orthotics

For extra support according to your foot anatomy, seek custom-made orthotics. Even if you are just walking around the house, wear shoes and orthotics to prevent stressing out your posterior tibial tendon.

What cardio can I do with posterior tibial tendonitis? ›

Posterior Tibial Tendonitis is typically aggravated by impact activities such as walking or running therefore cycling is a good alternative for cardiovascular exercise.

Can tight calves cause posterior tibial tendonitis? ›

Posterior tibial tendon dysfunction is the result of a repetitive injury to the posterior tibial tendon during standing, walking, or climbing stairs. Often patients have tight calf muscles which can increase the stress on the posterior tibial tendon, rendering the tendon more prone to injury.

What does a torn posterior tibial tendon feel like? ›

Tenderness over the midfoot, especially when under stress during activity. Gradually developing pain on the outer side of the ankle or foot as the arch flattens even more. A popping sound associated with pain on the inside of the ankle when the tendon is suddenly torn during an activity.

Does a torn posterior tibial tendon require surgery? ›

If you recently tore your posterior tibialis tendon, you might need this surgery. A tear can happen during a fall. It can also happen if you recently broke (fractured) your ankle or dislocated it. Surgery may also be done for chronic inflammation from overuse.

Can posterior tibial tendon tear heal? ›

PTTD is a painful injury, and it can take several months to heal. You may have to change the ways you approach your daily activities. Slowly and carefully ease yourself back into any activities or exercises that you participated in before your injury.

Do orthotics help posterior tibial tendonitis? ›

Orthotics are a popular treatment choice for people with posterior tibial tendon problems. If you suffer from this condition, you may benefit from using them to decrease your pain and improve your mobility. Your treatment for PTT dysfunction needs to be individualized for your specific condition.


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