Posterior Tibial Tendon Tear

Posterior tibial tendon tear is an injury to a tendon that passes behind and under the inside of the ankle (posterior tibial tendon). A tendon is a strong band of tissue that connects a muscle to a bone.

The posterior tibial tendon attaches the calf muscles to the inside bones of the foot. Your posterior tibial tendon and calf muscles support the arch of your foot and allow you to rise up on your tiptoes.

A tear of this tendon can be partial or complete. This condition causes foot and ankle pain and can lead to a flat foot. It is a common injury in athletes who run or play sports that put high stress on the foot and ankle.

What are the causes?

This condition may be caused by a sudden (acute) injury, such as a fall or a severe twisting of the foot. It can also happen gradually from the wear and tear of repeated stress (overuse). In athletes, overuse injuries can result from overtraining on hard surfaces.

What increases the risk?

This condition is more likely to develop in:

• Athletes who do any of the following:
  • Run on hard surfaces.
  • Play a sport that involves high-impact forces being placed on the foot and ankle. These include tennis, basketball, and soccer.
  • Train too hard.
  • Participate in a sport without having proper fitness or training.
• Women.
• People who are age 40 or older.
• People who are overweight.
• People who have diabetes, gout, or rheumatoid arthritis.

What are the signs or symptoms?

The main symptom of this condition is pain on the inside of the foot or ankle. The pain may start suddenly or gradually. It may get worse with activity or when standing. Other symptoms include:

• Ankle swelling.
• Inward tilting of the ankle.
• Flattening of the arch.
• Pain when pressing on the tendon.
• Stiffness of the foot and ankle.

How is this diagnosed?

This condition may be diagnosed based on:

• Your symptoms and medical history.
• A physical exam. During the exam, your health care provider may check your foot for pain and stiffness. You may be asked to stand on tiptoe.
• Imaging studies, such as:
  • X-ray or CT scan to check for bone damage, such as a fracture or avulsion.
  • Ultrasound or MRI to check for tendon damage.

How is this treated?

Treatment for this condition may include:

• Stopping activities that cause pain.
• Keeping body weight off your ankle until pain and swelling improve. You may need to use crutches or a walker.
• Resting and supporting your foot. You may need to wear an ankle brace, splint, or boot.
• Icing the inside edge of your ankle.
• Taking NSAIDs to reduce pain and swelling.
• Physical therapy exercises. These will begin when pain and swelling improve.
• Wearing a supportive shoe or shoe insert (orthotic) to support your arch.
• Surgery. This may be needed if you have a complete tear (rupture) or if your condition has not improved after 6–8 weeks of treatment.

Follow these instructions at home:

If you have a brace, splint, or boot:

• Wear it as told by your health care provider. Remove it only as told by your health care provider.
• Loosen it if your toes tingle, become numb, or turn cold and blue.
• Do not let it get wet if it is not waterproof.
• Keep it clean.

Managing pain, stiffness, and swelling

• If directed, put ice on the injured area.
  • Put ice in a plastic bag.
  • Place a towel between your skin and the bag.
  • Leave the ice on for 20 minutes, 2–3 times a day.
• Move your ankle and toes often to avoid stiffness and to lessen swelling.
• Raise (elevate) your ankle above the level of your heart while you are sitting or lying down.

Driving

• Do not drive or operate heavy machinery while taking prescription pain medicine.
• Ask your health care provider when it is safe to drive if you have a brace, splint, or boot on your foot.

Activity

• Return to your normal activities as told by your health care provider. Ask your health care provider what activities are safe for you.
• Do exercises as told by your health care provider.

Safety

• Do not use the injured limb to support (bear) your body weight until your health care provider says that you can. Use your crutches or walker as told by your health care provider.

General instructions

• Do not use any tobacco products, such as cigarettes, chewing tobacco, and e-cigarettes. Tobacco can delay healing. If you need help quitting, ask your health care provider.
• Take over-the-counter and prescription medicines only as told by your health care provider.
• Keep all follow-up visits as told by your health care provider. This is important.

How is this prevented?

• Warm up and stretch before being active.
• Cool down and stretch after being active.
• Give your body time to rest between periods of activity.
• Use equipment that fits you and is appropriate to your athletic activity.
• Be safe and responsible while being active to avoid falls.
• Do at least 150 minutes of moderate-intensity exercise each week, such as brisk walking or water aerobics.
• Maintain physical fitness, including:
  • Strength.
  • Flexibility.
  • Cardiovascular fitness.
  • Endurance.

Contact a health care provider if:

• Your symptoms have not improved after 6–8 weeks of home care.
• Your symptoms are getting worse.
• You develop new symptoms.
• Your brace, splint, or boot becomes damaged.

Posterior Tibial Tendon Tear Rehab

Ask your health care provider which exercises are safe for you. Do exercises exactly as told by your health care provider and adjust them as directed. It is normal to feel mild stretching, pulling, tightness, or discomfort as you do these exercises, but you should stop right away if you feel sudden pain or your pain gets worse. Do not begin these exercises until told by your health care provider.

Stretching and range of motion exercises

These exercises warm up your muscles and joints and improve the movement and flexibility of your ankle. These exercises also help to relieve pain, numbness, and tingling.

Exercise A: Gastroc and soleus stretch

1. Sit on the floor with your left / right leg extended.
2. Loop a belt or towel around ball of your left / right foot. The ball of your foot is on the walking surface, right under your toes.
3. Keep your left / right ankle and foot relaxed and keep your knee straight while you use the belt or towel to pull your foot and ankle toward you. You should feel a gentle stretch behind your calf or knee.
4. Hold this position for __________ seconds.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise B: Dorsiflexion/plantar flexion

1. Sit with your left / right knee straight or bent.
2. Flex your left / right ankle to tilt the top of your foot toward your shin.
3. Hold this position for __________ seconds.
4. Point your toes downward to tilt the top of your foot away from your shin.
5. Hold this position for __________ seconds.

Repeat __________ times with your knee straight and __________ times with your knee bent. Complete this exercise __________ times a day.

Exercise C: Ankle plantar flexion, passive

1. Sit with your left / right leg crossed over your opposite knee.
2. Use your opposite hand to pull the top of your foot and toes toward you. You should feel a gentle stretch on the top of your foot and ankle.
3. Hold this position for __________ seconds.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise D: Ankle eversion

1. Sit with your left / right ankle crossed over your opposite knee.
2. Grip your left / right foot with your opposite hand, with your thumb on the top of your foot and with your fingers on the bottom of your foot.
3. Gently push your foot downward with a slight rotation so the smallest toes rise slightly toward the ceiling. You should feel a gentle stretch on the inside of your ankle.
4. Hold this stretch for __________ seconds.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise E: Ankle inversion

1. Sit with your left / right ankle crossed over your opposite knee.
2. Hold your left / right foot with your opposite hand, with your thumb on the bottom of your foot and your fingers on the top of your foot.
3. Gently pull your foot. Your smallest toe should come toward you, and your thumb should be pushing against the ball of your foot. You should feel a gentle stretch on the outside of your ankle.
4. Hold the stretch for __________ seconds.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise F: Ankle alphabet

1. Sit with your left / right leg supported at the lower leg.
   1. Do not rest your foot on anything.
   1. Make sure your foot has room to move freely.
2. Think of your left / right foot as a paintbrush, and move your foot to trace each letter of the alphabet in the air. Keep your hip and knee still while you trace.
3. Trace every letter from A to Z.

Repeat __________ times. Complete this exercise __________ times a day.

Strengthening exercises

These exercises build strength and endurance in your lower leg. Endurance is the ability to use your muscles for a long time, even after they get tired.

Exercise G: Dorsiflexors

1. Secure a rubber exercise band or tube to an object that will not move if it is pulled on, such as a table leg.
2. Secure the other end of the band around your left / right foot.
3. Sit on the floor, facing the object with your left / right leg extended. The band or tube should be slightly tense when your foot is relaxed.
4. Slowly flex your left / right ankle and toes to bring your foot toward you.
5. Hold this position for __________ seconds.
6. Let the band or tube slowly pull your foot back to the starting position.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise H: Plantar flexors

1. Sit on the floor with your left / right leg extended.
2. Loop a rubber exercise band or tube around the ball of your __________ foot. The ball of your foot is on the walking surface, right under your toes. The band or tube should be slightly tense when your foot is relaxed.
3. Slowly point your toes downward, pushing them away from you.
4. Hold this position for __________ seconds.
5. Let the band or tube slowly pull your foot back to the starting position.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise I: Towel curls

1. Sit in a chair on a non-carpeted surface, and put your feet on the floor.
2. Place a towel in front of your feet. If told by your health care provider, add __________ to the end of the towel.
3. Keeping your heel on the floor, put your left / right foot on the towel.
4. Pull the towel toward you by grabbing the towel with your toes and curling them under. Keep your heel on the floor.

Repeat __________ times. Complete this exercise __________ times a day.