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PTTD - The Complete Guide

by Jessica Hegg June 28, 2017 0 Comments

foot in pain

Do you have unexplained pain in your foot or ankle, does it seem that your arches aren’t as high as they used to be? This may be the first sign you're developing posterior tibial tendon dysfunction or PTTD.

What is PTTD?

PTTD is a flat foot condition caused by inflammation or a tear in the posterior tibial tendon - the tendon which connects from the calf muscle, along the ankle, to the inner foot bones.

The primary role of this tendon is to form the arch of the foot, and to provide support when walking. When it becomes damaged or inflamed, it is unable to hold the arch and leads to pain.

Also known as Adult Acquired Flat Foot, this condition mainly affects those over 40 years of age, particularly women. In fact, some research suggests PTTD may affect as many as one in ten older women.

We're here to explain all you need to know about PTTD - including the signs and symptoms, causes and risk factors, methods of diagnosis, and treatment options.

PTTD Stages & Symptoms

When a doctor diagnoses PTTD, they will typically class the condition as being in one of four stages.

Stage 1 PTTD

Not many people are diagnosed with Stage 1 PTTD - simply because there are little to no noticeable symptoms! At most, some people may experience swelling or inflammation along the tendon, or they may find their feet tire easily.

Stage 2 PTTD

Those in stage 2 PTTD will start to experience some symptoms, and may even notice a visible change in the shape of the foot. Signs and symptoms include:

  • Mild to moderate foot pain
  • Inflammation along the tendon
  • A falling of the arch of the foot
  • Partial dislocation of joints in the foot
  • A turning outward of the toes and foot

Stage 3 PTTD

Stage 3 PTTD involves significant physical signs and symptoms such as:

  • Moderate to severe pain
  • Weakness in the foot
  • Foot deformity
  • Arthritis in the foot

Stage 4 PTTD

The final stage of the condition is that of severe flat foot. At this stage, there is little that can be done to reverse any damage - highlighting the importance of seeking medical treatment as early as possible.

In stage 4 PTTD, patients experience:

  • Severe pain
  • Extreme damage to the joints of the foot
  • Arthritis in the foot or ankle

Causes and Risk Factors of PTTD

Flat feet Arches can fall over time as the tendon along the inside of your ankle (which supports the arch) starts to weaken ( Image Reference).

The posterior tibial tendon may become torn or inflamed from an injury like a fall, or a sports-related impact.

Overuse of the foot can also cause damage to the tendon. If you take part in high-impact activities such as tennis or running, you may be at greater risk of experiencing PTTD as a result of damage to the tendon over time.

In addition, there are other risk factors for the development of PTTD. It is most common in:

  • Women
  • Older adults
  • Diabetics
  • People with high blood pressure (hypertension)
  • The overweight or obese
  • People with one leg slightly shorter than the other (this can happen over time or can be caused by knee replacements, hip fractures, poor pelvic alignment etc.)

PTTD Diagnosis

Posterior tibial tendon diagram

The posterior tibial tendon attaches the calf muscle to the bones inside the foot. It works to hold up the arch and support the foot as you walk ( Image Reference).

Posterior tibial tendon dysfunction should always be diagnosed by a qualified medical health professional. As mentioned earlier, if you suspect you may have PTTD it is important to seek medical advice as soon as possible to avoid the condition progressing through the stages.

Doctor Diagnosis: Medical History and Physical Examination

Your doctor will make a diagnosis of PTTD based on a comprehensive medical history, current symptoms, and physical examination.

They will look for:

  • Swelling - particularly any swelling along the posterior tibial tendon (from the calf to the inside of the foot).
  • Abnormalities in the shape of the foot - in PTTD, the heel can turn outward and the arch becomes less pronounced.

PTTD Those with flat feet may develop the appearance of "too many toes" where the 3 last toes are visible from behind ( Image Reference).

  • The appearance of "too many toes" - the doctor may stand behind you and view your foot and ankle from that position. In those with PTTD, more than two toes can be seen. 

The doctor may also request you complete some small exercises to help confirm a diagnosis or inform a treatment plan. For example, the doctor may ask you to:

  • Perform a one-legged heel raise. Here, you should stand on one leg and raise the other heel (i.e. stand on your “tiptoes”). If you are unable to do this, or the heel turns outward during the exercise, it can help to indicate PTTD - patients in stage 2 or subsequent stages are unable to balance on one foot.
  • Move your foot from side to side and up and down. Your level of flexibility will help the doctor to determine the stage of PTTD, and which treatments may be best suited to your needs.

In addition, imaging tests can help with diagnosis:

  • An X-ray or CT scan may be performed to rule out arthritis in the foot or ankle, which can have similar symptoms to PTTD.
  • An MRI scan or ultrasound can be carried out to confirm PTTD if the doctor is unsure based on the physical examination alone.


Although there is no substitute for a qualified medical examination for PTTD, this simple home test may help you decide if you have a flat foot condition:

  1. Submerge your bare feet in a basin of water, or thoroughly wet them with a shower or hose.
  2. Stand on a flat surface where the imprint will be visible - such as on a bathroom tile or concrete sidewalk.
  3. Check your footprint. Healthy feet will show a ‘missing’ piece of the print, indicating a complete arch. Those with flat feet will see a complete imprint showing the entire foot, indicating a fallen arch.

PTTD Treatment

PTTD Your doctor will examine your arches to help determine the best methods of PTTD treatment ( Image Reference).

A proper treatment plan for PTTD is vital, particularly because the condition can progress if left untreated. The earlier you seek treatment, the easier it will be to manage your symptoms. You also have a greater chance of stopping the condition’s progression to subsequent stages.

Untreated PTTD leads to pain, limited mobility, and the risk of arthritis in the foot and ankle.

Non-surgical Treatment Options

Most treatment regimens for PTTD begin with non-surgical approaches. These treatments usually relieve symptoms for most people within 3 to 6 months.

Rest and Ice

Be sure to rest your feet as much as possible, and avoid repetitive or high-impact activities which can cause or exacerbate PTTD symptoms. This gives the tendon time to heal.

If you miss working out, switch to low-impact activities which don’t cause strain to the foot, like swimming or cycling.

Apply ice packs directly to the painful areas for 20 minutes, three times a day, or after exercising. This helps to reduce inflammation and pain.


Over-the-counter or injected medications are available to those with PTTD.

Nonsteroidal anti-inflammatories (NSAIDs) such as ibuprofen or naproxen reduce inflammation and pain. Long-term use of NSAIDs has been linked to an increased risk of heart attack, stroke, stomach problems, and kidney problems, according to Harvard Health. Therefore, it’s always important to discuss use of these medications with your doctor.

Your doctor may suggest injected medications known as corticosteroids. These powerful anti-inflammatories can be injected into the foot or ankle to relieve swelling.

PTTD Orthotics

Vivesole PTTD orthotics can provide the missing support to your arches & have shown to significantly reduce foot pain ( Image Reference).

An orthotic device is the term used for any kind of foot pad, heel insert, or shoe insert. Orthotics are recommended for most people with PTTD as they provide support to the arch.

Those with mild PTTD may simply require an over-the-counter orthotic. However, custom-made devices may be necessary for those with moderate to severe PTTD.

Before visiting your podiatrist, do your research. Custom orthotics tend to be pricey. Are they worth the money?

The type of orthotic device recommended by your doctor will depend on the shape of your foot and your symptoms. Available options include:

  • Full-length orthotics: fit fully inside the shoe, providing additional support to the entire foot.
  • Three quarter length orthotics: fit into the shoe, providing support to the heel and arch of the foot.
  • Heel flares: help prevents strain on the ankle.
  • Heel cushions: absorb impact from walking or other activities, reducing stress on the heel and ankle.
  • Arch supports: specifically support the arch of the foot. Check the top 6 arch supports here!

PTTD Braces

Moderate to severe cases of PTTD, or people with both PTTD and arthritis, often require the use of an ankle brace to support the foot joints and reduce strain on the tendon. Utilizing a brace early on can reduce the progression of PTTD and help to avoid undergoing any surgical procedures.

Immobilizing Casts or Boots

If the PTTD is severe enough, your doctor may recommend you wear a short cast or special boot for 6 to 8 weeks. This helps to immobilize the foot and ankle, giving the tendon time to heal and inflammation to subside.  

Because immobilization leads to the wasting of muscle and a reduction in strength (known as muscle atrophy), it is only recommended if the other treatments listed above fail to achieve the desired results.

Physical Therapy

Physical Therapy Physical therapy sessions, techniques, & exercises can help to minimize pains associated with PTTD ( Image Reference).

Exercises that help to strengthen the posterior tibial tendon may be helpful for those with mild or moderate PTTD.

In addition, physical therapy may be necessary following immobilization of the foot to help regain muscle mass and strength.

PTTD Surgery & Recovery Time

Surgery is usually considered only when other treatments have failed to relieve symptoms or to halt the progression of the condition. However, for some people - particularly those diagnosed in the advanced stages - surgery may be the only option.

Surgical options vary depending on the stage your PTTD is in, and the symptoms you are experiencing. Your doctor will advise you of your options, and recommend the best approach for your specific case.

Options include:

  • Lengthening of the calf muscles - this is especially helpful for those who have difficulty with ankle flexibility.
  • Cleaning the tendon - used in mild cases of PTTD, this surgery removes inflamed tissue around the tendon.
  • Tendon transfer - the damaged posterior tibial tendon is removed in this procedure, and another tendon from the foot is used to replace it.
  • Osteotomy - this involves cutting bones to change the shape of the foot to a healthier arched shape. It is typically used in cases where there is some degree of foot flexibility. In more severe cases, bones may be joined together (fused) to support the arch and stop the flat foot from returning.
  • Joint fusion - in a severe flat foot or in people with arthritis of the foot, joints in the foot are fused to help remove arthritis and return the normal shape to the foot.

The more severe the case of PTTD, the longer the recovery time. It can take up to 12 months to notice improvements in pain levels following surgery.

Complications of surgery include:

  • Failure to completely relieve pain
  • Failure of the bones to fuse together in cases of osteotomy and fusion
  • Wound infection

Preventing PTTD

This condition may be prevented by taking proper care of your feet and ankles. This includes avoiding repetitive activities that put excessive strain on the feet and posterior tibial tendon, such as running or other high-impact sports. Wearing supportive shoes most, if not all of the time, is also recommended.

Additionally, limiting the risk factors associated with PTTD may help prevent it. This means reducing your risk for diabetes, high blood pressure, and obesity. If you already have one or more of these conditions, ensure you keep up with your treatment regimen to keep symptoms under control.

Finally, maintaining proper alignment of the body will reduce strain on the tendons in the feet and ankles.

Remember to take care of your feet!

Because PTTD is a painful and progressive condition - which can ultimately lead to permanent foot damage and reduced mobility - it’s important to take the necessary steps to prevent or treat PTTD as soon as possible.

Wearing supportive footwear, choosing your activities wisely, and giving your feet plenty of R&R are some of the basic things you can do to ensure happy and healthy feet through all stages of life.

If you think you are experiencing some of the signs and symptoms of PTTD, discuss your concerns with a doctor. Those who have already been diagnosed with the condition should take care to closely follow their prescribed treatment plan. 

Jessica Hegg
Jessica Hegg

Jessica Hegg is the content manager and at ViveHealth.com. With vast product knowledge and understanding of individual needs, she aims to share valuable information on making smart buying choices, overcoming obstacles and overall improving the quality of life for others. Avid gym-rat and nutrition enthusiast, she’s interested in all things related to staying active and living healthy lifestyle.

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