Posterior tibial tendon dysfunction in runners

I am going to type this really slow:
Posterior tibial tendon dysfunction is serious.
Posterior tibial tendon dysfunction is NOT the same as posterior tibial tendonitis.

I try to pull out what little hair I have left when I come across a post on a running forum from a runner wanting advice on posterior tibial tendon dysfunction (PTTD) and the responses assume that it is posterior tibial tendonitis. They are not the same thing. I have anonymously joined a number of forums to berate posters about their advice and how dangerous it is. It is a perfect example of why you should not be getting medical advice online!

PTTD is a condition of degeneration in the muscle-tendon complex of the posterior tibial muscle and tendon. Essentially what happens is the complex just gives up on its job of supporting the arch of the foot and supinating the foot, so a progressive flat foot develops (usually called adult acquired flat foot). Medial foot and ankle pain develops and it will continue to get progressively worse. This is not a very common problem in runners (posterior tibial tendonitis is way more common), but when it does happen it has to be taken very seriously. There are a number of stages of PTTD and it has to be stopped at Stages 1 or 2, otherwise a surgical reconstruction of the rearfoot will invariably be needed if it progresses beyond that (and you probably will not ever be running again). PTTD can develop into a very disabling condition if it is not dealt with properly and promptly.

Even though PTTD is rare in runners, it is becoming more common and there are more and more reports of it and more people asking advice in running forums about it (assuming they were given the right diagnosis that they really do have PTTD and did not get confused with tendonitis). Forefoot & midfoot striking and minimalism will increase the risk for PTTD or make it worse, as the posterior tibial muscle works harder when forefoot striking. So you can imagine the “anger” that I feel when I see advice being given to either start minimalism or keep going with it. This may be the right approach for other injuries, but NOT this one.

Whenever I have seen a runner with PTTD, what running form they are using is the last thing I will be thinking about. They need to stop running for 6 months! That is how serious this is. They need to be counseled as to the seriousness and consequences of this problem. I would often suggest that they consider never running again (the risk of recurrence is high) and take up another fitness activity. The eversion moments in the rearfoot causing the muscle to work so hard have to be countered. I would make foot orthotics out of steel for these people if I could. That is the kind of force that they need to counter those joint moments that are causing this.

If you have developed PTTD, please take it seriously, please make sure the diagnosis is right (ie its not tendonitis), and do not follow the advice on online forums, no matter how well meaning it is.

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19 Responses to Posterior tibial tendon dysfunction in runners

  1. Ex-runner March 31, 2013 at 7:22 am #

    Where were you a year ago? I had PT dysfunction and was convinced to change to minimalist running and ditch my usual running shoes. Boy, was I sold some BS over this. I have not run again and,as you said, had some joints fused in my heel. I now can’t run. I needed your advice a year ago.

  2. Craig March 31, 2013 at 7:28 am #

    Sorry I was not here a year ago! It was anecdotes just like this that motivated me to start this blog due to that BS. I would hate to think how many similar stories to yours I have heard over posterior tibial tendon dysfunction in the last yr or so. I am held legally accountable for any treatment advice I give and use clinically; unfortunately those posting on forums and blogs are not – maybe it is time that they are.

    Generally, there is nothing necessarily wrong with minimalist running….it is just going to be an absolute disastrous thing to do if you have posterior tibial tendon dysfunction. Its probably the best thing to do if you have anterior compartment syndrome.

    It all comes down to there being no one best way to run and there is no panacea or no “second coming of the messiah” with any particular running technique. Sadly, you have learnt that the hard way.

    There is no reason why you can not be cycling or swimming or some other activity.

  3. Jason Eade April 7, 2013 at 2:17 am #

    How do you differentiate dysfunction from tendonitis?

  4. Craig April 7, 2013 at 8:55 am #

    The heel raise test. Imagine what running does to the muscle/tendon complex and the foot if they are positive for the heel raise test! If they can not invert on this test, the damage that weightbearing, let alone running is doing is not hard to imagine!
    Here is some research on the heel raise test.

  5. Brett April 14, 2013 at 1:23 am #

    As an orthopedic foot and ankle specialist, I am not sure that i understand the emphasis that you make on differentiating PTTD from posterior tibial tendinitis. I generally use the terms interchangeablly, but I assume that you are defining posterior tibial tendinitis as Stage 1 PTTD. The muscle in PTTD never deteriorates before the tendon has become stretched out (Stage 2 or higher). The muscle becomes atrophied and dysfunctional because the tendon does not allow it to work, because the stretched tendon allows the muscle to recoil. Posterior tibial tendinitis sometimes, but not always, progresses to more severe stages of PTTD. They are all dangerous problems.

    While no research exists to identify a link between the progression of posterior tibial tendinitis and minimalist shoe wear, I expect that it would be fairly stupid to continue to run, whether in minimalist or traditional shoewear, while suffering from significant posterior tibial tendinitis or PTTD. While significant tendinitis is present, it makes sense to decrease athletic activity to a point that the injury is not being aggravated and to gradually resume activity as recovery occurs, cross-training to other activities to maintain aerobic fitness and muscle conditioning. My own experience is that unfortunately PTTD with any significant deformity (grade 2 or above) is usually (there are exceptions) the end of even recreational running.

    Minimalist shoe wear makes a good deal of sense to improve the strength of an already healthy foot, but it should not be expected to be a cure for a foot that is suffering from a serious injury. The transition from traditional to minimalist shoe wear should be gradual, should only be done in the absence of significant preexisting problems, and with attention for the development of stress injuries to the tendons, bones, or ligaments. I would expect that the healthy foot that is accustomed to minimalist shoes to be stronger and more resilient than a foot accustomed to traditional shoe wear, but unfortunately there is no evidence for this either.

  6. Mina April 22, 2013 at 2:59 pm #


    I also wish I could have met you a couple of years ago. I’m suffering from PTTD and I think that I am at stage 2 although possibly advanced stage 2. I’ve given up so much activity over the last few years and have found it difficult to get access to knowledgeable clinicians. Have you come across a technique which uses the ‘hyprocure’ stent which I believe is a type of sinus tarsi implant? If so, in your opinion, could this help? I’m desperate to avoid complex surgery but also want to return to the activities that I used to enjoy. Any comments would be more than welcome.

  7. Tommy Generou July 18, 2013 at 5:40 am #

    Hi Mina

    I also suffered from relatively serious PTTD after 3 decades of distance running and just recently (8months) had the Hyprocure procedure/implant done. Before having the hyprocure implanted, I had exhausted every other “conservative option”, and I absolutely did not want to settle for what other Orthopedic surgeons trying to convince me I needed to have a fusion or some other highly invasive procedure. As the surgeon explained it, the underlying cause for my condition was partial talotarsal dislocation (PTTD or TTD). He suggested Hyprocure as a great option that would be reversible if it ended up not providing relief or something I could not tolerate. After doing my own research and continued consult with my physician, I discovered that Hyprocure is essentially the evolution of a procedure called Subtalar arthroereisis; the caveat being that it had a unique design the allows the devices to stabilize the rearfoot (talus and calcanues) as opposed to block its motion and ultimately enabling it for a broader range of indiciations. He had been doing these procedures through various methods and products for decades and said he would not have suggested doing this procedure with the previous options. So, I opted to have the procedure done. Everything went smoothly: it was done at an outpatient facility and I ended up only having to be there for about 3 hours in total. The recovery went quick. He started me out with a surgery shoe,after about 2 weeks a walking boot, and then apprx. 1 month i was back in regular shoes. He suggested i wear a quality pair of walking/running shoes with good support. After about 6 weeks I was able to begin walking for a mile or two at a time. Then at the 2 month mark I managed to being light jogging. This was nothing more than half mile-mile at a time. My ankles were obviously sore and tired, but with adequate icing and rest, it was tolerable. Fastforward 8 months, I am now back to near full activity level. In fact, just this evening, after a full days work where I had been on my feet a considerable time, I put in 8 miles. My feet and ankles feel great, just the legs are a bit tired :). Looking back, having this procedure done has been a godsend and cant be thankful enough to my physician and his staff. Hope this helps out and you can start getting back to pain free, whatever solution you come to.


    • Craig Payne July 18, 2013 at 6:23 am #

      Thanks Tommy; you help to emphasize the point I tried to make, that posterior tibial tendon dysfunction is runners is serious!

  8. Phil September 5, 2013 at 2:30 am #

    I too have been diagnosed with PTTD. One doctor said it was Stage II, but my therapist believed I was stage one. Either way, I have been looking at Hyprocure as a possible solution. I was diagnosed a year ago and have been wearing custom orthotics ever since, but they are as much a problem as they are a solution. They take some strain of the PTT, but cause knee pain if I walk for more than an hour. For crying out loud, I used to hike every week, and run 4 times a week for 3-4 miles at a time!. Tommy, I hope I can get similar results.

  9. josh james December 2, 2013 at 12:16 am #

    i broke my ankle in 2 places almost 2 years ago now, I was told i should be walking in 3 weeks after i came out my cast it took me 3-5 months, i think I had something wrong with my tendon in the break but obviously I didn’t have a clue about nothing, after doing lots of research i have found out. the doctor only X rayed it.. it took 7-8 months for an MRI maybe even longer. I couldn’t run for almost a year. i had pain on the posterior tibial tendon and also on the right side of my foot, the pain on the right side of my foot has sort of gone away now when i attempt to run. but the posterior tibial tendon is so weak and my foot is completely flat. im on the nhs so they dont really care as long as i can walk and im healthy thats all they care about. i got given lots of physio exercises i would do them and the improvement would be so slow. they found a piece of bone or something getting in the way, they operated just to clean it out, it done absolutely no good. my posterior tibial tendon will get weak after 20-30 minutes of physical exercise, i got given orthotox. they haven’t even diagnosed me with this problem but i know i have it as my foot is completely flat and the left side of my ankle is pushed over to much.will i ever run as fast? what would happen if i just ran through the pain? i am getting sports orhtox will they help? will i ever be able to play football like i ustoo? will i ever be able to move my foot inwards with out pain? will the stiffness ever go away? this has had a huge impact on my life not being able to do what i love is the hardest thing in the world for me. if anyone can help i would be much appericated and be willing to send pictures of my foot. some one help please.

  10. Mina December 19, 2013 at 2:54 pm #

    It’s been a while since I’ve been back to this site but Tommy, thanks ever so much for your feedback. I’m really interested in the procedure that you had.
    I’m managing my PTTD by some stretching, exercises (including balance and core strength) and accupuncture but I do also wear orthotics. I have recovered some activity but definately no running and long distance walking would be difficult, I think it is important to try and be as active as possible and if there is a flare up of pain or inflammation then rest.
    I’m going to make an appointment with a consultant in the new year to talk through the Hyprocure Stent procedure. PTTD is a hard condition to accept especially if it comes out of the blue and you are normally an active person (or like wearing high heels!). I chose to believe that I can improve my condition but have had to accept that it’s going to take time.

  11. Lysa Marie July 4, 2014 at 5:52 pm #

    I just got diagnosed after months of pain! I look back now an it has been there for quite some time! I just didn’t know what was slowly happening! I’m not a runner, but, I lost 155lbs an began to work out like a mad woman an do a lot of walking an running of stairs.

    now, I have to accept that I have to get rid of my treadmill an heels forever! I’m way to young for this crap!!! I’m so depressed! is this going to make me a criple? I rather die than be a criple!

    Sigh…… what kind of exercise am I going to do now? Rowing machine? eliptical? what? an where do I get the correct shoes? their casting my foot next week for some sort of custom insert for my shoes! anyone have any thoughts on my situation? it would be much apreciated!


  12. Lise Patterson August 25, 2015 at 1:32 am #

    Can PRP injections help to reverse stage 1 PTTD?

    • Craig Payne August 25, 2015 at 1:37 am #


  13. Kevin October 2, 2016 at 11:37 am #

    “PTTD is a condition of degeneration in the muscle-tendon complex of the posterior tibial muscle and tendon”, ” … as the posterior tibial muscle works harder when forefoot striking.”

    How can the tendon degenerate when the muscle has to work harder in forefoot running? Tendons and muscles that “aren’t used” tend to degenerate so that doesn’t make sense logically. Please explain this

    • Craig Payne October 2, 2016 at 7:40 pm #

      No idea; but possibly outcome of inflammatory process. Degeneration is present in the tendon in those with PTTD; that’s been shown. The tendon works harder in forefoot striking.

  14. magnru February 17, 2017 at 1:16 pm #

    I am a male runner dx with PTTD in 2010. My PTT had completely severed over time ( I was born with flat feet). Doc told me my running was over unless I had surgery. I was running again 4-5 months after a calcaneal osteotomy and double tendon transfer. At the time I was 52 years old and a 3 year consecutive finisher of the American River 50 mile endurance run (Sacramento, California). Recovery was difficult- followed all the pt advice and was able to continue running the American River 50 seven consecutive years only ending my streak after moving out of state. To this day I still run ultras at age 59 even though I am not as fast as I used to be. Don’t let PTTD keep you from your passion. Have surgery and get it fixed.

    • Craig Payne February 17, 2017 at 6:46 pm #

      Hi magnru
      Unfortunately, your experience is the exception and not the rule. Most will not be able to do any significant running after that surgery.

  15. MizzKriztal May 3, 2017 at 1:37 am #

    I was recently diagnosed with PTTD and it is a very painful condition. The first podiatrist diagnosed me incorrectly in Oct 2016 so fast forward to May 2017 and my new podiatrist has taken me out of work for 8 weeks and has put me in a tall boot cast and told me to stop all activity like work, working out, etc. I am taking this condition very serious and hope that I dnt need any sugery in the future. This forum is very helpful and informs people to how serious PTTD is and how they should take the condition serious if they want to keep the ability to walk in the future. My doctor told me that I should not do any high impact excercise after I heal and that I will have to wear a good shoe with good insoles to insert and hopefully I will be better after my treatment. We arw trying to prevent surgery because that is a hard surgery to bounce back from quickly. Thanks for the forum and take care.

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