What Causes Posterior Tibial Tendon Dysfunction? A Complete Guide

If you’ve been diagnosed with posterior tibial tendon dysfunction (PTTD) or are experiencing symptoms, you’ve probably asked yourself: “Why did this happen to me?” The answer isn’t always straightforward. Most cases of PTTD don’t stem from a single cause—instead, multiple factors typically combine to stress the tendon beyond what it can handle.

Understanding what causes PTTD isn’t just about satisfying curiosity. Knowing the factors that contributed to your condition helps you make informed decisions about treatment and reduces the likelihood of recurrence. Let’s break down the various causes and risk factors.

Understanding the Posterior Tibial Tendon

Before diving into causes, it helps to understand what the posterior tibial tendon actually does. This tendon attaches the tibialis posterior muscle to the bones on the inside of your foot. Its job is to support the arch and help you push off when walking or running.

The posterior tibial tendon is under constant stress. It bears your body weight with every step, and unlike some other tendons, it has a relatively limited blood supply. This makes it more susceptible to wear and degeneration over time.

One of the most common factors in PTTD is simply the passage of time. The tendon undergoes natural wear and tear throughout our lives, and after age 40 or 50, its ability to repair itself diminishes. This age-related degeneration weakens the tendon gradually, making it more vulnerable to injury from everyday activities.

This doesn’t mean PTTD is inevitable as you age. Many people live their entire lives without developing the condition. But when other risk factors are present, age becomes an important contributing factor.

Acute Injuries

Sometimes PTTD develops suddenly following a specific injury. A fall, a twisted ankle, or a direct impact to the inside of the foot can damage the posterior tibial tendon. These acute injuries can cause the tendon to tear partially or completely, initiating the cascade of dysfunction.

What makes this tricky is that the initial injury might seem minor at the time. You might twist your ankle, experience some pain and swelling, but assume it’s just a sprain. Weeks or months later, persistent pain and arch collapse become noticeable.

Overuse and High-Impact Sports

Athletes and active individuals face increased risk of PTTD, particularly those who participate in high-impact sports. Running, basketball, tennis, and hiking place repetitive stress on the posterior tibial tendon. Over time, this overuse can lead to microtrauma and degeneration.

The problem often develops gradually. You might notice mild pain after activities that progresses to constant discomfort. Athletes sometimes push through the early signs, not realizing they’re damaging the tendon further.

If you’re an athlete with flat feet or overpronation, your risk is even higher. The biomechanical inefficiency places additional strain on an already-stressed tendon.

Biomechanical Factors: Overpronation

Overpronation—when the foot rolls excessively inward during walking or running—is one of the most significant mechanical contributors to PTTD. With each step, the posterior tibial tendon must work harder to stabilize the arch and control the pronation motion.

People with naturally flat feet are particularly prone to this issue. Their arches collapse more easily, placing continuous stress on the posterior tibial tendon. Over years, this chronic overload leads to tendon degeneration.

Interestingly, some people develop flat feet as adults (acquired flatfoot) even if they had normal arches in youth. This acquired flatfoot is often a sign of early PTTD itself—another reason why understanding the causes matters.

Systemic Conditions

Several underlying health conditions increase your risk of developing PTTD:

Diabetes significantly elevates PTTD risk. Research indicates that people with diabetes are two to three times more likely to develop the condition. Diabetes affects the tendons through multiple mechanisms, including impaired healing, neuropathy, and changes in connective tissue.

Hypertension (high blood pressure) is another significant risk factor. The exact mechanism isn’t fully understood, but the association is well-documented in medical literature. Hypertension may affect blood flow to the tendon or contribute to overall connective tissue health.

Obesity places additional mechanical stress on all weight-bearing structures, including the posterior tibial tendon. The tendon must support more force with every step, accelerating wear and tear.

Rheumatoid arthritis and other autoimmune conditions affecting connective tissue can weaken tendons. The inflammatory process directly damages tendon structure.

Genetic Predisposition

Your family history matters more than you might think. Some people inherit structural variations that predispose them to PTTD:

  • Naturally loose ligaments (hypermobility)
  • Variations in foot anatomy
  • Family history of flat feet or tendon problems

If your parents or siblings have experienced foot tendon issues, your risk may be elevated. This doesn’t mean PTTD is inevitable—rather, you should be more attentive to early symptoms and preventive measures.

Previous Foot or Ankle Injuries

Prior injuries to the foot or ankle create long-term consequences. An old ankle sprain might have left you with slightly altered biomechanics. A previous fracture might have changed how forces distribute through your foot. Even injuries that healed well can create subtle compensations that stress the posterior tibial tendon over time.

This is why your doctor asks about your injury history when evaluating for PTTD. Past trauma creates a foundation upon which current problems may develop.

It’s Rarely Just One Thing

Here’s the key takeaway: most cases of PTTD involve multiple contributing factors. A 55-year-old with slightly flat feet who enjoys jogging has age-related tendon changes, biomechanical stress, and overuse—all combining to overwhelm the tendon’s capacity to repair itself.

This is actually reassuring news. It means that even if you can’t change certain factors (like your age or genetics), you can often address others. Losing weight, modifying activities, or using orthotics can shift the balance toward healing.

What You Can Do

Understanding causes empowers you to take action:

  • Manage systemic conditions: Keep diabetes, hypertension, and inflammatory conditions well-controlled
  • Modify activities: If you’re an athlete, cross-training and proper progression matter
  • Address biomechanics: Custom orthotics can help control overpronation
  • Maintain healthy weight: Reduces mechanical stress on the tendon
  • Listen to early warning signs: Don’t ignore persistent inner ankle or arch pain

Sources

  • American Academy of Orthopaedic Surgeons (AAOS) - Posterior Tibial Tendon Dysfunction Overview

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of any medical condition.