A peritendinous bursa at the posterior tibial tendon as it courses behind the medial malleolus, in the critical zone where degenerative PTTD changes begin. This watershed zone bursa becomes inflamed in early stage posterior tibial tendon dysfunction.
Peritendinous inflammation at the posterior tibial tendon medial malleolus junction is the earliest detectable change in PTTD, preceding frank tendon tearing. Ultrasound demonstrates peritendinous fluid and intratendinous signal at this level in stage I PTTD. Targeted injection at the medial malleolus level provides temporary relief but should avoid the tendon itself to prevent weakening. Custom orthotics addressing hindfoot valgus reduce mechanical stress at this critical zone and are the mainstay of stage I management.
Bursal inflammation at the posterior tibial tendon medial malleolus junction, the earliest indicator of posterior tibial tendon dysfunction, confirmed by ultrasound and managed with orthotics and targeted injection.
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