The posterior tibial tendon passes through a fibro-osseous tunnel behind the medial malleolus, where it is redirected from the posterior leg direction to the plantar-medial foot direction by the medial malleolus acting as a pulley. This change in direction creates a compressive load on the tendon as it curves — the site of highest stress and the location where most PTTD tears begin.
The medial malleolus acts as a pulley redirecting the tibialis posterior force from a posterior to a plantar-medial direction for arch support and inversion
The posterior tibial tendon tears most commonly at the fibro-osseous tunnel behind the medial malleolus — MRI shows the progressive thickness change and signal abnormality at this level. Ultrasound demonstrates longitudinal split tears and tenosynovial fluid. Medial malleolus groove abnormalities (shallow or fibrous) contribute to tendon dysfunction in some cases.
Posterior tibial tendon tearing at the fibro-osseous pulley of the medial malleolus producing flatfoot — managed by stage with orthotics, FDL transfer, and calcaneal osteotomy.
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