The posterior tibial tendon sheath extends 6 cm proximal to the medial malleolus and is the site of early tenosynovitis in posterior tibial tendon dysfunction. Ultrasound demonstrates sheath distension with fluid and tendon thickening in Stage I PTTD. The sheath can be decompressed by tenosynovectomy in early-stage disease before tendon structural failure.
Allows the tibialis posterior tendon to glide smoothly within the fibro-osseous tunnel behind the medial malleolus
Stage I PTTD (tenosynovitis without structural tendon failure) produces medial ankle pain reproduced by single-leg heel rise. Ultrasound shows tendon thickening and peritendinous fluid within the sheath. Conservative management (orthotics, physiotherapy, anti-inflammatory injection) succeeds in most Stage I cases. Tenosynovectomy is reserved for Stage I cases failing 6 months of conservative treatment.
Tibialis posterior sheath inflammation without structural tendon failure managed with orthotics, physiotherapy, and injection — tenosynovectomy for refractory Stage I.
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