The tibialis posterior tendon is the deepest and most medial tendon in the medial ankle, passing posterior to the medial malleolus in the first compartment of the flexor retinaculum to fan out and insert primarily on the navicular tuberosity with secondary slips to multiple tarsal and metatarsal bones. It is the primary dynamic stabiliser of the medial longitudinal arch.
Tibialis posterior tendon dysfunction (PTTD) is the most common cause of adult-acquired flatfoot, progressing from tendinopathy (stage I) through flexible deformity (stage II) to rigid deformity (stage III-IV). The too-many-toes sign and failed single-heel rise test are the clinical hallmarks. MRI demonstrates longitudinal splitting, attenuation, or complete rupture. Stage I is managed with orthotics; stage II requires FDL tendon transfer with medialising calcaneal osteotomy; stage III-IV requires hindfoot arthrodesis. The tendon's watershed zone behind the medial malleolus is the most vulnerable point for degeneration.
Medial ankle pain and early flatfoot collapse from tendon degeneration behind the medial malleolus.
Sudden flatfoot worsening with inability to perform a single-leg heel rise — typically requiring surgical reconstruction.
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