Posterior Tibial Tendon Transfer

What is the posterior tibialis?
The posterior tibialis is the most central of all the muscles of the legs and is located in the deep posterior compartment of the tibia. It is the main stabilising muscle of the leg. It is supplied with blood by the posterior tibial artery, and is innervated by the tibial nerve. It arises from the medial and posterior surfaces of the tibia and fibula. It is also attached to the medial hymen, which connects to the tibia and fibula. The tendon of the posterior tibialis muscle descends behind the medial malleolus and ends by dividing into three segments at the scaphoid, the medial sphenoid, the cuboid, the heel and the base of the 2nd – 3rd and 4th metatarsals. In addition to its basic stabilising role, the posterior tibia contributes to the subtalar and plantar flexion of the foot.

What is the role of the posterior tibia?
The posterior tibia plays an important role in supporting the arch of the foot. Dysfunction of the posterior tibialis can lead to flatfoot in adults, as well as claudication due to excessive pronation of the foot. Foot drop is the condition in which the patient is unable to perform dorsiflexion of the foot. That is, lifting the foot off the ground, resulting in difficulty walking. This impairment is due to peroneal nerve aneuropathy (due to diabetic neuropathy, compression or injury of the nerve and herniated disc) or damage to the anterior tibial muscle.

What does the treatment involve?
Initially, conservative treatment with orthotic splints is recommended. If symptoms persist after a year of conservative treatment, and the nerve cannot be surgically repaired, surgical treatment is applied. This treatment involves the transfer of the posterior tibial tendon to the dorsal surface of the dorsal foot. The operation is contraindicated in the case of isolated damage to the superficial peroneal nerve, disruption of the tarsal bones, Achilles tendon rickets, posterior tibial insufficiency and acquired flat feet.

What is the procedure for posterior tibial tendon transfer?
The procedure is performed under general or regional anesthesia and takes approximately one hour. For posterior tibial tendon transfer, incisions are made in the dorsal surface of the foot. The tendon is taken, guided under the skin and held in place with an absorbable screw or anchor on the dorsum of the foot (external or medial sphenoid, base of 2nd and 3rd metatarsal, cuboid). The tendon may be carried either through the medial membranes or around the tibia. The tendon is pinned slightly stretched to allow it to perform dorsiflexion of the foot once the foot has healed. The patient’s hospital stay lasts only one day.

Post-operative course
Postoperatively, patients walk with bacterias for 6 weeks, without weight bearing on the lower limb, until the tendon has healed. They also wear a shin splint for 2 to 4 months. It is considered necessary to use anticoagulant dressings for 6 weeks to prevent deep vein thrombosis. The sutures are removed 2 weeks after the operation and after the 6 weeks a programme of physiotherapy follows.

Complications of surgery include deformity, pain and stiffness, infections, deep vein thrombosis, tarsal tunnel syndrome, nerve injuries and neuropathic pain. If the tendon is pinned with insufficient tension, reduced dorsal extension or hippopotamia may result.


If you experience any of the above symptoms, contact Dr. Anthony Pettas immediately for an early diagnosis and treatment. The orthopaedic surgeon, Dr. Antonios Pettas, was responsible for the foot and ankle surgeries at Norrtälje Hospital in Stockholm. He has many years of experience, with a high success rate of operations.