Underrecognized Subclinical Tibialis Posterior Dysfunction in High-Impact Athlete: A Narrative Review

Introduction

In high impact sports such as Soccer, Tennis and basketball the overuse of tibialis posterior tendon (TPT) is a common scenario. The inflammation of TPT is widely reported in case of acute injury or overuse of this tendon. The recurrent bouts of tendinitis leads to tendinopathic cascade potentially leading to posterior tibial tendon insufficiency (PTTI).TPT is the major dynamic stabilizer of the medical longitudinal arch(MLA). The main action of the muscle is to provide plantar flexion in ankle , inversion in foot and supination in hindfoot during gait.¹ In the published research articles, it is recommended to rename this condition as Progressive Collapsing Foot Deformity (PCFD). They describe this condition as a complex three-dimensional deformity with different degrees of hindfoot valgus, forefoot abduction, and midfoot varus. Hence the words progressive and collapsing are used as they provide more clear presentation about worsening and evolving nature of the complexity of this three dimensional deformity. This helps us to understand the clinical condition in a better way and drive us to avoid using the old terminologies such as posterior tibial tendon, because there exist no problem with the tendon. It is also advised to avoid using the term acquired flatfoot, because many individuals born with flatfeet and are never symptomatic, and the collapsing of the arch is just a single aspect of the 3-dimensional components of the deformity. It is worth to understand that the failure of tendon leads to sequential collapse of the MLA into progressive collapsing foot deformity (PCFD) follows a predictable yet often insidious course.²

Tibialis posterior dysfunction is well recognised among orthopaedic surgeons specialising in foot and ankle surgery and by podiatrists. Although the greater general awareness of this condition is less among the medical fraternity. Many cases were mis- diagnosed as ankle joint ligaments sprain or ankle joint arthritis. By the time when they arrive at propre diagnosis it is very late and the condition would be chronic, many medical professionals pass this condition without identifying the specific diagnosis. Interestingly in recent days, tibialis posterior dysfunction (TPD) is increasingly appreciated as a condition which also affects younger

individuals, athletes involved in high impact activities such as gymnastics, soccer, volley ball etc, whereas it was traditionally thought that the prevalence of rupture is increased in middle-aged and obese women. Many published articles have proved the clinical importance of TPD . It is interesting to learn that athletes frequently modify their movement pattern to mask the early signs of tendon dysfunctions and so not be captured during screening process. However, tibialis posterior dysfunction need not remain a “specialist diagnosis” as it is usually diagnosed without any investigations, from a history and physical examination. It is proved that many patients had found solutions to their problems with exercise regimen and orthotic devices.⁴

The literature review about the pathophysiology of the condition gives valuable insights , it states that the causes varies and are wide. It include the age related degeneration to overuse of the tendon followed by recurrent tenosynovitis and inflammatory arthritis. In few patients with psoriatic arthritis, ankylosing spondylitis , Reiter’s syndrome a abnormality of tendon was noted. The tendon at the region of medial malleolus have the zone of hypervascularity and is the most prone zone of weakness and common site of rupture but the causes for rupture to the tendon proximal to the malleolus or near to the navicular insertion is under discussion. The progressive weakness of the tendon leading to deformity ends with tendon elongation , laxity in ligaments and misaligned bony architecture, which reduces the treatment options and delay the recovery process.⁵ There exist less studies explaining the exact pathology of The TPD and very few discuss about TPD among high-impact athletes. No narrative review study have been published focussing on subclinical presentation of TPD, about clinically used screening tools, and early intervention strategies tailored to the demands of competitive sport. This review addresses this research gap by providing a comprehensive, clinically actionable synthesis to guide sports medicine practitioners, physiotherapists, and orthopaedic surgeons.

Methods

Literature Search Strategy

A detailed review of published research was conducted on multiple databases including PubMed, Scopus, CINAHL, Embase, SPORTDiscus, and Web of Science was conducted from January 2000 to March 2026. A PRISMA -style methodology was followed. Search was performed using MeSH hierarchical terms and free-text constructs of the following terms: “Tibialis posterior dysfunction,” “Posterior tibial tendon dysfunction,” “PTTD,” “Tibialis posterior tendinopathy,” “high-impact athletes,” “progressive collapsing foot deformity,” “foot orthosis,” “eccentric exercise,” “navicular drop,” and “single leg heel raise.” To find more appropriate and suitable studies, reference lists of filtered studies were searched.

Inclusion and Exclusion Criteria

The studies that were included are the research studies published in peer-reviewed journals in English language involving human subjects that describes a) TPD diagnosis b) TPD screening c) TPD treatment. The studies that were excluded are the research studies that include a) Stage 3 and stage 4 PCFD, b) paediatric subjects , c) post – traumatic tendon rupture d) case reports with less than 5 subjects.

Table- 1- PRISMA -Style (Literature search)
No.	Stage	Details
1	Database searched	PubMed, MEDLINE, Scopus, CINAHL, SPORTDiscus, Embase, Web of Science
2	Date range	January 2000 to March 2026
3	MeSH terms	“Tibialis posterior dysfunction,” “Posterior tibial tendon dysfunction,” “PTTD,” “Tibialis posterior tendinopathy,” “high-impact athletes,” “progressive collapsing foot deformity,” “foot orthosis,” “eccentric exercise,” “navicular drop,” and “single leg heel raise.”
4	Studies identified	n =1250
5	Studies that were removed due to duplication	n =312
6	Records screened by Title and Abstract	n=938
7	Records excluded at Title and Abstract level	n=791 (Articles not relevant to athlete population, not relevant to non-human studies, articles in languages other than English)
8	Full texts article assessed	n = 147
9	Records excluded at Full text level	n=98 (unrelated population, wrong outcome, duplicate data, case reports with insufficient data and improper outcome)
10	Studies included in the current narrative review	n=49(Metanalysis /systematic review -12 Original research articles – 19Clinical guidelines / review articles -12Diagnostic& Imaging studies-6 )

Functional Anatomy of Tibialis posterior Tendon

The Tibialis posterior muscle is situated in the deep posterior leg compartment and creates the posterior surface of the interosseous membrane and the adjacent fibula and tibia. Its course is behind the medial malleolus. The anatomical landmark at medial malleolus is known for its poor vascularity. The tendon continues underneath the flexor retinaculum and primarily inserts to the navicular tuberosity. Its secondary tendinous slips insert to the cuneiforms and the bases of the metatarsals, first through third.¹ The tibialis posterior muscle is the dynamic stabilizer of the medial longitudinal arch, the invertors of the midfoot, and the secondary planar flexor.⁶ Its function during the stance phase of gait is to convert the flexible midfoot to a rigid midfoot lever for toe-off. This is critically dependent on the integrity of the tendon and neuromuscular timing.⁷ At the retro malleolar region, the attenuation of peritendinous vascularity is noted. Along with age, blood flow to the tendon decreases due to an increase in mechanical loading. This decreases the tendon's capacity to repair and affects responsiveness. Tendons consume oxygen 7.5% lower than skeletal muscles, increasing the risk of sustained hypoxic injury in the TPT due to high impact loading.⁸

Patho mechanical Cascade in Athletes

During the high-impact sports, the ground reaction forces will be three to five times of body weight across multiple runs and jumps, producing forces that are higher than normal on the TPT.⁹ The Collagen disorganization, vascularization of the tendon, and changes in concentration gradients of glycosaminoglycan are observed. The loss of normal structural changes that are seen in the continuum of reactive tendinopathy to tendon disrepair. 10 Without early intervention, the changing forces on the TPT that cannot contain hindfoot valgus will produce stress on the spring and deltoid ligaments and produce PCFD. 2 Notably, the ability to compensate for changing forces is better in athletes. An EMG has shown that in early PTTD, tibialis posterior muscle recruitment increases during the second part of stance. This is a protective recruitment but will lead to tendon fatigue faster. 11 This will delay the deformity for

a greater time period and will aid in the under recognition of the symptoms and problem for athletes.

Staging and classification

According to Johnson and Strom classification which was later modified by Myerson delineates 4 stages of TPD. In Stage I-Inflamed but structurally intact tendon and no deformity. Stage II -There is tendon elongation with flexible hindfoot valgus. In Stage III there is fixed deformity; and in Stage IV there will be tibiotalar involvement. 3 A very recent research articles reclassify the advanced disease as PCFD to explain its multifactorial, ligamentous origin2 Among the athletes, the most important clinical action is to detect the stage I and ideally pre-Stage I—disease. A pre stage I classification is associated with mild tenosynovitis interpreted during ultrasound imaging before the actual clinical symptoms develops among the athletes. 12 In a scoping review documented by Rhim et al. in a 2022, proves that most of the published studies focus on stages II to IV Stages with insufficient research about the early stage of disease process which are the subclinical diseases found among athletes.¹³

Under recognition of subclinical TPD in High impact Athletes

According to the recent literature evidence the most common patients reported with early TPD are the athletes such as soccer players, volley ball players, tennis players, runners and gymnastic players.³ In case of sports players it is quite common that they tolerate early stage of ankle issues than the sedentary population with the same type of symptoms. This is reported to be the prime cause for overuse and ankle sprain sequelae.¹⁴ When athletes try to "tough it out" through pain, they delay seeking help until their injury has advanced to a much more severe stage. Several factors contribute to this dangerous delay in diagnosis: Hidden early stages: In the beginning (Stage I), the foot still looks completely normal. This absence of a visible flatfoot deformity creates a false sense of security for both the athlete and the physician.

Masked by footwear: Athletic shoes with built-in arch support can temporarily relieve pressure on the failing tendon. This hides the severity and progress of the injury.

Low suspicion: Because tibialis posterior dysfunction is highly unusual in young athletes, doctors rarely expect to see and evaluate it in this age group.⁴ Frequent misdiagnoses: Due to this low awareness, the injury is routinely mistaken for other conditions, such as tarsal tunnel syndrome, a lingering medial ankle sprain, or an accessory navicular issue.¹⁴

Specific risk factors associated with High impact sports

The documented intrinsic risk factors related to TPD for athletes include 1.Increased Navicular drop > 10mm 2. Foot pronatio 3. Pes Planus 4. Obesity 5. Sex- especially among females 6. old ankle injuries.¹³ The reported Extrinsic factors include 1.Training in hard surface 2. Rapid escalation of training volume, 3. Fatigue-induced alterations in foot strike mechanics. The asymmetry of Navicular drop height between the two lower limbs are considered as one of the predictor of lower injury among recreational athletes. Therefore the literature suggest the assessment of asymmetry in foot mobility as a mandatory assessment during pre -participation screening among athletes.¹⁶

Screening tools and Clinical tests

Clinical Tests

The systematic review study conducted by Banweel et.al (2024) on assessment methods for diagnosis of PTTD and its application in administration of non -surgical treatment proved that the following tests such as single-leg heel rise test (SLHR), navicular drop test, foot posture index (FPI), and too-many-toes sign as the most clinically utilized assessment tools.¹⁷ The review of these 15 observational studies also revealed that the tendinopathies of foot and ankle and posterior tibial tendinopathy are usually overlooked by the primary care physicians in spite of available tests and evaluation.¹⁸

The literature review suggest that a study conducted by Ross et.al among 52 subjects with medial foot or ankle pain to test the reliability of 4 clinical tests such as 1. pain on tendon palpation, 2. swelling around the tendon, 3. pain/weakness with isometric tibialis posterior contraction, and 4. SLHR15. The studies have provided many useful research insights to the clinicians. Among all the 4 tests the SLHR demonstrated highest inter-rater reliability (κ = 0.74; 95% CI: 0.54–0.93) and was found to be strongly associated with grayscale structural changes on ultrasound.

It was recorded that a positive SLHR was 6 times more likely to be associated with structural changes in the tendon.¹⁹ When any patient is unable to perform 5-10 single-limb heel raises without pain then it is important to refer for further investigation.¹⁸

The Biomechanical analysis of stage I PTTD revealed significant reduction in muscle strength of invertors of the ankle joint. Increased rearfoot eversion during Gait and reduction in arch height comparing with matched controls, all these features are detectable before the visible deformity.²⁰ Combining palpation tests with a weight bearing tests SLHR or isometric contraction increase the association with structural pathology confirmed through ultrasound investigation.

Imaging Investigations

MRI is currently the most accurate test for diagnosing posterior tibial tendon dysfunction(TPD), with studies showing it correctly identifies tendon tears about 96 % of the time.²¹ The Ultrasound imaging are considered as slightly less precise but highly reliable in locating the tendinopathy to about 80-90 %. It is the first imaging tool opted by the physicians during their clinical practice. The ultrasound imaging is more affordable and allows for real time movement assessment and is widely available , aligning with the current European guidelines. The signs that are detected using Ultrasound are the fluid around the tendon even without any obvious thickening or texture changes, it helps to detect TPD in early stages before the symptoms become more obvious. Ultrasound is beneficial to measure tendon size.²² The latest technique like elastography is more advantageous in measuring tendon stiffness and can also detect the changes in the tendon much earlier than Ultrasound.¹⁷ Although the research evidences are supportive but still strong evidences are required for athletes. While comparing the advantages and disadvantages among these imaging investigations, ultrasound is a more accessible modality, less expensive and beneficial in assessing tendon vascularity and morphology, although it is influenced by the operator who performs the ultrasound investigation. MRI has multiple benefits but remains expensive. Elastography can provide valuable clinical information about tendon stiffness and helps to detect early mechanical changes. However, its practical applicability in PTTD remains insufficiently validated.²⁰

Functional Movement and Load Assessment

Along with the specific clinical tests , the functional movement screening among high impact athletes includes single leg squat assessment , tuck jump landing mechanics and sport specific cutting pattern analysis. Excessive contralateral pelvic drop, ipsilateral knee valgus, and loss of arch during propulsion are indirect indicators of tibialis posterior compromise. 4 Wearable sensor technologies and pressure plate gait analysis offer quantitative load monitoring tools that can detect asymmetric foot loading patterns consistent with early TPD in athletic training environments. 1

Early Intervention Strategies

Therapeutic Exercise

Therapeutic exercise interventions and evidence based rehabilitation remains the cardinal management steps for early-stage TPD.

In a systematic review of RCT published by Ross et.al.2018 supported eccentric calf strengthening combined with tibialis posterior-specific loading as the best supported therapeutic approach for TPD.²³

In a study performed by Kulig et al., it was documented that combining custom foot orthoses with eccentric and concentric progressive resistive exercises produced superior outcomes compared to orthoses and stretching alone, with the most selective tibialis posterior activation occurring during closed-chain resisted foot adduction while wearing arch-supporting orthoses.³

A structured conservative treatment approach known as the Alvarez protocol combines the use of foot orthoses with a targeted strengthening program for the muscles that support foot function. This protocol has demonstrated promising outcomes, with an 83% success rate in individuals with Stage I and II posterior tibial tendon dysfunction (PTTD), helping many patients avoid surgery.²⁴ For athletes, rehabilitation should go beyond standard exercise progression by incorporating sport-specific loading demands and adjusting training based on whether the athlete is in-season or off-season. An emerging strategy, blood flow restriction training (BFRT), may further enhance rehabilitation by providing a strong neuromuscular stimulus while using relatively low loads. This approach can help preserve muscle mass and strength during the early stages of recovery while minimizing excessive stress on the healing tendon. The recent clinical trial by Antonio Rejas.et.al 2026 supports including US guided percutaneous electrolysis along with exercises and manual therapy will improve pain and function.³³

Orthotic and Bracing Intervention

Foot orthoses (FOs) play a central role in the conservative management of tibialis posterior dysfunction (TPD). Custom-designed orthoses that provide medial arch support and correct heel valgus alignment can reduce excessive ankle inversion forces, improve plantar pressure distribution, and enhance activation of the tibialis posterior muscle.²⁵ Evidence from a 2020 Cochrane-informed systematic review supports the use of orthotic interventions for individuals with Stage I and II PTTD, although considerable variation exists in orthotic designs and prescription approaches across studies. For athletes involved in high-impact sports, semi-rigid orthoses are often preferred because they offer a balance between arch support, shock absorption, and the flexibility needed for optimal athletic performance. Imaging can also play an important role in guiding orthotic management. Surveys of foot and ankle specialists in the United Kingdom identified ultrasound as the most frequently selected first-line imaging modality in non-surgical care. Its popularity stems from its ability to provide dynamic, real-time assessment of the posterior tibial tendon during movement, helping clinicians tailor orthotic prescriptions and monitor treatment progress more effectively.²²

Extracorporeal Shockwave Therapy (ESWT)

ESWT is one of the popular treatment adjunct for conditions such as tendinopathies. The study published by Robinson et.al supported the application of ESWT combined with foot core exercises. It showed clinically important improvements in Foot and Ankle Ability Measure scores in 90% and 80% of patients with PTTD, who had failed standard conservative treatment for activities of daily living and sports sub scores, respectively, at a median follow-up of four months.²⁶ A 2024 systematic review in the British Journal of Sports Medicine by Rhim et al. of ESWT in athletes and physically active individuals, including 56 studies with 1,874 participants concluded that ESWT may be effective alone or as an adjunct to exercise therapy in selected sports-related injuries with minimal adverse events.²⁷ For in-season athletes, ESWT offers the practical advantage of allowing continued sports participation when tendon load is maintained below the pain threshold (typically <3/10 on the visual analogue scale), positioning it as a viable option within competitive schedules. 28 ESWT should be regarded as a supplement to, not a replacement for, structured physical therapy and progressive tendon loading programs.

Biologic Therapies

The modern biologic therapies such as Platelet-rich plasma (PRP) and other biologic injectables have gained increasing interest in tendinopathy management. The mechanisms involving neovascularization promotion in the collagen matrix and acceleration of tissue healing are documented. 29

The research studies supporting PRP in TPD are minimal, the published data extrapolated from Achilles and patellar tendinopathy trials. An evidence based review study published in Current Physical Medicine and Rehabilitation

Reports noted that emerging treatments including PRP and ESWT have demonstrated promise across tendon pathologies and are being increasingly incorporated into clinical practice, still higher-quality TPD-specific trials are not available30 In TPD the Corticosteroid injections are generally discouraged because it has few risks of tendon rupture and impaired collagen synthesis.

Surgical intervention

Surgical intervention is generally considered beneficial when the structured non-operative management for at least 3–6 months fails to restore the function. Although the 2025 systematic review and meta-analysis by Adukia et al supports both conservative and surgical treatments for favourable outcomes, there is currently no consensus regarding the optimal treatment sequence. In athletes with Stage II disease and high functional demands, procedures such as flexor digitorum longus (FDL) tendon transfer combined with calcaneal osteotomy may be indicated when conservative treatment is unsuccessful.³¹ The review submitted by Arya Kermanshah .et.al 2026 highlighted the current innovations in tendon augmentation. They support fibre tape reinforcement and three dimensional-bioprinted grafts. Monitoring post operative graft integration by MR imaging helps to optimize long-term term outcomes.³²

Proposed Screening Protocol for High-Impact Athletes

According to the synthesized evidence, there is a documented evidence on three-tier screening protocol for subclinical TPD in high-impact athletes proposed by the researchers.

Tier 1 – Pre-season Screening: Athletes should undergo initial screening using the navicular drop test, foot posture index (FPI-6), single-leg heel raise (SLHR) assessment, and palpation of the tibialis posterior tendon from its musculotendinous junction to its insertion at the navicular bone. Positive findings include a navicular drop greater than 10 mm, pain during testing, or fewer than five SLHR repetitions.

Tier 2 – Functional Movement Assessment: Athletes with potential risk factors should be evaluated during functional tasks, including single-leg squats, sport-specific cutting movements, and tuck jump landings. Video analysis is recommended to identify excessive medial longitudinal arch collapse and abnormal movement patterns under load.

Tier 3 – Imaging Confirmation: Athletes with positive findings from the screening or functional assessment should undergo point-of-care ultrasound examination. Key features include

teno-synovial fluid accumulation, tendon thickening, and areas of reduced tendon echogenicity. MRI should be considered when ultrasound findings are inconclusive but clinical suspicion of a partial tendon tear remains high.

Research Gaps and Future Directions

As the awareness about the TPD is growing among the health professionals, many research are initiated and encouraged to explore the critical gaps present in the assessment and management of TPD. There exist a paucity of prospective longitudinal data on the natural history of subclinical TPD in young athletes. There is no conclusive data available to Validate sport-specific screening algorithms with defined diagnostic threshold.¹³

There is no studies that explains the gender -specific biomechanical differences specifically the hormonal influences which leads to laxity of tendon . The role of advanced imaging biomarkers such as Sono elastography, quantitative MRI T2* mapping, and diffusion tensor imaging in subclinical TPD detection warrants prospective investigation. Future trials should be conducted to prove the evidence-based return-to-sport criteria for the athletes following early TPD interventions,

Conclusion

Tibialis posterior dysfunction (TPD) in high-impact athletes remains an underrecognized condition despite its potential to cause significant long-term functional impairment. Current evidence suggests that the development of subclinical TPD is influenced by a combination of vascular insufficiency, repetitive mechanical loading, and compensatory neuromuscular adaptations that may mask early dysfunction. Among the available assessment methods, the single-leg heel raise test, navicular drop test, and musculoskeletal ultrasound have emerged as the most practical and evidence-supported tools for detecting early tendon pathology. Structured eccentric strengthening programs, sport-specific foot orthoses, and adjunctive therapies such as extracorporeal shockwave therapy (ESWT), when appropriately indicated, show benefits in clinical outcomes and may reduce the likelihood of disease progression and subsequent surgical intervention. One of the noticed limitations in the current review is that the availability of a limited number of published research conducted among the high - impact athletes. The reviewed research articles have used heterogenous assessment tools and clinical tests which remains as a principal limitation for this review. Validated clinical tests and functional movement assessment should be practiced specific to the sport participation . In preseason and in-season athlete evaluations, load monitoring will support the professionals to identify subclinical TPD. It also provides a framework for the development and prospective validation of sport-specific screening protocols aimed at improving clinical outcomes and preserving athletic performance.

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