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What is the tibialis posterior tendon?

The tibialis posterior tendon serves as one of the major supporting structures of the foot, helping it to function while walking. Sometimes this tendon can become overstretched or inflamed leading to a progressively flat foot. There are several names for this type of condition such as, tibialis posterior tendon dysfunction, adult acquired flatfoot deformity and tibialis posterior insufficiency. These terms all describe the same condition.

Tibialis posterior tendon reconstruction: Text

How is the reconstruction done?

You will be admitted on the day of operation. The operation takes about 1.5 to 2 hours and is done under a general anaesthetic or a spinal anaesthetic. You will be kept in overnight.

The operation is done through several skin incisions (cuts). A bone cut is made on the heel bone (calcaneal osteotomy) and the bone is moved inwards and fixed with a screw to reduce the heel deformity. The damaged part the tibialis posterior tendon is then removed and reconstructed using another foot tendon (FDL tendon transfer). The FDL tendon is one of two tendons that bend your lesser toes. The tendon is cut on the inside of the foot and transferred into to the navicular bone using bone anchors to function like your tibialis posterior tendon (most patients do not notice any loss of strength or function to the toes). The spring ligament which supports the arch of you foot is also reinforced (see Xray A). Not infrequently, additional procedures may be required including calf muscle lengthening or further bone cuts (Evans and/or Cotton osteotomy) especially if your deformity is severe (See Xray B).

The wound is closed with dissolvable stitches. You will be non-weight bearing on the operated leg for a period of 6 weeks and have a below-knee cast / boot for that duration to protect the foot. After 6 weeks, you will be placed in a boot for a further 3 – 4 weeks and you may start gradual weightbearing.

Calcaneal osteotomy and FDL transfer by Dev Mahadevan Reading, Berkshire

Xray A showing screw and bone anchors used to perform surgery

Evans & Cotton_edited.jpg

Xray B showing plates and screws following Evans & Cotton osteotomies to realign flat foot

Tibialis posterior tendon reconstruction: Text

Aftercare and FAQs

It is important to keep the leg elevated as much as possible especially for the first 2 weeks. You will usually be able to go home when you feel ready. You will need to arrange for someone to drive you home.

Your first clinic follow-up is usually 12 to 14 days after surgery.

Wound care – The plaster cast should be kept dry. At yours first clinic appointment, would inspection and suture removal would be undertaken.


Work - If you have a sedentary job you should be able to return to work within 2 weeks (if you can arrange safe transport). If your job is physical, you may need to stay off work until the boot / cast is removed.

Recovery - Your ankle will continue to improve up to 12 months following surgery. Intermittent swelling and aches are common in the initial phase of recovery.

Driving - You will not be able to drive for 10 weeks following surgery. However, if you drive an Automatic and it was your LEFT side that was operated on; then you may start short drives 2 weeks following surgery. It is advisable to check the terms of your car insurance to ensure your cover is valid, as some policies state that you must not drive for a specific time period after an operation.

Flying after surgery - It is generally recommended to wait at least six weeks to fly. It may be possible to fly on short-haul or domestic flights at an earlier time, but you should always check with your GP or surgeon. Always consult your doctor, your health insurance provider and the airline you are flying with before making your flight reservation.

Tibialis posterior tendon reconstruction: Text

What are the surgical risks?


  • Infection

  • Nerve damage – causing numbness and painful scar

  • Deep vein thrombosis (DVT) and pulmonary embolism (PE) – blood clots in the vein or lungs – to reduce this risk you would be prescribed heparin injections for a few weeks (unless contraindicated)

  • Non / Delayed union of bone

  • Reconstruction failure

  • Prolonged swelling and stiffness

  • Prolonged recovery

  • Residual pain and deformity

It is beyond the scope of this document to list rarer risks (less than one in a thousand) but I will be very happy to discuss any worries about specific concerns and also about any family history or your past health problems. If there is anything you do not understand or if you have any questions or concerns, please feel free to discuss them with me.

Tibialis posterior tendon reconstruction: Text
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