Posterior Tibial Pulse

The posterior tibial pulse is the palpable arterial pulsation of the posterior tibial artery at the posteromedial aspect of the ankle. It is one of the principal distal pulse points of the lower limb and is commonly assessed together with the dorsalis pedis pulse when examining arterial circulation to the foot.^[1][2]

The pulse is usually palpated posterior and slightly inferior to the medial malleolus, where the posterior tibial artery passes beneath the flexor retinaculum through the tarsal tunnel. The medial malleolus provides a prominent and reliable bony landmark for locating the vessel.

Because the posterior tibial artery supplies the plantar aspect of the foot through its medial and lateral plantar branches, examination of its pulse provides useful information about distal lower-limb perfusion.

Location

The posterior tibial pulse is located on the medial side of the ankle, posterior and slightly inferior to the medial malleolus.

The artery passes through the interval between the medial malleolus and the calcaneal region beneath the flexor retinaculum.

At this location, the vessel is sufficiently superficial to be palpated against the underlying tissues and bones.

General Anatomy

Feature	Anatomy
Pulse	Posterior tibial pulse
Artery palpated	Posterior tibial artery
Location	Posteromedial ankle
Primary landmark	Medial malleolus
Typical palpation site	Posterior and slightly inferior to medial malleolus
Proximal source	Popliteal arterial system
Terminal branches	Medial and lateral plantar arteries
Clinical use	Assessment of distal lower-limb arterial circulation

Posterior Tibial Artery

The posterior tibial artery is one of the principal arteries of the posterior compartment of the leg.

It arises from the distal popliteal arterial pathway and descends through the deep posterior compartment accompanied by venae comitantes and the tibial nerve.

Near the ankle, the artery passes behind the medial malleolus and enters the foot, where it divides into the medial and lateral plantar arteries.

Origin

The popliteal artery terminates near the inferior border of the popliteus muscle, giving rise to the major arterial pathways of the leg.

The posterior tibial artery continues through the posterior compartment and supplies muscles and other structures along its course.

It also gives rise to branches that contribute substantially to the vascular supply of the leg, ankle, and foot.

Course Through the Leg

The posterior tibial artery descends within the deep posterior compartment of the leg.

It travels with the tibial nerve and accompanying veins, initially deep to the superficial muscles of the posterior compartment.

As it approaches the ankle, the vessel becomes more accessible and passes posterior to the medial malleolus beneath the flexor retinaculum.

Medial Malleolus

The medial malleolus is the principal surface landmark used to locate the posterior tibial pulse.

It is formed by the distal tibia and creates the prominent bony projection on the medial side of the ankle.

The posterior tibial artery passes immediately posterior to this landmark, making the malleolus an easily identifiable reference point during vascular examination.

Tarsal Tunnel

The posterior tibial artery passes through the tarsal tunnel, a fibro-osseous passage on the posteromedial side of the ankle.

The tunnel lies posterior and inferior to the medial malleolus and is covered superficially by the flexor retinaculum.

Several tendons and neurovascular structures pass through this confined region on their way from the posterior leg into the foot.

Flexor Retinaculum

The flexor retinaculum extends across the posteromedial ankle and forms the roof of the tarsal tunnel.

It retains the flexor tendons and neurovascular structures close to the underlying bones as they pass into the foot.

The posterior tibial artery and tibial nerve therefore occupy a predictable anatomical relationship beneath this retinacular structure.

Structures Behind the Medial Malleolus

The major structures passing behind the medial malleolus can be arranged from anterior to posterior as:

1. Tibialis posterior tendon
2. Flexor digitorum longus tendon
3. Posterior tibial artery and accompanying veins
4. Tibial nerve
5. Flexor hallucis longus tendon

This arrangement is important for understanding both pulse palpation and the anatomy of the tarsal tunnel.

Relationship to the Tibial Nerve

The tibial nerve accompanies the posterior tibial vessels through the distal leg and tarsal tunnel.

Behind the medial malleolus, the nerve generally lies posterior to the posterior tibial artery.

The close relationship between the nerve and artery is clinically important during surgical procedures and when evaluating pathology of the tarsal tunnel.

Relationship to Tibialis Posterior

The tendon of tibialis posterior passes behind the medial malleolus anterior to the posterior tibial artery.

It occupies the most anterior position among the major structures passing beneath the flexor retinaculum.

The tendon continues toward its major insertion on the navicular and adjacent bones of the foot.

Relationship to Flexor Digitorum Longus

The tendon of flexor digitorum longus also passes behind the medial malleolus.

It lies posterior to tibialis posterior but anterior to the posterior tibial vessels.

After entering the foot, the tendon divides into slips that continue toward the lateral four toes.

Relationship to Flexor Hallucis Longus

The tendon of flexor hallucis longus lies posterior to the tibial nerve within the posteromedial ankle region.

It is therefore the most posterior of the major structures commonly listed within the tarsal tunnel.

The tendon continues into the sole toward the distal phalanx of the great toe.

Palpation

The posterior tibial pulse is usually palpated with the foot and ankle relaxed.

The examiner identifies the medial malleolus and places the pads of the index and middle fingers immediately posterior and slightly inferior to it.

Gentle pressure is applied into the groove between the medial malleolus and calcaneal region until the pulsation is detected.

Palpation Technique

1. Position the foot comfortably and allow the ankle to relax.
2. Identify the medial malleolus.
3. Place two or three fingertips immediately posterior to the malleolus.
4. Move slightly inferiorly toward the interval between the malleolus and calcaneus.
5. Apply gentle, gradually increasing pressure.
6. Identify the arterial pulsation.
7. Compare with the opposite side when appropriate.

Why Light Pressure Is Important

The posterior tibial artery can be compressed by excessive finger pressure.

Using the fingertips rather than the thumb helps reduce confusion between the examiner's own pulse and the patient's arterial pulsation.

If the pulse is not initially detected, the fingers can be moved slightly anteriorly, posteriorly, superiorly, or inferiorly because the exact course of the artery can vary.

Surface Projection

The distal posterior tibial artery can be projected along the posteromedial ankle toward the plantar aspect of the foot.

Its most clinically useful superficial segment lies behind the medial malleolus, where it can be palpated before dividing into its plantar branches.

This position makes the vessel one of the principal distal pulse points used during examination of the lower limb.

Termination

After passing beneath the flexor retinaculum, the posterior tibial artery enters the plantar aspect of the foot.

It divides into the medial plantar artery and lateral plantar artery.

These vessels contribute to the extensive arterial network supplying the sole and toes.

Medial Plantar Artery

The medial plantar artery is usually the smaller terminal branch of the posterior tibial artery.

It travels along the medial aspect of the sole and supplies structures in the medial plantar region.

It contributes to arterial communications within the foot.

Lateral Plantar Artery

The lateral plantar artery is generally the larger terminal branch.

It travels laterally and then medially across the deep plantar region, contributing substantially to formation of the deep plantar arch.

The plantar arch communicates with the dorsalis pedis arterial system through the deep plantar branch.

Relationship to the Dorsalis Pedis Pulse

The posterior tibial and dorsalis pedis pulses are the two principal distal pulses routinely examined in the foot and ankle.

Feature	Posterior Tibial Pulse	Dorsalis Pedis Pulse
Artery	Posterior tibial artery	Dorsalis pedis artery
Location	Posteromedial ankle	Dorsum of foot
Primary landmark	Medial malleolus	Extensor hallucis longus tendon
Palpation site	Posterior and slightly inferior to medial malleolus	Usually lateral to extensor hallucis longus tendon
Primary distal territory	Plantar foot	Dorsal foot

Relationship to the Popliteal Pulse

The posterior tibial arterial pathway originates from the popliteal arterial system.

The popliteal artery lies behind the knee and gives rise distally to the major arterial pathways of the leg.

Comparison of the popliteal and posterior tibial pulses can provide information about arterial flow through the posterior leg.

Relationship to the Femoral Pulse

Blood reaching the posterior tibial artery travels through the femoral and popliteal arterial pathways.

The femoral artery becomes the popliteal artery after passing through the adductor hiatus, and the popliteal artery subsequently supplies the arterial branches of the leg.

Sequential examination of femoral, popliteal, posterior tibial, and dorsalis pedis pulses can help localize the approximate level of reduced arterial flow.

Comparison of Lower Limb Pulse Points

Pulse	Surface Landmark	Relative Depth
Femoral	Immediately inferior to inguinal ligament near midinguinal point	Relatively superficial
Popliteal	Central popliteal fossa	Deep
Posterior tibial	Posterior to medial malleolus	Relatively superficial
Dorsalis pedis	Lateral to extensor hallucis longus tendon	Superficial

Anatomical Variation

The course and caliber of the posterior tibial artery can vary between individuals.

Variations in branching of the popliteal artery and arteries of the leg can alter the expected anatomy of the distal vessel.

Consequently, difficulty palpating a posterior tibial pulse should be interpreted together with the dorsalis pedis pulse and other findings rather than considered diagnostic of arterial disease by itself.

Clinical Significance

Peripheral Vascular Examination

The posterior tibial pulse is routinely assessed during the peripheral vascular examination of the lower limb.

Its presence, strength, and symmetry are considered together with the dorsalis pedis, popliteal, and femoral pulses.

Examination may also include skin temperature, color, capillary refill, trophic changes, and other findings related to arterial perfusion.

Peripheral Arterial Disease

A reduced or absent posterior tibial pulse can occur with peripheral arterial disease.

The distribution of diminished pulses can provide clues about the anatomical level of arterial stenosis or occlusion.

Because palpation is subjective and anatomical variation occurs, suspected disease is evaluated using objective vascular tests when appropriate.

Ankle-Brachial Index

The posterior tibial artery is one of the arteries used to measure ankle systolic pressure during calculation of the ankle-brachial index.

A Doppler probe is placed over the posterior tibial artery while a blood pressure cuff around the ankle is inflated and gradually released.

The resulting ankle pressure is compared with brachial systolic pressure to assess lower-limb arterial perfusion.

Acute Limb Ischemia

Sudden loss of a previously detectable posterior tibial pulse can occur with acute arterial occlusion.

The pulse finding is interpreted with other signs of impaired perfusion, including pain, pallor, reduced temperature, sensory disturbance, and motor dysfunction.

Acute compromise of arterial flow to the limb requires prompt clinical evaluation.

Lower Limb Trauma

The posterior tibial pulse is an important distal pulse to assess after significant trauma involving the knee, leg, ankle, or foot.

Fractures, dislocations, penetrating injuries, vascular injuries, and severe swelling can impair distal circulation.

Comparison with the dorsalis pedis pulse and repeated assessment over time can help identify changes in perfusion.

Ankle Fractures and Dislocations

Because the posterior tibial artery passes close to the medial ankle, significant ankle fractures and dislocations can threaten the vessel or alter distal blood flow.

Assessment of both posterior tibial and dorsalis pedis pulses is therefore important during neurovascular examination of an injured ankle.

Pulse presence alone does not exclude partial vascular injury when the mechanism or other findings raise concern.

Tarsal Tunnel Syndrome

The posterior tibial artery and tibial nerve both pass through the tarsal tunnel.

Tarsal tunnel syndrome primarily involves compression of the tibial nerve or its branches, producing sensory and sometimes motor symptoms in the foot.

The posterior tibial pulse provides a useful anatomical landmark when examining the posteromedial ankle, although the presence or absence of the pulse does not diagnose tarsal tunnel syndrome.

Posterior Tibial Tendon Pathology

The tibialis posterior tendon lies anterior to the posterior tibial vessels behind the medial malleolus.

Pain, swelling, or structural changes involving this tendon can alter the local anatomy and may make palpation of nearby structures more difficult.

Understanding the normal arrangement of the tendon, artery, and tibial nerve helps distinguish structures during examination.

Diabetic Foot Assessment

Assessment of the posterior tibial and dorsalis pedis pulses forms part of vascular examination of the foot in people at risk of impaired peripheral circulation.

Reduced arterial perfusion can affect tissue viability and wound healing, particularly when combined with sensory impairment or structural abnormalities of the foot.

When pulse findings are uncertain or abnormal, objective vascular assessment may provide more reliable information about perfusion.

Doppler Examination

A handheld Doppler ultrasound device can be used to identify flow in the posterior tibial artery when the pulse is difficult to palpate.

The medial malleolus remains the key surface landmark for positioning the probe over the expected course of the vessel.

Duplex ultrasound can provide more detailed information about arterial anatomy, stenosis, occlusion, and blood-flow characteristics.

Imaging

Duplex ultrasonography provides noninvasive visualization of the posterior tibial artery and assessment of its blood flow.

CT angiography and MR angiography can demonstrate the artery as part of the broader arterial tree of the leg and foot.

Catheter angiography may be used when detailed vascular mapping or endovascular intervention is required.

Surface Anatomy

The posterior tibial pulse is an important surface vascular landmark of the medial ankle. The medial malleolus provides the principal bony reference point for locating the artery.

The pulse is sought immediately posterior and slightly inferior to the malleolus, within the groove leading toward the calcaneal region. Gentle pressure with the fingertips is usually sufficient when the artery is readily palpable.

Its accessible position makes the posterior tibial pulse, together with the dorsalis pedis pulse, particularly useful for assessing arterial circulation at the distal end of the lower limb.