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Posterior Tibial Pulse in Vascular Exams: Technique & Findings
Bryant Schmitz • Updated Aug 20, 2025 • 90 hits
The posterior tibial pulse is a critical indicator of distal lower limb perfusion, frequently assessed in routine vascular, neurologic, and diabetic foot examinations. Clinicians use it to evaluate the functional integrity of the posterior tibial artery, which supplies the plantar aspect of the foot. Palpation of this pulse, along with the dorsalis pedis pulse, helps determine the presence and severity of peripheral arterial disease (PAD) and informs decisions about further vascular workup. Its accessibility and diagnostic value make it a standard part of physical assessment in emergency, inpatient, and outpatient settings.
While generally straightforward to locate in healthy individuals, factors such as edema, obesity, or arterial disease can obscure the pulse, underscoring the need for proper technique. A non-palpable posterior tibial pulse may suggest impaired arterial flow, but it must be interpreted in context with other clinical findings and diagnostic tests. Understanding the anatomy and method of assessment is essential for accurate and reproducible examination results.
Anatomy of the Posterior Tibial Artery
The posterior tibial artery originates from the popliteal artery in the popliteal fossa and descends along the posterior compartment of the leg. It courses between the deep flexor muscles and passes posterior to the medial malleolus through the tarsal tunnel. Within this fibro-osseous tunnel, the artery is accompanied by the tibial nerve and the posterior tibial vein, all enveloped by the flexor retinaculum.
Distally, the artery bifurcates into the medial and lateral plantar arteries, which contribute to the plantar arch and supply the sole of the foot. The position of the artery just posterior to the medial malleolus and anterior to the Achilles tendon makes it a favorable site for clinical palpation, though its depth can vary based on body habitus and local edema. Understanding this anatomy is essential for consistent identification during physical examination.
Table of Contents
(1) Locating the Posterior Tibial Pulse
(2) Clinical Significance of the Posterior Tibial Pulse
(3) Normal & Abnormal Findings
(4) Posterior Tibial Pulse in Specific Conditions
(5) Documentation, Troubleshooting, & Follow-Up
(6) Clinical Pearls & Pitfalls
Locating the Posterior Tibial Pulse
1. Position the patient in a supine or seated position with the foot relaxed and slightly dorsiflexed.
2. Identify the medial malleolus and Achilles tendon.
3. Place the pads of your index and middle fingers in the groove just posterior and slightly inferior to the medial malleolus.
4. Apply gentle pressure to palpate for the pulse.
5. Slightly invert the foot to relax the flexor retinaculum if the pulse is not easily palpable.
6. Compare both sides for symmetry, as anatomical variation is common.
7. Avoid excessive pressure that may occlude the pulse or cause confusion with nearby venous flow.
8. If the pulse remains undetectable, use Doppler ultrasonography to confirm presence or absence.
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Clinical Significance of the Posterior Tibial Pulse
Assessment of the posterior tibial pulse plays a key role in diagnosing and monitoring vascular conditions. In peripheral arterial disease, a diminished or absent pulse may correlate with significant arterial narrowing or occlusion. It is one of the two pedal pulses routinely evaluated when calculating the ankle-brachial index (ABI), a noninvasive screening tool for PAD.
In diabetic patients, the posterior tibial pulse helps distinguish between neuropathic and ischemic causes of foot ulceration. Preservation of the pulse often suggests neuropathy rather than critical ischemia. In trauma settings, absence of this pulse can raise concern for compartment syndrome or arterial injury. Consistent pulse assessment is also used to monitor perfusion after revascularization procedures or bypass grafts.
Normal & Abnormal Findings
The posterior tibial pulse is typically graded on a scale from 0 to 4+:
• 0 Pedal Pulse: Absent
• 1+ Pedal Pulse: Diminished
• 2+ Pedal Pulse: Normal
• 3+ Pedal Pulse: Full
• 4+ Pedal Pulse: Bounding
A normal pulse is symmetric and easily palpable with minimal pressure. Diminished pulses may reflect early vascular disease, while an absent pulse suggests a need for further evaluation. Bounding pulses can indicate increased cardiac output or arterial stiffness. Inconsistent or asymmetric findings should prompt a more comprehensive vascular assessment, including Doppler ultrasound or ABI testing. It is also important to differentiate true arterial absence from technical challenges in palpation, such as anatomical depth or patient edema.
Posterior Tibial Pulse in Specific Conditions
In diabetes, chronic hyperglycemia can lead to both neuropathy and macrovascular disease. A palpable posterior tibial pulse in a diabetic patient with foot ulcers usually suggests adequate perfusion and shifts clinical focus to pressure redistribution and neuropathic care. However, vascular insufficiency must still be excluded with ABI or toe pressures.
In peripheral arterial disease, the posterior tibial pulse serves as a key indicator of segmental perfusion. A non-palpable pulse may correspond with moderate to severe arterial obstruction. This pulse is also relevant in assessing acute limb ischemia, where its absence, in conjunction with pain and pallor, raises the index of suspicion.
Postoperative monitoring following vascular interventions often includes serial palpation of the posterior tibial pulse to ensure graft patency and adequate limb perfusion. Loss of this pulse may indicate thrombosis or anastomotic failure.
Documentation, Troubleshooting, & Follow-Up
Standardized documentation improves communication and follow-up. A common format includes notation such as “PT +2/4 bilaterally” or “Posterior tibial pulse non-palpable R > L.” Inconsistencies or changes should be documented with accompanying clinical context and follow-up plans.
When the pulse is difficult to detect, repositioning the limb, adjusting finger pressure, or using a handheld Doppler may be necessary. Doppler assessment can confirm presence or absence of flow and assist in mapping arterial patency. Referral to vascular surgery or noninvasive vascular lab is indicated when persistent abnormalities are found or when ABI testing reveals significant occlusive disease.
Clinical Pearls & Pitfalls
Consistent technique and bilateral comparison are key to accurate posterior tibial pulse assessment. The pulse lies deep in the tarsal tunnel, and firm but not excessive pressure is required. Palpating over the flexor hallucis longus or nearby veins can lead to false identification.
Misidentifying the tibial nerve or tendon structures as a pulse is a common error, particularly in inexperienced hands. Incorporating posterior tibial pulse checks into routine lower extremity exams increases diagnostic accuracy and helps identify early vascular compromise. When in doubt, confirm with Doppler to avoid overlooking significant arterial disease.
Additional resources:
[1] Standring, S. (Ed.). (2020). Gray's Anatomy: The Anatomical Basis of Clinical Practice (42nd ed.). Elsevier.
[2] Mills, J. L., Armstrong, D. G., & Pomposelli, F. B. (2014). The Society for Vascular Surgery lower extremity threatened limb classification system. Journal of Vascular Surgery, 59(1), 220–234. https://doi.org/10.1016/j.jvs.2013.08.003
[3] American Diabetes Association. (2024). Standards of Medical Care in Diabetes—Foot Care. Diabetes Care, 47(Suppl. 1), S221–S231. https://doi.org/10.2337/dc24-S011
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Cite This Podcast
BackTable, LLC (Producer). (2024, May 24). Ep. 448 – Below the Ankle Expertise: Distal Pedal Access [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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