Posterior Tibial Tendon Dysfunction

Most people either know of, or have experienced, ankle injuries and these typically tend to be lateral (outside) ligament sprains by ‘going over’ on your ankle, Achilles tendon issues at the back of your ankle and lower leg, or plantar fasciitis which affects the foot under the arch and into the heel pad.  But have you heard of PTTD, or posterior tibial tendon dysfunction?

The posterior tibialis muscle runs along the inside your lower leg, and its tendon wraps around the inside of your ankle and attaches to the medial (inside) arch of your foot.  This tendon attaches the calf muscles to the medial foot, and is vital to help support the arch and stabilise the foot when walking and running.  Tendons notoriously have a poor blood supply, reduced further by the sharp angle of this tendon wrapping under the inner ankle bone (medial malleolus).

A posterior tibialis injury involves damage or irritation to the tibialis posterior tendon. 

Injury usually falls under:

• Posterior tibial tendonitis, where the tendon becomes inflamed, swollen and painful.

• Posterior tibial tendon dysfunction (PTTD), a progressive weakening or tearing of the tendon.  This degeneration of the tendon (tendinosis), can lead to a collapsed arch (flatfoot deformity), if left untreated.

Symptoms

• Pain along the inside of the ankle and/or foot

• Swelling around the ankle bone or the inside of the foot

• Flattening of the arch over time

• Weakness when trying to stand on tiptoe (single-leg heel raise)

• The foot turning out (seeing too many toes when looking from behind).

Causes

More often than not, PTTD is caused by:

• Chronic overuse from long-distance running or hiking, especially on hills and uneven terrain

• Jobs involving being on your feet all day

• People with flat feet or over-pronation – the tendon is either already weak or has additional strain put on it due to the rolling in of the foot

• A sudden increase in activity which the tendon is not conditioned to/not strong enough eg. doing a long charity walk without enough prior training.

In addition, other risk factors include:

• Age: adults over 40 – tendon regeneration slows as we age

• Sex: post-menopausal females – reduced oestrogen affects tendon structure

• Anatomy: an accessory (lengthened) navicular bone, increasing the angle which the tendon has to wrap around

• Other health conditions: being overweight, type 2 diabetes, chronic steroid use (eg, inhalers or multiple corticosteroid injections), hypothyroidism and rheumatoid arthritis.

When to seek help:

• Pain lasting more than 2–3 weeks, despite rest

• Inability to walk without a limp

• Inability to do a single-leg heel raise

• Increasing swelling, pain or instability

• Visible flattening of the foot

If you start to feel pain or swelling on the inside of the ankle:

• Don’t ignore this or push through the pain.  It will only get worse and result in a longer rehabilitation time

• Avoid excessive stretching (a common mistake) which can irritate the tendon further

• Wear more rigid shoes which support the arch.  A slight heel can help shorten and ‘deload’ the tendon in the short-term

• Don’t walk barefoot in the house; even slippers (with a back and rigid sole) can help

• Wear orthotics with a medial (inside) arch support

• Seek expert help and rehabilitation as soon as possible, as this improves outcome.

Rehabilitation:

Recovery time depends on the severity of the injury and how long you’ve had it before seeking help.

• Mild tendonitis: 4–8 weeks

• Moderate dysfunction: 8–16 weeks

• Chronic / severe PTTD: several months (3–6+)

• Tear requiring surgery: 6–12 months recovery

Tendons do not heal quickly and understanding/accepting the process is important to help with recovery.

• Rest is needed initially to reduce inflammation and pain. 

• However, tendons do need some degree of stimulation to encourage regeneration; how much and how often is the tricky part. Too much in a short space of time can cause irritation and re-inflammation; too little stagnates recovery. 

• An experienced physical therapist can guide appropriate treatment and a progressive, timely rehabilitation plan focussing first on whole-foot stability and strength. Then specific strengthening, agility and dynamic multi-direction movement exercises, to increase tolerance and resilience of the tendon.  Finally, a graded return to run/walk/play programme…

If you'd like further information or advice regarding injury treatment and rehab plans, please contact amanda@amandaheading.com

Amanda Heading, BSc (Hons), DipION

10/04/2026

Injury treatment, rehab and training plans, nutrition; sports performance nutrition, health maintenance.