Pain on the inside of your ankle, a foot that seems to be getting flatter, or difficulty standing on one tiptoe can all be signs of posterior tibialis tendon dysfunction (PTTD).
The posterior tibialis tendon is one of the major supporting structures of the foot. When it becomes painful, weakened or damaged, it can affect how well the foot supports itself during standing and walking. Over time, some people develop a progressively flatter and more unstable foot.
The good news is that early treatment doesn’t necessarily mean surgery. Most people begin with conservative treatment such as temporarily reducing aggravating activity, changing footwear, using orthotics or bracing where appropriate, and completing a progressive strengthening program.
The key is identifying the problem early and working out why the tendon is struggling.
Quick summary
- The posterior tibialis tendon runs behind the inside of your ankle and helps support your arch during standing and walking.
- Pain and swelling behind or below the inside ankle bone are common early symptoms.
- As the condition progresses, the arch can become flatter and the position of the heel can change.
- Treatment commonly involves modifying aggravating activity, appropriate footwear, orthotics and progressive strengthening exercises.
- Earlier assessment is worthwhile if your foot appears to be changing shape or your symptoms are becoming progressively worse.
What is the posterior tibial tendon?
The posterior tibialis muscle sits deep within the back of the lower leg.
Its tendon travels down the leg and behind the prominent ankle bone on the inside of your ankle before attaching around the middle of the foot.
Although most people have never heard of the posterior tibial tendon until it hurts, it performs an important job.
It helps:
- Support the arch of your foot
- Control how your foot moves when it contacts the ground
- Stabilise the foot as your body moves over it
- Create a stable platform as you push off during walking
When the tendon becomes painful or weakened, it may struggle to perform these functions effectively.
What is Posterior Tibialis Tendon Dysfunction?
Posterior Tibialis Tendon Dysfunction describes a problem where the posterior tibial tendon becomes painful, weakened or less effective at supporting the foot.
In the early stages, the main problem may simply be pain and swelling along the tendon.
If the condition progresses, the tendon can become less effective at supporting the arch. This can lead to gradual changes in the position and shape of the foot.
This is why someone with PTTD might initially present with pain on the inside of the ankle, but later notice that the affected foot looks flatter than the other one.
What does Posterior Tibialis Tendon Dysfunction feel like?
Symptoms vary depending on how long the problem has been present and how much the tendon has been affected.
Early symptoms
You might notice:
- Pain behind or underneath the inside ankle bone
- Tenderness when pressing along the tendon
- Swelling around the inside of the ankle
- Pain after longer walks
- Pain during or after exercise
- Aching or fatigue through the arch
- Reduced strength when pushing off the affected foot
At this stage, there may be little or no obvious change in the shape of your foot.
As the condition progresses
You may begin to notice:
- Your arch looks lower than it used to
- One foot appears flatter than the other
- Your ankle or heel appears to roll inwards
- Your foot feels increasingly tired during walking
- Difficulty standing on tiptoe on the affected side
- Increasing difficulty walking longer distances
- Pain beginning to occur around the outside of the ankle as well
A foot that is visibly changing shape is worth having assessed rather than simply waiting to see if the pain disappears.
Why does Posterior Tibialis Tendon Dysfunction happen?
There isn’t always one identifiable cause.
Tendons need to tolerate the loads we place on them every day. Problems can develop when the demands being placed on the posterior tibial tendon repeatedly exceed its ability to tolerate and recover from those loads.
Sometimes there is an obvious trigger – such as suddenly increasing walking, running or exercise.
In other people, symptoms develop gradually.
Factors that can contribute include:
- A sudden increase in walking, running or exercise
- Spending significantly more time standing
- Foot mechanics that increase demand on the tendon, such as a pronated or hypermobile foot type
- Reduced foot and ankle strength
- Previous foot or ankle injuries
- Age-related changes within the tendon
- Higher body weight
- Certain inflammatory or metabolic health conditions
PTTD is particularly associated with middle-aged and older adults, although it can occur at other ages.
Importantly, having flat feet doesn’t automatically mean you have PTTD.
Many people naturally have low arches and never experience pain. What matters is whether you have symptoms, reduced function or a foot that appears to be becoming progressively flatter.
How is Posterior Tibialis Tendon Dysfunction diagnosed?
There isn’t one single test.
A podiatry assessment usually considers your symptoms, activity history, foot posture, strength, joint movement and how your foot behaves when you walk.
Your podiatrist may assess:
The painful area
Feeling along the posterior tibial tendon can help determine whether your symptoms correspond with the location of the tendon and whether swelling or tenderness is present.
Your foot posture
Both feet can be compared to look for differences in arch height and heel position.
The way you walk
Watching your foot while you’re moving can provide information that isn’t always obvious while you’re sitting or lying down.
Your ability to perform a heel raise
One useful test involves standing on one leg and lifting your heel from the ground.
This movement places significant demand on the posterior tibial tendon. Someone with more advanced dysfunction may struggle to lift their heel or may be unable to perform the movement.
Do you need an ultrasound or MRI?
Not everyone with posterior tibial tendon pain needs a scan.
A thorough clinical examination can often provide considerable information. Imaging becomes more useful when the diagnosis isn’t clear, symptoms aren’t improving as expected, or we need additional information about the tendon.
Point-of-care ultrasound
Musculoskeletal ultrasound allows us to look at the posterior tibial tendon in real time.
Depending on the presentation, ultrasound can help assess:
- Tendon thickness and structure
- Fluid or swelling around the tendon
- Areas of tendon degeneration
- Partial or complete tendon tears
- How the tendon moves
At Prosper Health Group, our podiatrists have access to point-of-care ultrasound (POCUS) in the clinic. This allows us to combine ultrasound findings with your physical examination when imaging is clinically appropriate.
X-ray and MRI
Weight-bearing X-rays may be useful if there has been a noticeable change in the structure or alignment of the foot.
MRI can provide more detailed information about the posterior tibial tendon and surrounding structures and may be requested in more complex cases.
Importantly, imaging should answer a specific clinical question. A scan isn’t automatically necessary simply because the inside of your ankle hurts.
How is Posterior Tibialis Tendon Dysfunction treated?
Treatment depends on how irritated the tendon is and whether the shape of the foot has started to change.
1. Reduce the aggravating load
This doesn’t necessarily mean complete rest.
Instead, we identify the activities currently exceeding the tendon’s capacity and temporarily adjust them.
For example, someone who has recently increased their daily walking might temporarily reduce their distance. A runner may need to alter their running volume, while someone who stands all day at work may benefit more from footwear and support.
The goal is to settle symptoms without unnecessarily stopping all activity.
2. Improve footwear
Shoes can influence how much work the posterior tibial tendon needs to perform.
Depending on the individual, we may recommend footwear with:
- Good rearfoot support
- A stable base
- Appropriate fit
- Adequate room through the forefoot
- Features appropriate for your work and daily activities
There isn’t one “best shoe” for everyone with PTTD.
3. Orthotics
Foot orthotics can help support the foot and reduce the load being placed on painful structures.
Depending on the severity of the condition, this might involve an off-the-shelf device or a customised orthotic.
Orthotics don’t physically repair the tendon or permanently rebuild your arch. Their role is to change the forces acting through the foot and reduce demand on the tendon while symptoms settle and strength improves.
4. Strengthening and rehabilitation
Getting rid of the pain is only part of treatment.
Once appropriate, rehabilitation aims to progressively improve the amount of load the posterior tibial tendon and surrounding muscles can tolerate.
Your program might include:
- Calf raises
- Posterior tibialis strengthening
- Foot and ankle exercises
- Balance exercises
- Progressive walking exercises
- Gradual return to running or sport
The appropriate exercise – and particularly the appropriate amount of resistance – will vary from person to person.
Research examining exercise for posterior tibial tendon dysfunction suggests that strengthening exercises, particularly when combined with orthoses and stretching, can improve pain and function.
5. Bracing or temporary immobilisation
More painful cases sometimes require greater support.
A brace or walking boot may be used temporarily to reduce load through the tendon and allow symptoms to settle before rehabilitation begins.
This isn’t required for everyone.
6. Surgery
Most people presenting with earlier-stage PTTD will begin with non-surgical treatment.
Surgery may be considered when there is significant deformity, persistent symptoms despite appropriate conservative treatment, or substantial damage to the tendon and supporting structures.
The operation required varies considerably depending on the severity of the condition, which is another reason earlier assessment is preferable.
Can Posterior Tibialis Tendon Dysfunction be fixed?
In earlier stages, pain and function can often improve considerably with appropriate treatment.
If the condition has already caused a significant structural change to the foot, conservative treatment isn’t necessarily going to return the arch to exactly how it looked previously.
The goals may instead become:
- Reducing pain
- Improving walking capacity
- Supporting the foot
- Improving strength
- Preventing or slowing further deterioration
The earlier the problem is identified, the more conservative treatment options are generally available.
Can you keep walking with PTTD?
Often, yes.
Having PTTD doesn’t automatically mean you need to stop walking or exercising.
What matters is whether your current activity is repeatedly aggravating the tendon.
For example, if your pain is significantly worse after a five-kilometre walk but relatively comfortable after two kilometres, temporarily reducing the distance may allow you to stay active while treatment begins.
Your walking can then be progressively increased as symptoms and strength improve.
The same principle applies to running, gym training and other exercise.
When should you see a podiatrist?
Consider having your foot assessed if:
- Pain on the inside of your ankle persists or keeps returning
- You notice swelling behind the inside ankle bone
- Walking or running is becoming increasingly painful
- One foot appears flatter than the other
- Your arch seems to be getting lower
- You struggle to stand on tiptoe on one foot
- Your symptoms aren’t improving despite reducing activity or changing footwear
The aim isn’t simply to identify where it hurts, but to work out why the tendon has become painful and what needs to change to improve its capacity.
FAQs about Posterior Tibialis Tendon Dysfunction
Is Posterior Tibialis Tendon Dysfunction the same as flat feet?
No. Many people naturally have flat feet without pain or tendon dysfunction. PTTD becomes more concerning when there is pain along the posterior tibial tendon, loss of strength or a noticeable change in the shape of the foot.
Does PTTD heal on its own?
Mild symptoms can sometimes settle when aggravating activity is reduced. Persistent pain, swelling, weakness or a changing foot shape should be assessed rather than repeatedly ignored.
Do orthotics fix Posterior Tibialis Tendon Dysfunction?
Orthotics don’t directly heal the tendon. They can reduce the forces being placed through the posterior tibial tendon, which can be particularly useful while symptoms settle and strength is progressively rebuilt.
Is walking good for posterior tibial tendonitis?
Walking isn’t inherently good or bad for the tendon. It depends on how much load the tendon can currently tolerate. Walking within a comfortable level can often continue, while repeatedly exceeding that level may aggravate symptoms.
What is the single-leg heel raise test?
This involves standing on one foot and lifting your heel off the ground. It challenges the muscles and tendons responsible for controlling and supporting the foot, including the posterior tibial tendon. Difficulty performing it can be one sign of posterior tibial tendon dysfunction.
What’s the difference between posterior tibial tendonitis and tendinopathy?
“Tendonitis” traditionally refers to inflammation of the tendon. “Tendinopathy” is a broader term used for tendon pain and changes in tendon structure and function. In many persistent tendon problems, the process is more complicated than inflammation alone.
How long does PTTD take to recover?
There isn’t one recovery time. It depends on how long the problem has been present, the condition of the tendon, whether the shape of the foot has changed, your activity demands and how the tendon responds to treatment. Tendon rehabilitation typically occurs over weeks to months rather than days.
Pain on the inside of your ankle? Get it assessed.
If you’ve developed persistent pain or swelling around the inside of your ankle, noticed that one arch is becoming flatter, or you’re finding walking and exercise increasingly difficult, it may be time to have it assessed.
At Prosper Health Group, our podiatrists can assess your foot mechanics, strength, walking pattern and posterior tibial tendon to determine what’s contributing to the problem.
Where clinically appropriate, we can also use point-of-care ultrasound within the clinic to assess the tendon and help guide your treatment plan.
Treatment may include activity modification, footwear advice, orthotics and a progressive strengthening program based on your individual presentation.
Book a podiatry assessment at Prosper Health Group.
