Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

What Is Posterior Tibial Tendinopathy?

The posterior tibial tendon runs from the muscle in the back of the lower leg, passes behind the medial malleolus (inner ankle bone), and fans out to attach to multiple bones on the medial and plantar foot. Its primary functions are to supinate the subtalar joint (invert the heel), decelerate pronation during the contact phase of gait, and assist push-off. When this tendon develops tendinopathy — degeneration from repetitive overload — it produces medial ankle and arch pain that, if untreated, can progress to complete tendon failure and acquired flatfoot deformity.

At Balance Foot & Ankle, posterior tibial tendinopathy is one of the most important overuse conditions we manage. The window for effective conservative treatment is early — once the tendon fails and flatfoot deformity becomes fixed, surgical reconstruction becomes necessary. Early recognition and aggressive conservative treatment gives most patients the opportunity to avoid surgery.

Stages of Posterior Tibial Tendon Dysfunction (PTTD)

PTTD is classified in four stages. Stage 1 involves tendinopathy without significant deformity — the foot is flexible and the tendon, while painful, is still functioning. Stage 2 involves a weakened or partially torn tendon with flexible flatfoot deformity — the heel can still be passively corrected to a neutral position. Stage 3 features rigid flatfoot with fixed subtalar valgus. Stage 4 extends to ankle joint valgus from medial deltoid ligament failure. Conservative treatment is most effective in Stage 1 and Stage 2A (mild to moderate Stage 2); surgical reconstruction is typically required for Stage 2B (moderate to severe), Stage 3, and Stage 4.

Symptoms and Clinical Presentation

Medial ankle and arch pain — specifically along the course of the posterior tibial tendon from behind the medial malleolus to the navicular insertion — is the cardinal symptom. Pain worsens with activity and may be present with even light walking in advanced tendinopathy. Swelling along the tendon sheath may be visible and palpable. The single-heel-raise test is the most important clinical assessment: the patient stands on one foot and attempts to rise onto the ball of the foot (plantarflexion). Normal patients can perform 10 to 20 consecutive single-heel raises; patients with significant posterior tibial tendinopathy cannot rise at all, or can perform only a few repetitions with pain and weakness. Progressive flatfoot and external rotation of the forefoot (“too many toes” sign on the affected side) indicate deformity is developing.

Conservative Treatment for Stage 1 and Stage 2 PTTD

Custom Orthotics and Bracing

Custom orthotics that control hindfoot valgus and support the medial arch are the most effective non-surgical intervention for PTTD. By reducing the mechanical load on the weakened tendon, orthotics allow the tendon to heal and prevent progressive deformity. For Stage 1, a molded functional orthotic with medial heel post and arch fill is appropriate. For early Stage 2, a more aggressive support — a UCBL (University of California Biomechanics Laboratory) orthosis or a custom ankle-foot orthosis with rigid medial support — is required to control hindfoot valgus that a standard orthotic cannot contain.

Arizona brace (custom lace-up leather ankle brace) is a proven, durable option for Stage 2 PTTD that provides excellent medial support while being significantly less cumbersome than a rigid AFO. Many patients prefer the Arizona brace for its balance of effectiveness and comfort.

Physical Therapy

Eccentric strengthening of the posterior tibial muscle — performed by slowly lowering the heel from a raised position on a step with the affected foot inverting against resistance — is the most evidence-based exercise intervention for PTTD. This exercise loads the tendon in a way that stimulates collagen remodeling and progressive tendon strengthening. A formal physical therapy program addresses all contributing factors: calf tightness, hip abductor weakness, and gait mechanics that increase medial ankle loading.

Anti-Inflammatory Treatment

NSAIDs reduce pain and inflammation during acute exacerbations. Ultrasound-guided corticosteroid injection around the tendon sheath — not into the tendon itself — provides anti-inflammatory relief for active tenosynovitis. Injection directly into the tendon body is contraindicated as it increases rupture risk. PRP (platelet-rich plasma) injection is increasingly used for posterior tibial tendinopathy as an alternative to corticosteroid, particularly for chronic tendinopathy where tissue healing is the goal rather than anti-inflammatory effect.

Activity Modification

Temporarily reducing activities that load the posterior tibial tendon — particularly running, stair climbing, and prolonged walking — allows active tendinopathy to quiet while treatment is initiated. Complete rest is rarely needed or helpful; the tendon heals better with controlled loading than with total immobilization. A walking boot may be used for two to four weeks in severe Stage 1 or early Stage 2 cases to provide a period of protected loading during the initiation of treatment.

Frequently Asked Questions

Posterior Tibial Tendon Treatment in Michigan

Early-stage posterior tibial tendon dysfunction responds well to bracing, orthotics, and physical therapy. Our podiatrists specialize in conservative PTTD management at our Howell and Bloomfield Hills offices.

Learn About Flatfoot Treatment | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Alvarez RG, et al. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol. Foot Ankle Int. 2006;27(1):2-8.
2. Kulig K, et al. Effect of posterior tibial tendon dysfunction on unipedal standing balance test. Foot Ankle Int. 2011;32(8):S462.
3. Neville C, et al. Comparison of changes in posterior tibialis muscle length between subjects with posterior tibial tendon dysfunction and healthy controls. Foot Ankle Int. 2007;28(9):1020-1025.

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Dr. Tom Biernacki, DPM

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Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.