What Is the Posterior Tibial Tendon?
![Posterior Tibial Tendonitis Treatment [Fix Inside Of The Ankle Pain!] | Balance Foot Ankle](https://www.michiganfootdoctors.com/uploads/2021/04/posterior-tibial-tendonitis-treatment-fix-inside-of-the-ankle-pain-1.avif "Posterior Tibial Tendon Pain: Why Your Inner Ankle Hurts 1")
The posterior tibial tendon is the primary dynamic support of the medial longitudinal arch—the inner arch of the foot. It runs behind the medial malleolus (inner ankle bone) and attaches to multiple bones of the midfoot, where it acts to invert the foot, plantarflex the ankle, and lock the midfoot joints to allow a rigid push-off during walking. When this tendon degenerates, tears, or fails, the arch progressively collapses—a condition called posterior tibial tendon dysfunction (PTTD), the most common cause of adult-acquired flatfoot.
Pain along the posterior tibial tendon—running from behind the inner ankle to the bottom of the foot along the arch—is the hallmark symptom of PTTD in its early stages. This is a critical window: early-stage PTTD (Stage I, tendinitis without deformity) responds well to conservative treatment, while late-stage disease requires complex reconstruction. Recognizing and treating PTTD before significant arch collapse occurs is the most important principle in management.
Symptoms: What PTTD Feels Like
The classic presentation is a middle-aged to older adult—most commonly a woman—who notices pain and swelling along the inner ankle and arch that develops gradually over months. The pain is typically worse with activity (prolonged standing, walking, climbing stairs) and better with rest. As the disease progresses, patients notice that their arch seems to be flattening and that the affected foot points outward more than the other when walking. The single-heel-rise test—attempting to rise on tiptoe on the affected foot alone—becomes difficult or impossible as tendon function declines. In severe PTTD, patients develop progressive flatfoot deformity even after the acute tendon pain has resolved.
Diagnosis
Clinical examination is the primary diagnostic tool: tenderness directly along the posterior tibial tendon behind the medial malleolus and along its course to the navicular bone, weakness with resisted foot inversion, and inability to perform single-heel rise on the affected foot. Weight-bearing X-rays demonstrate arch collapse (decreased calcaneal pitch, talonavicular coverage angle) when deformity is present. MRI is the gold standard for characterizing tendon pathology—showing peritendinitis, tendinosis, partial tear, or complete rupture—and directly guides surgical planning.
Treatment
Stage I: Tendinitis Without Deformity
Early PTTD without arch collapse responds well to anti-inflammatory treatment (NSAIDs, ice) and immobilization in a CAM boot for 4–6 weeks to rest the tendon. A custom orthotic with aggressive medial arch support and heel valgus posting is then prescribed for long-term tendon support. Physical therapy for progressive posterior tibial tendon and calf strengthening is an essential component—eccentric strengthening exercises for the posterior tibial tendon are the most effective physical therapy intervention. Most Stage I PTTD patients improve substantially with conservative treatment.
Stage II: Flexible Flatfoot
When arch collapse has developed but remains flexible (correctable passively), conservative treatment with an Arizona brace (a custom ankle-foot orthosis providing rigid arch support) may stabilize the deformity. When conservative treatment fails, surgical reconstruction combines posterior tibial tendon debridement or FDL tendon transfer, medial calcaneal osteotomy (shifting the heel inward), and sometimes lateral column lengthening—reconstructing the arch anatomy.
Frequently Asked Questions
How do I know if my posterior tibial tendon is torn?
You cannot reliably determine tendon tear severity from symptoms alone—MRI is required for definitive characterization. Clinically, a complete posterior tibial tendon tear is suggested by: inability to perform a single-heel rise on the affected foot, progressive flatfoot deformity that has developed relatively quickly, and very significant tendon tenderness. Partial tears may present with tendinitis-like symptoms but more persistent disability than expected for simple inflammation. In clinical practice, the most important distinction is whether the deformity (if present) is flexible or rigid—which determines treatment options—rather than the exact degree of tendon tearing. MRI showing complete tendon rupture without viable tissue changes the surgical approach from tendon debridement/reinforcement to FDL tendon transfer reconstruction.
What exercises help posterior tibial tendon pain?
Physical therapy for PTTD focuses on posterior tibial tendon strengthening, calf flexibility, and arch support exercises. Key exercises: seated foot inversion against resistance (resistance band or towel around the ball of the foot, resisting inversion), single-leg heel raises (building to 25–30 reps, which is the functional strength target), eccentric heel drops on a step for Achilles/calf flexibility, and intrinsic foot strengthening (towel scrunches, marble pickups). These exercises must be performed consistently over months—occasional exercise provides minimal benefit for tendon rehabilitation. The exercises are most effective in Stage I PTTD before arch collapse—once significant flatfoot deformity is present, strengthening alone is insufficient and orthotic support or surgery is needed.
Can posterior tibial tendon dysfunction be reversed?
Stage I PTTD—tendinitis without deformity—can fully resolve with appropriate treatment, allowing return to normal function without long-term orthotic dependence in some patients. Stage II PTTD (flexible flatfoot) can be stabilized with orthotics to prevent further progression, but the existing arch collapse typically does not fully reverse. Surgical reconstruction can correct the flatfoot deformity in Stage II, restoring more normal alignment. Stage III (rigid flatfoot) cannot be corrected without fusion surgery. The window of opportunity for reversal or conservative control is early in the disease—this is why any progressive arch flattening or inner ankle pain in an adult should be evaluated promptly rather than watched indefinitely without assessment.
Medical References & Sources
- American Orthopaedic Foot & Ankle Society — Posterior Tibial Tendon Dysfunction
- PubMed Research — PTTD Conservative Treatment
- PubMed Research — PTTD Staging and Surgical Treatment
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Dr. Tom Biernacki, DPM is a board-certified podiatric surgeon at Balance Foot & Ankle in Howell and Bloomfield Hills, Michigan. He diagnoses and manages posterior tibial tendon dysfunction with MRI evaluation, custom orthotics, physical therapy, and flatfoot reconstruction surgery.
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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.
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