Medically reviewed by Dr. Tom Biernacki, DPM
Board-certified podiatric surgeon | Balance Foot & Ankle, Howell & Bloomfield Hills, MI
Last reviewed: May 2026
The most important clinical decision with Posterior Tibialis Tendonitis: Symptoms, Diagnosis and Treatment isn’t which treatment to choose — it’s identifying which subtype you have first. Our podiatrists see patients treated for the wrong subtype for months before the correct diagnosis leads to full resolution. Call (810) 206-1402 — expert podiatric care across Michigan.
| Feature | Posterior Tibialis Tendinitis | Medial Ankle Sprain | Tarsal Tunnel Syndrome |
|---|---|---|---|
| Pain location | Along posterior tibialis tendon: behind medial malleolus, navicular insertion, medial arch | Medial ligament (deltoid): diffuse over medial ankle; worse with eversion stress | Medial ankle and plantar foot; burning and tingling; nerve distribution |
| Single-leg heel rise test | Positive (Stage 2+): unable to perform or severe pain; heel fails to invert | Negative or mildly positive | Negative |
| Arch collapse | Present (Stage 2+): progressive flatfoot; too-many-toes sign | Absent | Absent |
| Ultrasound / MRI | Tendon thickening, tearing, peritendinous fluid; tendon degeneration | Deltoid ligament edema, tear | Tibial nerve compression; hypoechoic mass if space-occupying |
| Onset | Gradual; often in middle-aged overweight women; may follow minor injury | Acute; post-inversion or eversion injury | Gradual; may have history of ankle fracture or flat foot |
The most important clinical decision with Posterior Tibialis Tendonitis isn’t which treatment to start with — it’s identifying the correct subtype. That changes everything. Call (810) 206-1402.
What Is Posterior Tibialis Tendonitis?
Posterior tibialis tendonitis (also called posterior tibial tendinitis) is inflammation and degeneration of the posterior tibialis tendon — the primary dynamic stabilizer of the medial arch of the foot. The tendon runs behind the medial malleolus (inner ankle bump) and inserts at the navicular bone and plantar midfoot. When this tendon is inflamed or torn, patients develop pain along the inner ankle and arch that worsens with walking and standing. If untreated, posterior tibialis tendon dysfunction (PTTD) progresses to progressive adult flatfoot deformity — the most common cause of acquired flatfoot in adults over 40.
Symptoms and Diagnosis
The classic presentation is medial ankle pain — specifically behind and below the medial malleolus — that worsens with walking, running, or prolonged standing. Swelling is often visible along the tendon course. The single-leg heel rise test is the most important clinical exam: standing on the affected foot only, attempt to rise onto the ball of the foot. Patients with posterior tibialis tendon involvement cannot complete the rise or do so with pain; the heel typically fails to invert (swing inward) as it normally should during the rise. Advanced cases show obvious arch collapse when standing (Stage 2 PTTD) and the “too-many-toes sign” when viewed from behind — more than 1–2 toes visible lateral to the heel compared to the other foot.
Treatment by Stage
Stage 1 (inflammation without deformity): Immobilization in a CAM boot for 4–6 weeks reduces acute tendon stress; physical therapy targeting progressive tendon loading follows. A rigid custom orthotic with a medial arch post and heel wedge is essential for long-term offloading. NSAIDs or a cortisone injection adjacent to (not into) the tendon reduces inflammation. Cortisone inside the tendon sheath is generally avoided due to rupture risk. Stage 2 (flexible flatfoot deformity): Physical therapy and orthotics are tried; surgical reconstruction (flexor digitorum longus tendon transfer to replace the failing PTT, combined with calcaneal osteotomy to realign the heel) is indicated for failure of conservative treatment. Stage 3–4 (rigid flatfoot deformity): Triple arthrodesis (fusion of the subtalar, talonavicular, and calcaneocuboid joints) may be necessary.
At Balance Foot & Ankle, Dr. Tom Biernacki and Dr. Carl Jay diagnose and treat posterior tibialis tendinitis using diagnostic ultrasound, custom orthotics, and surgical reconstruction at both the Howell and Bloomfield Hills offices. Call (810) 206-1402.
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For a complete clinical overview: Ankle Pain Conditions Guide — location-by-location ankle pain diagnosis and treatment
Doctor Answer
What is the difference between posterior tibialis tendonitis and PTTD?
Posterior tibialis tendonitis refers to inflammation of the tendon with pain and swelling along the inner ankle and arch. Left untreated, it can progress to posterior tibial tendon dysfunction (PTTD), where the tendon gradually tears and loses the ability to support the arch, leading to adult-acquired flatfoot. Early tendonitis responds well to orthotics, physical therapy, and bracing. PTTD with significant arch collapse often requires surgical reconstruction.
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.