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Posterior Tibial Tendinopathy: Causes and Treatment

Posterior Tibial Tendinopathy: Causes and Treatment


Posterior tibial tendinopathy is a condition characterized by the dysfunction and degeneration of the posterior tibial tendon, which runs along the inner side of the ankle and foot. This vital tendon plays a crucial role in supporting the arch of the foot and controlling foot movement during walking.

 Understanding the causes, symptoms, and treatment options for posterior tibial tendinopathy is essential for effectively managing this condition and maintaining optimal foot function. This article aims to explore the causes and treatment of posterior tibial tendinopathy, providing valuable insights into managing this debilitating foot condition.

Anatomy of the Posterior Tibial Tendon

The posterior tibial tendon is a critical structure in the lower leg, playing a pivotal role in maintaining the normal foot arch and stability. This tendon originates from the Tibialis Posterior muscle, positioned deep within the calf. It extends downward, passing behind the medial malleolus—the bony prominence on the inner aspect of the ankle—before attaching to the bones of the midfoot.

The primary function of the posterior tibial tendon is to support the arch of the foot during walking and standing. It also aids in the inversion of the foot, allowing the sole to turn inward. The tendon receives its blood supply from small vessels that are susceptible to injury and inflammation, often leading to conditions like tibial tendonitis.

Understanding this tendon’s anatomy is vital for clinicians in diagnosing issues and crafting treatments such as physical therapy or surgical reconstruction when needed.

Causes of Posterior Tibial Tendinopathy

Causes of Posterior Tibial Tendinopathy

Posterior Tibial Tendinopathy, commonly associated with tibial tendon dysfunction, is a condition characterized by pain and impaired function in the posterior tibial tendon. Understanding the causes is crucial to proper diagnosis and treatment.

Overuse and Microtrauma

The most frequent cause of posterior tibial tendinopathy results from overuse and repetitive microtrauma to the tendon. This typically occurs in athletes or individuals engaged in high-impact sports or occupations that place continuous stress on the ankle and calf muscles. Microtrauma leads to small tears within the tendon fibers, resulting in inflammation and pain.


A sudden injury, often seen in high-impact sports like basketball and hockey, such as an ankle sprain or a direct blow to the medial malleolus, can cause significant damage to the posterior tibial tendon. In the realm of hockey, this condition is recognized as one of the most common hockey injuries due to the sport’s physical demands, including rapid direction changes, collisions, and the stress of skating motions. Basketball ankle injuries, in particular, due to the sport’s rapid direction changes, jumping, and landing, heighten the risk of such trauma. This can range from mild inflammation to complete rupture, greatly affecting the tendon’s ability to support the arch.

Age-Related Factors

As we age, the tendons lose some of their elasticity and capacity to handle stress, increasing the risk of tendinopathy. The posterior tibial tendon is no exception, and deterioration can progressively lead to tibial tendon insufficiency, particularly in adults over 40.

Flat Feet (Pes Planus)

An individual with flat feet lacks natural arch support, placing extra strain on the posterior tibial tendon. This can exacerbate or even cause tibial tendon dysfunction over time, leading to the development of adult-acquired flatfoot deformity.

Hypertension and Diabetes

Medical conditions such as hypertension and diabetes can affect the blood supply to the soft tissues, including tendons. A compromised blood supply can delay healing or contribute to the degeneration of the tendon fibers, increasing the likelihood of tendinopathy.


Excessive body weight puts additional strain on the tendons and can lead to overstretching and weakening of the posterior tibial tendon, increasing the risk for tendinopathy.

Inflammatory Diseases

Conditions that cause systemic inflammation, such as rheumatoid arthritis, can affect the posterior tibial tendon, leading to pain, swelling, and a weakened tendon.

Improper Footwear

Shoes that lack proper support can contribute to the abnormal positioning of the foot and excess stress on the posterior tibial tendon, potentially leading to tendinopathy.

Genetic Factors

There may be hereditary aspects that predispose individuals to weaker tendons or issues like flat feet, which in turn can increase the risk of developing posterior tibial tendinopathy.

Signs and Symptoms of the Posterior Tibial Tendinopathy

Pain and Swelling

  • Discomfort inside the ankle, near the medial malleolus.
  • Swelling may be present along the course of the tendon.

Change in Foot Shape

  • The development of adult-acquired flatfoot deformity.
  • Collapse of the foot’s arch, leading to a flatter foot.

Difficulty Walking

  • Challenges with activities that involve pushing off the foot.
  • A tendency to walk on the inner side of the foot.

Inability to Perform the Heel-Rise Test

  • Difficulty or inability to stand on tiptoes on the affected foot.
  • Known as the single heel raise, an indication of tendon dysfunction.


  • Sensitivity to touch along the posterior tibial tendon route.

Decreased Flexibility

  • Limited range of motion in the ankle joint.
  • Stiffness that impedes normal foot movement.

Diagnosis of Posterior Tibial Tendinopathy

Diagnosis of Posterior Tibial Tendinopathy

Diagnosis of Posterior Tibial Tendonopathy typically begins with a thorough physical examination followed by imaging tests.

Physical Examination

During a physical assessment, a healthcare provider will evaluate for tenderness along the Tibialis Posterior tendon, particularly in the area behind the medial malleolus. The single heel raise test is crucial for assessing the function of this tendon, where the patient attempts to stand on the toes of one foot. Difficulty or inability to perform this task can be indicative of tibial tendon dysfunction.

Imaging Test

Imaging tests such as Magnetic Resonance Imaging (MRI) play a vital role. MRIs allow physicians to visualize the inflamed tissues and the condition of the tendon and surrounding soft tissues. Other imaging tests may include ultrasound or X-rays to assess for flat feet or changes to the alignment of the ankle bones.

In a recent study, it was discovered that 67% of participants showed signs of tendinopathy in their tibialis posterior tendons, even though they did not experience any pain in the medial foot/ankle region. Additionally, almost half (48.1%) of the tibialis posterior tendons evaluated through ultrasound examination exhibited such changes. This highlights the importance of imaging tests in determining the prevalence of tendinopathy in individuals with tibialis posterior tendons, suggesting that it may be more common than previously thought.

Treatment Options for Posterior Tibial Tendinopathy

Posterior tibial tendonitis treatment option starts conservatively and may progress to surgical intervention depending on severity.

Physical Therapy: Strengthens calf muscles and the tibial tendon, improving foot mechanics.

Rest and Immobilization: A walking boot or cast helps decrease stress on the tendon, allowing it to heal.

Medications: Anti-inflammatory drugs can reduce pain and swelling.

Activity Modification: Avoiding activities that exacerbate symptoms is recommended, alongside incorporating specific posterior tibial tendinopathy exercises. These targeted exercises are designed to strengthen and stretch the affected tendon, promoting healing and reducing the risk of further injury.

Footwear: Shoe inserts or custom orthotics can provide support for a flat foot, relieving tendon strain.

Bracing: A posterior tibial tendonitis brace may help stabilize the ankle joint and limit tendon movement during recovery.

Surgical Intervention: Considered In severe cases or when nonsurgical treatments fail.

  • Posterior tibialis tendon surgery: Repairs the damaged tendon.
  • Surgical reconstruction: Addresses flat foot deformity or changes in the alignment of the ankle bones.

Prevention Of Posterior Tibial Tendon

Foot Care & Hygiene

Ensuring good foot care and maintaining proper hygiene are essential in preventing posterior tibial tendon dysfunction. This involves regular cleaning, drying of feet to prevent infections, and checking for any signs of inflammation or pain.

Proper Footwear

Selecting the right footwear significantly influences the health of your tibial tendon. Shoes should provide adequate arch support and cushioning, particularly for those with a flat foot predisposition. It’s advisable to avoid high heels or non-supportive shoes that may strain the Tibialis Posterior tendon.

Warm-Up & Stretching

A proper warm-up routine, including stretching before engaging in physical activities, helps maintain calf muscle flexibility and reduces the risk of tibial tendonitis. Specifically, exercises that enhance the range of motion and strengthen the ankle joint and surrounding soft tissues are beneficial.

Risk Monitoring

Lastly, monitoring for risk factors such as obesity, diabetes, hypertension, or steroid use is vital, as these can impact blood supply and lead to a condition known as tibial tendon insufficiency. If you notice any symptoms, consult a healthcare professional promptly.

Experience Effective Relief for Posterior Tibial Tendinopathy at Kendall Performance Physical

Struggling with tibial tendon dysfunction can be frustrating, but help is at hand at Kendall Physical Therapy. Our tailored programs offer relief and restoration, targeting specific symptoms such as ankle pain and flat foot concerns.

At Kendall Performance Physical, we’re dedicated to helping you return to normal foot function and live pain-free.


In summary, effective management of posterior tibial tendinopathy, commonly referred to as tibial tendon dysfunction or tibial tendonitis, hinges on early diagnosis and appropriate treatment. The spectrum of care for this condition ranges from conservative approaches to surgical interventions, depending on the severity and individual patient needs.

Should these nonsurgical treatments prove insufficient in managing tibial tendon dysfunction, an orthopaedic or ankle surgeon can discuss the potential for surgical options. Consistent follow-up and adherence to the treatment plan are vital for a successful outcome in managing posterior tibial tendinopathy.


Can posterior tibial tendinopathy be managed without surgery?

Yes, posterior tibial tendinopathy can often be managed effectively without the need for surgery. Nonsurgical treatments are considered the first line of approach and may include physical therapy, rest and ice, walking boots, and shoe inserts.

How do you fix posterior tibial dysfunction?

Fixing posterior tibial dysfunction involves comprehensive management that starts with conservative treatments and can progress to surgical options if necessary.

How long does it take for posterior tibial tendinopathy to heal?

The healing time for posterior tibial tendinopathy can vary significantly, depending on the severity of the condition and the patient’s adherence to treatment. Generally, nonsurgical treatments may require several months for improvements to be felt. Complete recovery could range from 6 months to a year. Surgical options may lead to a longer recovery period, often necessitating an extensive rehabilitation program post-surgery. It is crucial to maintain ongoing communication with a healthcare provider to monitor progress and adjust treatments as needed.

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Dr. Christopher Kendall PT

Kendall Performance PT

We help athletes and active adults move better, live pain-free, and get stronger to improve the health of our community and provide each client the knowledge to remain healthy and independent the rest of their lives.