Physical Therapy for Posterior Tibial Tendon Dysfunction
What is posterior tibial tendonitis?
Posterior tibial tendonitis is an inflammation or irritation of the tibialis posterior tendon. There can be an acute circumstance in which there is true inflammation. That typically occurs when an individual suddenly increases the volume and/or intensity of their training. However, we more commonly see posterior tibial tendinopathy, which occurs gradually when an individual is exceeding their tissue capacity over time. This means the tendon is becoming less capable of transferring forces from the muscle to the bone, and pain is experienced.
Tibialis Posterior
Posterior tibial tendonitis pain location
Posterior tibial tendonitis pain is located at the medial (inner) ankle and foot. Patients will point to the area just behind their inner ankle bone (medial malleolus).
Location of Pain of Posterior Tibial Tendonitis
Posterior tibial tendonitis causes
Posterior tibial tendonitis is caused by repetitive stress and small injuries to the tendon due to a sudden increase in activity. When these small injuries within the tendon occur faster than the tendon is able to heal, the tendon weakens and becomes more susceptible to further injury.
Posterior tibial tendonitis or dysfunction usually presents as a progressive collapsing foot deformity where there is insufficiency of the tibialis posterior muscle and tendon with progressive deformity of the foot, including collapse of the medial (inner) arch, and excessive pronation of the foot.
Posterior tibial tendonitis in runners
Posterior tibial tendonitis is a very common injury in runners. The tibialis posterior needs to support the medial arch of the foot and running requires a quick transfer of weight from the rear foot to the forefoot via pronation of the midfoot. Pronation is a normal part of walking and running, but if the runner has excessive, asymmetrical pronation on the painful side, then that may be a contributing factor worth considering.
When a runner suddenly increases volume, they are asking the tibialis posterior muscle to work for longer to control pronation. When the runner increases intensity, it forces the tibialis posterior to work harder and faster to control the rate of pronation of the foot/ankle complex.
That is why our therapists work closely with the running athlete to phase in volume and speedwork safely.
Posterior tibial tendonitis stages
According to this article, there are 4 stages of posterior tibial dysfunction in the most commonly used classification system.
The stages are progressive and based on the severity of symptoms and deformity of the foot and ankle.
These stages help to guide our treatment during rehab.
Stage I:
No deformity
Mild pain and swelling at the medial ankle
Normal heel raise test, but weakness with endurance testing
Normal tendon length
Tenosynovitis present (inflammation within the tendon’s sheath)
Stage II:
Deformity is flexible
Moderate medial ankle and foot pain
Abnormal heel raise test
Increased tendon length
Longitudinal tears in tendon
Stage III:
Deformity is rigid
Severe pain at the ankle and foot, both medially and laterally (outer)
Abnormal heel raise test
Tendon tearing
Stage IV:
Talus (ankle bone) is tilted laterally
Stage IVA: Flexible ankle valgus
Medial arch is collapsed with weight bearing (standing) but not when sitting or tiptoeing
No severe arthritic changes
Stage IVB: Rigid ankle valgus
Medial arch is collapsed regardless of position (remains collapsed with both standing and sitting)
Arthritic changes may or may not be present
Posterior tibial tendon dysfunction recovery time
The recovery time frame for posterior tibial tendon dysfunction will vary significantly depending on whether the injury is a tendinitis or tendinopathy. Posterior tibial tendonitis takes 2-4 weeks for a full recovery with rest from the offending activity. On the other hand, posterior tibial tendinopathy will take at least 3 months of progressive strengthening and reexposure to the offending activity for a full recovery.
Physical therapy for posterior tibial tendonitis
According to this article, most patients (67-90%) with early-stage (stages I and II), posterior tibial dysfunction can be successfully managed non-operatively with physical therapy.
Early treatment for this condition can improve function and quality of life, and may prevent the need for surgery. If treatment begins later at stages III or IV, surgical intervention may be necessary. In these types of cases, our therapists refer to a trusted local orthopedist.
Nonsurgical management is recommended for at least 4 months before surgery is considered, except when there is advanced deformity involved (stages III and IV).
How to treat posterior tibial tendonitis
Treatment usually begins with activity modification, anti-inflammatory medication (as recommended by a medical doctor), and temporary immobilization to decrease symptoms and inflammation.
A walking boot can be used to immobilize the foot and ankle for 3-8 weeks. If immobilization helps, your podiatrist can guide you in transitioning to a custom foot orthosis that supports the medial foot. But any type of bracing should be helpful, according to this article.
You will eventually wean off of the brace, guided by your physical therapist.
This article supports using high-repetition, progressive resisted strengthening exercises of the foot/ankle muscles for treating early stage posterior tibial tendon dysfunction.
Massage for posterior tibial tendonitis
Massage for posterior tibial tendonitis can help to increase blood flow, promote healing, and decrease pain temporarily.
However, it is important to only massage the muscle bellies of the calf and posterior tibialis muscles. Avoid massaging the posterior tibialis tendon itself. Massaging the posterior tibialis tendon is not recommended, as it can make the tendon more irritated.
Posterior tibial tendonitis exercises
Toe Yoga
Runner’s Clocks
Double Legged Calf Raises
Double to Single Leg Calf Raises
Single Leg Calf Raises
Side Stepping / Lateral Band Walk
Single Leg RDL
Glute Bridge Variations
Posterior tibial tendonitis stretches
Seated calf stretch (when symptoms are more irritable)
Standing calf stretch (when tolerated well)
Best shoes for posterior tibial tendonitis
The best shoes for posterior tibial tendonitis will have more cushioning, more medial arch support, and a higher heel drop (10-12 mm).
Here are 3 top shoe recommendations from popular brands:
This shoe only has a 6 mm heel drop but has great medial arch support and cushioning.
Posterior tibial tendonitis taping
Our therapists perform a taping technique for posterior tibial tendon pain in order to temporarily offload the soft tissue that is aggravated. Check it out below:
Running with posterior tibial tendonitis
Running with posterior tibial tendon tendonitis must be managed properly for full resolution of symptoms and a return to running. Our therapists discuss the warm up effect with our runners. This is a phenomenon that suggests painful symptoms decrease as the runner warms up into their run. We advise our runners to walk for at least 5-10 minutes before beginning their run. This gives the tendon a chance to warm up first.
Our therapists also discuss the classic tendinopathy pain monitoring scale. This scale suggests that the runner is allowed to feel pain that reaches a 4/10 during and after the run, provided that the painful symptoms resolve within 24 hours and are NOT worsening from week to week. Tendons need loading to heal. However, too much load prevents proper collagen fiber healing. And too little loading doesn’t stimulate the formation of collagen fibers (and therefore the tendon does not get more resilient to loads/demands placed on it through running).
Closing Remarks
If you are dealing with posterior tibial tendon dysfunction, contact us below to speak with a physical therapist.
Disclaimer: This is not intended to be formal medical advice. Your individual needs should be met by the appropriate health care practitioner. Please consult with a trusted provider.
Dr. Paul Nasri PT, DPT, OCS, COMT
Dr. Vincent Liu PT, DPT
Doctor of Physical Therapy