Posterior Tibialis Tendinopathy

Why you need to treat this cause of ankle pain with extra care.

What is a posterior tibialis tendinopathy?

A posterior tibialis tendinopathy (PTT) is when damage occurs to one of the tendons that runs on the inner side of your ankle. (Tendons are cords that attach muscle to bone.) It is also known as a medial ankle tendinopathy and non-achilles ankle tendinopathy.

The posterior tibialis tendon attaches to several bones, including a bone on your inner foot just above your arch.

You probably won’t even remember injuring (trauma) your ankle or foot. Instead, you may notice over several weeks slowly increasing pain and/or swelling along the tendon. There are many causes, including too much physical activity without enough rest. Depending on the amount of damage, you may need surgery.

What is causing your symptoms?

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What does a posterior tibialis tendon tear feel like?

Dr. Rx

Ask your doctor: If I follow your treatment plan, how long will it take me to improve without surgery? If this doesn’t work, what would require me to have surgery? —Dr. Bradley Graw

Pain and/or swelling that gets worse over several weeks. Generally, it would be along the inner ankle and inner foot—where the posterior tibialis tendon is.

This tendon allows you to turn your foot inward and downward. And it helps to maintain the arch in your foot. With a PTT, your foot may turn outward. The arch of your foot may collapse.

A PTT is often confused with an ankle sprain because they happen in the same area. The key difference is that ankle sprains are caused by an immediate injury to the ankle, whereas PTTs tend to happen over several weeks.

Main symptoms

  • Pain and/or swelling along the inner ankle and/or inner foot.
  • Foot turning outward when standing and/or walking.
  • Arch of foot may collapse.

Other symptoms you may have

If your foot begins to turn outward and/or if the arch of your foot collapses, you may have pain on the outside of your ankle and/or foot.

Next steps

If you can walk on your foot, make an appointment with your primary care doctor. Try to rest your foot by limiting physical activity. Use ice and elevate your foot. You can also take over-the-counter nonsteroidal anti-inflammatories to reduce pain and inflammation.

If you can’t walk on that foot, and you have severe pain around the inner ankle and foot bone, try to see your doctor immediately, or if after-hours, go to the emergency department.

Posterior tibialis tendinopathy causes

A PTT is caused by too much stress on the posterior tibialis tendon. This can be caused by wearing shoes that don’t fit, poor running form, not letting the foot rest enough, or being obese. Or your body is less able to repair the tendon on its own (because of repetitive stress that weakens the tendon over time, chronic health conditions, smoking, aging, etc.).

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Risk factors

You are more likely to have a PTT for the following reasons:

  • Overusing your ankle due to constant high-impact sports without rest.
  • Ankle trauma that is not recent: Some people recall twisting their ankle several weeks before noticing pain.
  • Wearing shoes that don’t fit properly.
  • Poor running form.
  • Obesity puts extra strain on tendons.
  • Smoking can weaken tendons and affect healing.
  • Older age.
  • Certain medical conditions can interfere with the healing of tendons and make you more prone to this type of injury: rheumatoid arthritis, gout, diabetes mellitus, and connective tissue disorders (like Marfan syndrome or Ehlers-Danlos syndrome).

What is the treatment for posterior tibialis tendinopathy?

Pro Tip

Having PTT doesn’t mean you need surgery. Most people do well with non-operative treatments including shoe changes, orthotics, and new habits. It takes patience to allow the PTT to heal—and new habits to keep it from recurring! —Dr. Graw

Treatment depends on the severity of the injury. It’s important to see a doctor (an orthopedist who specializes in bone issues) to confirm a diagnosis. Your doctor may perform an ultrasound to help diagnose a PTT. An ultrasound uses sound to take images of the inside your ankle and foot.

If you can still stand on your hurt foot and raise your heel off the ground (single heel rise), you can be treated without surgery. Rest your foot, take over-the-counter pain medications (Tylenol, ibuprofen) as needed, and try a shoe insert to support your arch. Your doctor can prescribe physical therapy to strengthen the supporting muscles. But if your pain doesn’t improve in 3 to 6 weeks, you may need to see an ankle and foot surgeon.

For severe pain, your doctor may recommend that you wear a removable boot for 4 to 6 weeks. A boot is a large protective shoe that decreases the force on your tendon while you walk. If you have completely torn your tendon (posterior tibial tendon rupture), then you will probably need to see an orthopedic surgeon specializing in foot and ankle issues. They will likely order an imaging test—an MRI—to confirm that you have a complete tear.

Posterior tibialis tendon surgery

An incision (cut) will be made in the back of your lower calf. The torn tendon may be replaced with a tendon from another part of your body. Afterward, your foot and ankle will be placed in a splint for 4 to 6 weeks. You will probably go home after your surgery.

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Follow up

Pro Tip

There isn’t a one-size-fits-all treatment. You need to get a diagnosis from a foot and ankle specialist. —Dr. Graw

If you had surgery, try not to put weight on your foot for several weeks after the surgery. Your doctor will remove the splint after two weeks to check the wound and then may make a new splint or cast. Complete recovery may take several months. Physical therapy can help with recovery.

If you are treating yourself, your doctor will probably ask to see you again after 3 months. You should probably not participate in physical activities that are aggravating or painful during that time. And do physical therapy. If your pain gets worse, set up an earlier appointment with your doctor.

Prevention

  • Prevention may require activity modification, shoe modification, and an exercise program.
  • Gradually increase exercise intensity or frequency.
  • If you have conditions such as diabetes or are obese, try to control your blood sugars and maintain a healthy weight.
  • Quitting smoking can also help.
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