Posterior Tibial Muscle Tendinopathy

The posterior tibial muscle is a deep muscle located on the back of the lower leg. It turns into a tendon in the lower third of the calf and runs behind the inner ankle bone, continuing to attach to the navicular bone on the inside of the foot.

This muscle and tendon are essential for:

• Turning the foot inward

• Supporting and lifting the arch of the foot

• Controlling foot stability during walking, running, and standing

When the posterior tibial tendon is not working properly, the foot arch may gradually collapse, leading to pain and long-term dysfunction.

What Is Tendinopathy?

A tendon connects a muscle to a bone and transfers force during movement.

Normally, small tendon injuries heal naturally through inflammation, which is the body’s repair process. However, tendinopathy develops when:

• Tendon damage happens faster than the body can repair it

• Recovery time is insufficient

• Overload continues for weeks or months

This leads to chronic irritation or inflammation, pain, and reduced tendon strength.

Causes of Posterior Tibial Tendon Tendinopathy

The most common cause is long-term accumulation of small tendon injuries. When damage repeatedly exceeds recovery, an acute problem turns into a chronic one that may last for months.

Activities that commonly overload this tendon include:

• Ballet

• Figure skating

• Sprinting

• Running and jumping sports

Risk factors include:

• Poor or unsupportive footwear

• Flat feet or postural problems

• Muscle imbalances

• Poor training preparation

• Insufficient recovery

• Faulty movement mechanics

• Systemic and metabolic conditions such as diabetes, gout, rheumatoid arthritis, thyroid disorders, lupus, inflammatory bowel disease

• Overuse of medications

• Dehydration

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Symptoms – Early Signs You Should Not Ignore

The first warning sign is usually pain on the inner side of the ankle. Early on, the pain may feel mild and disappear after warming up, which often causes people to ignore it.

This is dangerous because:

• Continuing activity causes further tendon damage

• Pain relief during movement is typical for inflammatory conditions

• Over time, pain may become constant and even disturb sleep

As the condition progresses, you may notice:

• Clicking or snapping sensations near the inner ankle

• Reduced ankle mobility

• Swelling along the tendon

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Diagnosis

Diagnosis starts with a clinical physiotherapy examination. Typical findings include:

• Pain when standing on tiptoes

• Pain during resisted inward ankle movement

• Pain when the ankle is stretched outward

For imaging:

• MRI provides the most detailed assessment

• Ultrasound (USG) is commonly used due to lower cost and good availability

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Physiotherapy Treatment

Effective physiotherapy starts with removing or modifying the cause of tendon overload.

This may include:

• Improving exercise or running technique

• Reducing training volume

• Temporarily changing or stopping the sport

• Correcting movement mechanics of the foot, ankle, and leg

Short-term pain relief methods (ice, anti-inflammatory medication, physical therapy modalities) may reduce symptoms, but complete suppression of inflammation can slow healing, as inflammation is necessary for tendon repair.

A more effective long-term strategy includes:

• Manual therapy to improve tendon and muscle flexibility

• Restoring proper cooperation between lower-leg muscles

• Progressive strengthening, especially eccentric exercises

• Deep transverse friction massage to improve blood flow and tendon nutrition

  
  

Additional Support Options

In more severe cases, temporary heel lifts may be used to reduce tendon strain. This should never be a permanent solution.

Overall recovery also depends on:

• Hydration

• Sleep

• Nutrition

• General health and stress levels

Medical Treatment Options

If conservative treatment is not effective, additional options may include:

• Nitroglycerin patches

• Shockwave therapy

• Sclerotherapy

• Platelet-rich plasma (PRP) or autologous blood injections

• Growth factor injections

⚠️ Steroid injections, although they can quickly reduce pain, significantly increase the risk of tendon rupture and degeneration and are generally not recommended.

Why This Condition Is Often Missed

Posterior tibial tendon tendinopathy is frequently mistaken for:

• General ankle pain

• Flat foot problems

• Plantar fasciitis

• Nerve-related pain

Proper assessment by an experienced physiotherapist is crucial.

References

1. Targońska-Stępniak B. et al. Tendinopathies. Medycyna po Dyplomie, 2012.

2. Kulig K. et al. Eccentric Exercise for Tibialis Posterior Tendinopathy. AOFAS, 2009.

3. Simpson M. R., Howard T. M. Tendinopathies of the Foot and Ankle. American Family Physician, 2009.

4. Murrell G. A. Understanding Tendinopathies. British Journal of Sports Medicine, 2002.