Posterior Tibial Tendinopathy

This page has been written to give you the right information about posterior tibial tendinopathy and what you can do to help with your recovery.

Only got a few minutes? Watch our x min summary of this page to get the key information points

What is posterior tibial tendinopathy?

Posterior tibial tendinopathy (PTT) is a condition where you can develop pain and swelling around the inside of your foot, particularly around the inside arch of your foot and the inside of the ankle.

Lady shrugging shoulders to indicate confuion.

Can you explain it a bit more?

Sure.

PTT is caused when a tendon (which attaches muscle to bone) called Tibilias Posterior get irritated. This tendon runs just behind the inside bone on the ankle (called the medial malleolus), across the arch and attaches to the bottom of the foot and is very important for supporting the arch of the foot.

What is a tendon and why are mine irritated?

A tendon is a normal part of your anatomy. Their main job is to connect muscle to bone so that when your muscle contracts (works), it passes the force (or energy) to the tendon and then to the bone, which creates movement.

Tendons are incredibly strong and robust things. This means they are designed to work and sometimes works hard, and they normally do this without any issues. Just like any other body part, they can be trained to work harder if you need them to (i.e. by lifting weights or doing your job), but equally, they can become less efficient at doing their job if you don’t use them.

Tendon irritation can be caused by many things, but in a lot of cases it is normally caused by one of the following:

1. Doing more than you are used to

2. Doing something new or different that you are not used to

3. Doing either of these things but having had a period (sometimes a long time) of doing less before

OK, so what happens to the tendon?

If you think of your tendons as being really good at doing their job (passing the energy from the muscle to bone to create movement), it means they can put up with a lot of work when they need to. If you find yourself doing more than you are used to, doing something you are not used to doing or more importantly, having a period of doing less activity before, you can push your tendon’s ability to cope. Most of the time you notice very little, maybe a bit of an ache here and there, but sometimes your tendons can react and say “I’m struggling”.

If this happens, you will normally notice some discomfort and may find that moving can be uncomfortable. Think of this as your tendon being an ‘unhappy worker’, now struggling to do its normal day job and complaining about the work it has to do. Most of the time the soreness will settle with time, but sometimes it can last a bit longer, maybe into weeks or months.

Man in construction attire sitting on a block with hand on head in defeated pose.

What are the common symptoms of PTT?

Discomfort around the inside of your foot and ankle is the most common symptoms with PTT. Walking, standing or being barefoot can often be a challenge with PTT.

Your foot might feel stiff particularly after a period of rest and when you are taking your first few steps of the day after waking up.

You might find that the foot feels week, especially when trying to rise onto tip toes or if you’re trying to run or jump.

In some cases of PTT,  you might find the inside arch of your foot looks flatter or the rest of the foot looks and feels like it is rolling inwards.

Ok, I think I might have PTT but what can I do about it?

Firstly, you need to know that you can feel better. Sometimes, these issues can be really quite sore and can get in the way of things that you would normally take for granted and can make you feel like you’ll never get better. However, if it hasn’t settled by itself, clinical input can help.

Understanding the issue is often the best place to start. Reading the information above can help you better understand that Achilles tendinopathy is not a damaging or dangerous problem and that it can get better.

Secondly, there are two important things that can help you on your recovery:

1. Calm the problem down

2. Build yourself back up again

What does ‘calm the problem down’ mean?

If you think back to the idea that your irritated tendon is an unhappy worker, then if you keep asking your tendon to do the same job, in the same way that it always has, the tendon will keep being sore. In other words, when something is sore, think of it like your tendons saying “I can’t do that as easily as I used to at the moment”. Making some changes to the things that are sore may help calm the issue down to allow you to move on with your recovery. Think of it as putting the tendon on lighter or amended duties whilst it’s sore.

We have written a whole page on ‘calming things down’ and called it ‘load management. You can find it here, along with some homework to try to help your leg’s recovery: Load Management.  

Can you give some examples of what you mean?

Sure, but remember everyone is different and you will have to do some thinking yourself around how your ankle is affecting you and some of the changes you might need to make.

 

Things that are sore
Why is it sore?
Possible solution

Standing for a long time

Sore tendons will tire more quickly

Try to take more breaks or shift your weight to the unaffected side from time to time

Walking (uphill or fast)

When tendons have to work harder they can tire quickly

Reduce the distance your walk and try and take breaks when able. Choose a different route which isn’t as difficult

Weightbearing after rest

Sore tendons sometimes take time to ‘loosen up’.

Some ankle movements before getting out of bed/following rest could help

Being barefoot

Minimal support will put more work on the irritated tendon

Wearing an ankle boot would be most supportive but a trainer could also help

How long should I work on ‘calming things down’?

This is a little tricky to be specific about and it is probably best to think about what your ankle/ foot is saying. If you have been good at adjusting, modifying and looking at the things that make your ankle sore, then you should notice some changes within a few short weeks.

Does what I wear on my feet make a difference?

Footwear is very important with most issues that affect the foot. If you’re wearing sandals or loose slippers this isn’t going to be providing you much support. It would be better to have ankle boot to support up around your ankle but failing that a supportive trainer. You don’t want a trainer which is very flat or flexible so try to go for something like a running trainer to offer you support.

Ok, what do I do once it feels calmer?

Firstly, well done! Often ‘calming it down’ is the hardest part of your recovery.

Now that your ankle feels somewhat calmer, the temptation might be to start going back to your normal activities in the same way you did before your ankle issue. Sometimes this can be ok, but equally, sometimes you might find that your ankle is not quite ready to return to normal just yet and may get irritated again. It might be best to think that your ankle needs to get fit and strong again in order to get back to doing normal things in normal ways.

As we’ve said before, if you consider your sore ankle as an unhappy worker, then you’ve adjusted and modified things (put it on ‘lighter duties’) to help calm it down. Now you’ve got to start a gradual or phased return to work (or normal). Jumping in at the deep end and going back to normal might result in your ankle becoming grumpy and sore again.

OK, I know I’ve got to build it up and understand it’s got to be done in the right way, but how?

Understanding that it might take some time and that your ankle/ foot will be more likely to cope better if you do things in a gradual way, is very important as the temptation will be to rush in, especially if it’s less sore than before.

No one is the same, just like no ankle/ foot problem is the same as the next, therefore there are no ‘formulas' that will be right for everyone. However, we have provided (below) an exercise programme that, if followed, can be effective to helping you move forwards with your ankle complaint.

A stack of jenga blocks in the shape of steps.

Before I start, I’d like to know what the exercises are trying to do.

Excellent point - it’s often useful to know what you’re aiming to do before you start.

Firstly, the exercises are aiming to introduce a little bit of work into the tendon by asking the muscles to do some work. The aim is to start with only a little bit of work (within what is comfortable) and not much movement.

As you move through the exercises (as your ankle/ foot allows), you will notice that the amount of work/effort and the amount of movement increases.

Lastly, one of the most important things about all of these exercises, is that they are trying to help you regain some trust in your foot. If your ankle/ foot has been sore for some time, it is only normal to be a little cautious when you start to move back into doing things that caused you pain before. This is why the exercises are done gradually and shouldn’t be rushed too much.

What should I expect with these exercises? Will they be painful?

This is a very important question.

If your ankle has been sore for some time, it would be a bit unrealistic to expect that it will be pain-free when doing these exercises. However, it is important that you don’t do too much to then upset the problem all over again.

A good marker for how hard to work is that you should feel some discomfort (not too much though), but it should settle within 24 hours. If you are still obviously sore the following day, you may have done too much/pushed too hard, therefore next time you do the exercises, reduce the effort a bit.

Is there anything I should look out for?

If your foot has changed shape (your foot arch has significantly flattened or your foot/ ankle has started turning inwards) we would encouraged you to Refer Yourself directly to our service

Will it get better?

For most people, foot pain will not be a pleasant experience but reassuringly, it does have the potential to get better. By understanding the issue as best you can and by adjusting what is sore to then allow you to explore some exercise/s, is often the best formula for success.

Dice with arrows and the words 'Step by step' written on them in the shape of stairs.

Frequently asked questions

A: A steroid injection is not usually recommended for the posterior tibial tendon due to the risk of injuring the tendon.

A: Normally, a scan is not needed for a posterior tibial tendinopathy. If required, the GP, podiatrist or physio can arrange this for you. In most cases, scans are only needed if the clinician is considering a different treatment option to the one that you are currently undergoing or if they need to check something. Scans are not offered routinely.  

A: A tendon rupture (where the tendon is injured to the point that it can no longer work properly) is rare. Please refer back to our ‘Is there anything I should look out for?’ section for things to keep an eye on and what to do if you’re concerned.

A: If pain is settling then you can consider starting to get back to normal but this should be done gradually.

A: Tendons can take time to settle and being patient isn’t easy, especially with ourselves. Tendon problems can often take several weeks into months to settle. If you have been really consistent with the ‘calming things down’ and the exercises and things still aren’t getting better then you can Refer Yourself  to our service.

Exercises

Phase 1

Phase 2

Eccentric ankle inversion in side lying

Phase Three

Exs band resisted heel swivels

Exs band resisted inversion

Phase Four

Tip toe raise – tandem

Single leg tip toe raise

Phase Five

Plyometric ankle drills