What it is

Posterior tibial tendinopathy (PTT) affects the tibialis posterior tendon, located along the inner aspect of the ankle, which is the most crucial tendon providing primary dynamic support for the arch of the foot. The tendon also plays a vital role, providing stability during walking and other weight-bearing activities. People often experience pain, tenderness and fatigue in the inside of their ankle and notice their foot rolling inward with longer walks.

Single-leg heel raises become weaker or shorter. Left to progress, posture can drift toward an adult-acquired flatfoot. With early unloading of the tendon and progressive strengthening, control and endurance return.

The prevalence of PTT is notably higher in certain populations, particularly in middle-aged and older adults, individuals with obesity, and those with a history of overuse or repetitive activities that strain the foot. Additionally, factors such as flat feet, diabetes, and hypertension can increase the risk of developing PTT.

What happens when it occurs

Repetitive loading and compression against the medial malleolus irritate the tendon, reducing its ability to support the arch during stance. Chronic injuries may lead to an inability to maintain a proper foot arch, resulting in persistent symptoms that can impact physical activity.

Common causes and risk factors

  • 3-10% of the population
  • Middle-aged and older adults
  • More common in women
  • Prolonged standing and walking on hard surfaces
  • Flatfoot posture, higher body mass (overweight), hypertension or diabetes, smoking
  • Previous ankle injury and reduced calf strength
  • Inflammatory conditions i.e. rheumatoid arthritis, psoriatic arthritis etc

Who is most affected

Middle-aged adults, especially women, walkers, retail and healthcare workers, and recreational athletes returning after a period of time off.

Typical symptoms

  • Pain, tenderness and swelling on the inside of your ankle and arch
  • Loss of single-leg heel raise height (standing on your toes)
  • Fatigue and pain that worsen with longer walks and stairs
  • A popping or clicking sound from the tendon

When to seek care

If pain persists beyond two weeks or if heel-raise weakness develops. Persistent pain that results in difficulty walking.

How we diagnose

History, single-leg heel raise test, hindfoot alignment.

Ultrasound or MRI if rupture or advanced degeneration is suspected.

Management

  • Arch-supporting taping or orthoses to unload the tendon
  • Heavy slow strengthening for tibialis posterior and calf
  • Hip and foot intrinsic work, gait retraining
  • Surgery only for progressive deformity or failed conservative care

Rehabilitation milestones

Phase 1, weeks 0–2: pain control, medial arch support, isometric inversion.

Phase 2, weeks 2–8: heavy slow tibialis posterior loading, calf raises with medial bias, walking endurance.

Phase 3, weeks 8–16: hills and stairs, resisted walking, return to jogging when heel raises are symmetrical.

Phase 4, weeks 16–24: higher-demand activities and change-of-direction tasks.

Readiness to progress

  • Symmetrical single-leg heel raises
  • Medial ankle pain was ≤2 out of 10 the next morning
  • Walking distance target met without flare

Prevention

  • Maintain calf and intrinsic foot strength
  • Rotate supportive footwear
  • Manage standing time and load spikes

Australia snapshot

  • Clinics report a clear female predominance, several times more common in women than in men.
  • Adult-acquired flatfoot most often stems from this condition
  • Occupations with long-standing and walking features heavily

Frequently Asked Questions

Timeframes depend on the grade and your starting capacity. Mild injuries often settle within weeks when loading is matched to tolerance. Moderate injuries take longer to recover from, as strength and control are rebuilt. Severe injuries or those with instability need a longer block and closer supervision. Progress is criteria-based.

Yes, if pain during activity stays at or below 3 out of 10 and does not worsen the next morning. Reduce volume and intensity, maintain a tidy technique, and avoid movements that exacerbate symptoms.

Flare-ups of pain are common. This is when your pain suddenly becomes very bad for a time. Some people have many flare-ups of pain, so it is important to know how best to manage these flare-ups. In most cases, a pain flare-up will settle within 6 weeks. Aim to get a balance between rest and activity. Reduce movements or tasks that exacerbate your symptoms and find positions and movements that alleviate your pain.

Imaging helps when red flags are present, progress stalls after two weeks, or instability or a tear is suspected. Your clinician will advise on whether an X-ray, ultrasound, or MRI is most suitable.

After 2-3 days, you may find that heat is more relaxing than icing. You could use a heat pad or a hot water bottle with an insulated cover. Make sure this is not too hot and is not directly touching your skin. You should do this for 10 to 15 minutes, 3 to 4 times a day.

As early as When next‑morning pain is 2 out of 10 or less, strength is within 90% of the other side, and you pass the functional test for this condition, such as single‑leg hops, figure‑of‑eight runs, or step‑downs.. Prompt assessment ensures accurate diagnosis, early rehabilitation, and reduced risk of secondary complications or prolonged recovery times.

Cut the next session’s volume by 20 to 30 per cent, keep strength work, and retest the following day. Progress again when baseline settles.

They can unload sensitive tissue early. Keep them while strength and control improve, then review fit and need.

Most people continue working on tasks and making standing adjustments. Drive when you can load and move the ankle safely and brake firmly without pain.