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Posterior tibial tendonitis and tendinopathy: causes, symptoms, treatment, and prognosis.

What is the posterior tibial muscle and tendon?

The posterior tibial muscle and tendon is located in the inside of the lower leg. It helps point the toes down and move the ankle inwards. It also helps support the arch of the foot.

Posterior tibial tendon pathology can be classified into three categories:

  • Posterior tibial tendonitis is acute inflammation of the tendon. This occurs after an injury or trauma.

  • Posterior tibial tendon tears can occur after severe injuries.

  • Posterior tibial tendinopathy is chronic overuse or overload of the tendon. This usually occurs after prolonged repetitive and overuse activities. Read more about tendinopathy here.

How does posterior tibial tendonitis and posterior tibial tendinopathy occur?

Posterior tibial tendonitis can occur after high impact activities that cause inflammation of the tendon. People with tendonitis can usually pinpoint a specific activity or injury that triggered the symptoms.

Posterior tibial tendinopathy results from repeated stress of the posterior tibial tendon. People with flat feet tend to over pronate. This adds extra stress on the posterior tibial tendon which can lead to tendon dysfunction. Those with posterior tibial tendinopathy tend to have pain that gets worse over the course of days to weeks.

Posterior tibial tendonitis and posterior tibial tendinopathy symptoms

Posterior tibial tendon pain is usually located at the inside of the ankle. Moving the toes downward and inward reproduces the pain. Symptoms can be worse with standing or walking. Prolonged symptoms can lead to a flat arch.

Diagnosis of posterior tibial tendonitis and posterior tibial tendinopathy

Posterior tibial tendon dysfunction can be diagnosed with a thorough physical exam. Swelling may be present around the inside of the ankle. There can be tenderness along the distribution of the posterior tibial tendon. Testing ankle range of motion may provoke pain. Strength testing may also reproduce pain. Performing a heel raise can be painful. It may also feel weaker compared to the unaffected side.

X-rays may be necessary in the setting of injury or trauma to rule out fracture.

Ultrasound can look for inflammation and assess the integrity of the tendon.

Posterior tibial tendinopathy treatment

Initial treatment involves resting and protecting the ankle. Avoid or modify activities that exacerbate pain. Once pain improves, gradually increase physical activity.

Acute pain

  • Icing the area can help reduce pain and swelling. Apply ice 15-20 minutes at a time. Do this every 4 hours for the first two to three days or until pain improves.

  • Oral or topical anti-inflammatory medications can help decrease inflammation and control pain.

  • Prescription nitroglycerin patches can help those with significant pain.

Supportive devices

  • Compression sleeves or ankle braces provide support and comfort.

  • Severe pain may require a walking boot or crutches to help immobilize and offload the ankle.

Persistent symptoms

  • Patients with persistent symptoms may need injections. This study showed platelet rich plasma injections can help tendon healing.

Posterior tibial tendon rehabilitation

The goal of rehabilitation is to return to activity as quickly and as safely as possible. Returning too soon can exacerbate symptoms. It can also weaken the tendon and lead to tendon tears.

A home exercise program will help improve range of motion, stability, and strength. Some people choose to participate in physical therapy. Physical therapists assess, guide, and teach you exercises and stretches. They also individualize a training program for you and your body.

Here is a link to a great example of a home exercise program for posterior tibial tendinopathy:

Try to do your home exercise program twice a day. When pain is severe, focus on stretching and range of motion. Include strengthening exercises as pain improves.

Recovery for posterior tibial tendon problems

Recovery is determined by the duration and severity of the injury. The longer you have symptoms, the longer it will take to get better. Use symptoms as a guide for progression. Avoid using time in days or weeks as a marker for recovery.

Decrease the frequency of your home exercise program as your symptoms improve. For example, if doing the exercises twice a day, decrease to once a day. Do this for about one week.

Many people choose to incorporate these exercises into their weekly workout routine. This can help prevent reinjury as well as maintain strength, mobility, and range of motion.


Disclaimer: Pictures were taken without permission from the Sports Medicine Patient Advisor. They are intended for educational purposes only.


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