What is Posterior Tibial Tendon Dysfunction?

Posterior tibial tendon dysfunction (PTTD) is a condition that affects the posterior tibialis tendon that runs along the inside of the ankle and foot. This tendon is responsible for supporting the arch of the foot and helping to stabilize the ankle during movement. If not treated this can progress to a flattening of the foot and in some cases stiffening of the joints.

What are the causes?

The most common cause of a posterior tibialis tendinopathy is compression or overloading the tendon, which if not given time to repair, leads to further injury in use.

Other causes can include:

  • Being Overweight
  • Older age
  • Muscle weakness / flat feet
  • Previous foot injury
  • A sudden change in activity levels
  • Training errors (excessive hill running, lack of conditioning)
  • Side effects of certain medications e.g fluroquinolone antibiotics, prolonged use of corticosteroids.
  • Systemic disease such as Rheumatoid Arthritis, Diabetes, hypertension, high cholesterol.
  • Smoking
  • Moderate alcohol usage

What are the symptoms?

Pain and/or swelling behind the inside of the ankle and along the instep, as this is the path the tendon travels from the leg into the foot. There might also be some occasional burning, shooting, tingling pain as result of inflammation and aggravation of nearby nerve tissue.

There can be difficulty in walking longer distances, with a reduced ability to stand on your tip toes on the affected side.

In posterior tendon dysfunction, the tendon tends to stretch, which causes the foot to flatten leading to an acquired flat foot deformity, often seen in older adults.


Managing weight is important, therefore a balanced, healthy diet is encouraged. This will aid your recovery and long-term health.

See our “Healthy Living” section for more information on local healthy weight services

Activity Modification

Some resting of the foot might provide relief in the early stages, especially if it is inflamed in the area. This will allow the foot to settle to then start your mobility and strengthening exercises. If you are doing activity/exercise, make adjustments to reduce high-impact activity. Although staying active is still encouraged for your health, walking distance might need to be adjusted. If you notice that certain tasks are aggravating your pain, you may need to reduce the amount, intensity or cease all together whilst your foot recovers.

Pain Management

An ice pack can help but be careful not to put ice or heat packs directly on the skin – wrap them with a tea towel cover. Elevate the foot if there is pain and swelling, and a compression bandage may also provide some relief.

Medication such as ibuprofen might interfere with the body’s ability to repair the tendon so paracetamol is preferred.



There is a high need to wear supportive, structured shoes as this will help manage the condition in the early stages and allow a quicker recovery. Changing to comfortable and practical running style trainers /shoes or hiking boots with a slight heel will provide the best support for the tendon.

Very flat-sole shoes with little support will not help. Ladies’ footwear often has harder narrow heels which might aggravate symptoms. If the shoes are overly flexible or offer little stability the soft tissues will be strained further.

Foot Orthotics

Foot orthotics can provide arch support which can reduce the stress upon the soft tissues and help your return to normal function. They will work best in more practical footwear, and it helps to remove the insole liner if they are full length. In flat painful feet foot orthosis tend to have a stiffer support to provide greater stability for the foot.

Insoles for Post Tib Tendonitis – ShoeInsoles.co.uk

Ankle Brace

An ankle foot orthosis is used to support the ankle by an external structure to provide stability. These might be used in tendon dysfunction cases where surgery is not suitable. Here is an example of an ankle brace:

Aircast AirLift PTTD Ankle Brace – ShoeInsoles.co.uk


In severe cases of tendon dysnfunction an offloading boot or cast might be applied to reduce the load on the tissue.


Exercises are used to increase the mobility of the ankle and strengthen the tendon itself.

You may have been assessed by a clinician and this program is a framework to build on; exercises could be added or taken away accordingly. If you have a foot that is stiff and limited in mobility you may struggle with the later phases. Often in older feet osteoarthritic changes may reduce your ability to perform some of the standing functional exercises and doing seated ones might be preferable.

Phase 1

Everyone is different with timelines so do not worry if you spend longer in a phase

Patient status: Pain and difficulty with all activities
Goal: Start to exercise, aim to offer some painful relief in the initial phase.
The following exercises can help with pain in the initial phase, although progression onto stage 2 is advised if these are relatively easy.

Phase 1: Ankle Mobility to Ceiling

  1. Sit down on a chair and cross one leg over the other.
  2. You can stabilize the working leg with your hands.
  3. Rotate the sole of the foot towards the ceiling, for it to face the ceiling as much as possible.
  4. Hold this for 5 seconds then relax and return to a normal foot position.
  5. Repeat for 2mins.

Phase 1: Ankle Mobility Towel

  1. Sit with your foot placed on a towel slightly pointing outwards
  2. Without moving your knee, turn the sole of your foot towards the inside by sliding the towel across the floor. It helps to do this on a smooth floor.
  3. Lift your foot, return to the starting position and repeat.

Phase 1: Towel Grab

  1. Sit up straight in a chair with a towel placed under your forefoot.
  2. Curl and release your toes to pull the towel towards you.
  3. Keep your heel on the ground.
  4. To progress, place a weight on the towel.
  5. Do for 2mins x3 Daily

Phase 1: Isometric Ball Squeeze

  1. Sit with a ball between your feet.
  2. Push the inside of your feet inward and up against the ball.
  3. Relax and repeat do for 2mins 3 times a day.
  4. As a variation, repeat the exercise with a book under your heel and your toes on the floor.

Phase 1: Seated Plantarflexion Elastic Band

  1. Whilst seated wrap an elastic strengthening band around the front of the foot. This can be done with shoes on or off.
  2. By holding the elastic in each hand apply tension by pulling the band towards you and place your leg stretched out in front of you.
  3. Now pushing your foot against the elastic band as far as it can go, hold for 3 seconds then slowly return to the initial starting position. The movement should only occur at the ankle.
  4. 15 repetitions x 3 Daily

Phase 1: Seated Heel Raise

  1. Sit with your knee bent at 90 degrees, feet flat to the floor
  2. Slowly raise both heels off the ground to full height (control rising)
  3. Hold for 3 seconds then slowly lower to the ground.
  4. 15 repetitions x 3 Daily

Phase 2

Phase 2 Goal: Progression from phase 1 – Start of strengthening and tissue adaptation. Now it’s time to start loading. This can sometimes cause pain at the tendon which should settle with rest overnight.

The following exercises can help build tolerance and strength in the tissues

Patient Status: Pain has improved with phase 1 but still struggling with functional tasks. Pain with exercise, morning stiffness, pain when performing heel raises – although tolerable.

Phase 2:  Standing Heel Raise

  1. Stand on both feet hold onto a sideboard or chair
  2. Slowly raise both heels off the ground to full height (control rising)
  3. Hold for 3 seconds then slowly lower to the ground.
  4. 15 repetitions x 3 daily

Phase 2: Resistance Band Ankle Inversion

  1. Sit and attach an elastic to a secure object and loop the elastic around the base of your foot, making sure it’s on the front half of your foot and
  2. Place tension on the band before you start the exercise.
  3. Keep your knee still and your heel in contact with the floor while you turn the sole of your foot towards the inside against the resistance of the band with control.
  4. Return to the starting position slowly and repeat.

Phase 3

Phase 3 Goal: Progression from phase 2 now time for Strengthening and greater tissue adaptation.

The following exercises can help build tolerance in the tissues

Patient Status: Pain has improved with phase 2 but still struggling with functional tasks move onto phase 3 loading.

Phase 3: Single leg Standing Heel Raise

  1. Using one leg raise the heel off the ground to full height. Slow controlled movement is encouraged.
  2. Hold for 3 seconds, then slowly lower the heel to the ground.
  3. Repeat 5 times.
  4. Too add weight place textbook or bag of potatoes in a back pack. Adding weight is important to provide greater resistance.

Single leg heel raise – YouTube

Phase 3: Seated Heel Raise with weighted resistance

  1. Sit with your knee bent at 90 degrees, feet flat to the floor
  2. Add a heavy text book and balance on the knee to provide resistance.
  3. Slowly raise both heels off the ground to full height (control rising)
  4. Hold for 3 seconds then slowly lower to the ground.
  5. 15 repetitions x 3 Daily

Phase 3: Continue Resistance Band Ankle Inversion + ankle mobility exercises in phase 2

Phase 4

Phase 4 Patient status: Handled the phase 3 exercise program, possibly decreased or increased morning stiffness

Goal: Heavier strength training, increase or start more physical activity
To do all phase 3 exercises as 1 set but 3 times a day and with heavier load, 2-3 times/week with the heel raises.

Phase 4: Standing Heel Raise flat surface-Quick rebound

  1. Aim is to add greater resilience and functionality so quick rebound raises will help if you have completed phase 3 pain-free.
  2. Stand on both feet hold onto a sideboard or chair- the aim is to do heel raises quickly
  3. Raise both heels off the ground to full height
  4. Lower to the ground then repeat by lifting the heels off the ground again.
  5. 20 repetitions x 3 Daily


Injections are not normally used in tendons due to the risk of rupture. In some cases the tendon shealth is injected, when this is problematic, but under ultrasound guidance. Often in posterior tibialis dsyfunction there also might be associated joint pain with osteoarthritic changes which might be suitable for an injection treatment.


Surgery is only considered when all other treatments have not worked. Not everybody will be a suitable candidate for surgical intervention so this can be discussed with a health professional.

More than one type of surgery might be offered depending on your foot condition and foot functionality to get the best outcome. It can involve tendon repair, transfer of the tendons in the foot, ligament repair, osteotomy (re-alignment) of the heel bone or a hindfoot fusion in some cases.

There are risks to foot and ankle surgery:

Off-work: There will be a requirement to elevate your foot and rest non-weight bearing then semi-weight bearing.

Infection: The act of surgery is invasive which is also a risk to infection. In some cases, this can delay healing and will require antibiotic treatment.

Delayed Healing: If the blood supply is not so good or you have poor health this might affect healing time. Smoking has been shown to affect healing to bones and soft tissues.

Blood Clots: A small risk of developing a blood clot after foot surgery. Following the pre and post-operative advice will help reduce this risk.

Scarring: Any type of surgery will leave a scar. Occasionally this can cause pain and irritation. If this happens, please discuss this with your consultant.

Metalwork: Occasionally screws or plates can cause pain after surgery. If this is the case, please discuss your concern with your consultant as it may be possible to remove the metalwork once the tissues have healed.

Swelling and Stiffness: The foot can swell as a response to surgery and as part of the healing process. It can take up to six months for swelling to completely settle in some cases. Although in some cases post-surgery there may be increased stiffness in the foot.

Numbness: Can exist in the surgical site if there has been disruption to a nerve.

Chronic Regional Pain Syndrome: Surgery can sometimes result in a swollen, painful and highly sensitive foot. This can be challenging to manage and often patients will be referred to the pain clinic for support.

If you are struggling to manage your foot condition?

Contact your general practice if you need further help and guidance, a referral to local musculoskeletal services is required in some instances, and they can advise on appropriate treatment or pathways suitable to you.

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