Quick Summary
Posterior tibial tendon dysfunction (PTTD) causes pain and swelling on the inside of your ankle and foot as the tendon that supports your arch gradually weakens, which over time can allow the arch to flatten.
It is one of the most common causes of adult-acquired flatfoot, and research suggests that early, well-structured physiotherapy gives you the best chance of settling symptoms and protecting the shape of your foot.
At J&J Therapy we combine hands-on treatment with a progressive strengthening programme, and most people attend for an initial course of around 6–12 weeks of guided rehabilitation, with review as you progress.
What Is Posterior Tibial Tendon Dysfunction?
The tibialis posterior muscle sits deep in your calf, and its tendon runs down behind the bony bump on the inside of your ankle (the medial malleolus) before fanning out to attach to several bones in the middle of your foot. Its main job is to support and lift the inner arch of your foot, and to help you rise onto your toes and push off when you walk, run or climb stairs.
PTTD develops when the load placed on this tendon repeatedly exceeds what it can tolerate. Early on there can be genuine inflammation of the tendon lining, but the more important and longer-lasting problem is tendon degeneration: the collagen fibres become disorganised and the tendon thickens and weakens rather than simply being inflamed. This is why rest alone rarely resolves it, and why gradual loading matters so much. As the tendon weakens it can lengthen and, in later stages, partially or completely tear, allowing the arch to collapse.
The four stages, in plain terms
• Stage I — The tendon is painful and possibly inflamed but still its normal length, and the shape of your foot looks normal. You can usually still rise onto your toes, though it may hurt.
• Stage II — The tendon has stretched and weakened and the arch has begun to flatten, but the foot is still flexible and the flat shape is not yet fixed. This is the stage most commonly seen in clinic.
• Stage III — The flatfoot has become rigid, with the joints stiffened into the flattened position.
• Stage IV — The ankle joint above the heel is also affected and tilts, with associated arthritis.
Stages I and II generally respond well to conservative care, whereas Stages III and IV involve fixed structural change and are usually surgical decisions. PTTD is common but frequently under-recognised: a survey of 1,000 women over 40 in England found a prevalence of symptomatic stage I–II PTTD of 3.3%, with every affected patient undiagnosed despite characteristic and prolonged symptoms.
(Kohls-Gatzoulis et al., Foot and Ankle Surgery, 2009; Ross et al., BMJ Open Sport & Exercise Medicine, 2018)
Do You Experience These Symptoms?
✓ Pain and often swelling along the inside of your ankle and the instep of your foot, especially behind the ankle bone
✓ Pain that worsens with prolonged standing, walking, running or going up on your toes, and eases with rest
✓ Difficulty, weakness or pain when trying to rise onto the toes of one foot
✓ A gradual flattening of the arch, or a foot that looks like it is rolling inwards, sometimes only on one side
✓ A “too many toes” appearance — more toes visible from behind on the affected side as the forefoot drifts outwards
✓ Aching or fatigue in the foot and inner lower leg after activity
✓ In later stages, pain that shifts to the outer side of the ankle as the heel drifts into a flattened position
These symptoms can be treated.
The sooner you begin, the better your chances of a smoother recovery.
What Causes Posterior Tibial Tendon Dysfunction?
• Repetitive overload and overuse
Most cases build up gradually rather than from a single injury, as walking, running or standing loads repeatedly exceed the tendon’s current capacity.
This is common in runners increasing mileage too quickly and in people whose work involves long periods on their feet.
• Age-related tendon degeneration
With age the tendon loses some of its elasticity and its ability to glide and repair, making it more vulnerable to injury.
This is one reason PTTD is most common in adults over 40, and particularly in women, in whom it occurs around three times more often than in men.
• Raised body weight and biomechanical factors
Extra body weight and a pre-existing flatter or over-pronated foot increase the strain the tendon must resist with every step.
Together these factors can push an already-loaded tendon past its tolerance.
• Medical and inflammatory conditions
Diabetes, high blood pressure and inflammatory conditions such as rheumatoid arthritis are associated with a higher risk of tendon problems.
These can reduce the tendon’s blood supply and resilience, accelerating degeneration.
• A sudden increase in load, or trauma
A rapid rise in training, an ankle injury or a slip that overstretches the tendon can trigger or accelerate symptoms.
In a tendon already weakened by degeneration, a relatively minor event can be enough.
How We Treat Posterior Tibial Tendon Dysfunction at J&J Therapy
Hands-On Manual Therapy
Our physiotherapists use hands-on treatment to help settle your symptoms and restore movement while your rehabilitation takes effect. This may include soft-tissue work to the calf and deep posterior compartment, gentle mobilisation of the foot and ankle joints to maintain mobility, and guidance on taping and footwear to offload the tendon during the early painful phase. Manual therapy is not a stand-alone solution for PTTD — evidence shows the tendon needs progressive loading to recover — but it is a valuable way to reduce pain and help you move more comfortably so you can engage fully with your exercise programme.
Shockwave Therapy*
Swiss Storz Medical MASTERPULS radial shockwave may complement your manual therapy and exercise programme when your physiotherapist identifies specific indications during assessment. It is not a first-line treatment here: direct research evidence for this particular tendon is currently limited to small case series, although shockwave has a stronger evidence base in related conditions such as Achilles tendinopathy and plantar fasciitis. Where we do consider it, it is offered in earlier-stage cases that have not responded to strengthening and orthotic support, always alongside your loading programme rather than instead of it. It is not suitable where the tendon has ruptured or where the flatfoot has become fixed and rigid. Non-invasive, and always assessment-led.
Targeted Exercise Programme
A progressive loading programme is the core of PTTD recovery, and evidence shows that strengthening the tibialis posterior is central to improving pain and function. We begin by managing load — temporarily reducing the activities overloading the tendon while keeping you as active as possible — then build strength through resisted inversion and slow, controlled heel-raise work, progressing from double-leg to single-leg heel raises as your symptoms allow. Alongside this we add foot intrinsic and arch-control exercises, calf flexibility work where the calf is tight, and single-leg balance training to restore the tendon’s role in controlling your foot when walking and running. Medial arch supports or custom orthoses are frequently used alongside the programme to reduce strain on the tendon, and we advise on footwear as part of your plan before grading you back to your usual activities.
When to Seek Urgent Medical Help
While most symptoms are not serious, urgent medical attention is required if you experience any of the following:
You suddenly cannot rise onto the toes of the affected foot, or you feel a sudden give-way, pop or sharp loss of your arch — this may indicate a tendon rupture.
Your arch is rapidly flattening or collapsing, or your foot is becoming increasingly deformed and stiff.
You notice signs of infection (spreading redness, heat, fever) or of a blood clot (calf pain, swelling, warmth and redness in one leg) — seek same-day medical care.
You have severe, unremitting pain, or numbness, pins and needles or weakness spreading into your foot.
FAQs About Posterior Tibial Tendon Dysfunction
Can posterior tibial tendon dysfunction heal without surgery?
In its earlier stages, yes. Research suggests most people improve well with conservative treatment such as activity modification, orthoses and a progressive strengthening programme, and surgery is usually only considered when several months of good non-surgical care have not helped, or when the deformity has become fixed. Because the condition is progressive, the earlier you start appropriate treatment, the better your outlook.
Do I need orthotics or insoles?
Often, yes. Medial arch supports or custom orthoses are commonly used alongside exercise to reduce strain on the tendon and support your arch, and evidence shows they are a mainstay of early management. Our physiotherapists will advise whether an off-the-shelf or custom support suits your foot and your stage.
How long does recovery take?
It varies. Milder cases may settle over roughly 6–12 weeks with consistent rehabilitation, whereas more established, degenerative cases can take several months, because a degenerative tendon remodels slowly. Sticking with your loading programme and load-management plan is the single biggest factor within your control.
Should I keep walking or running?
You do not usually need complete rest, but you do need to manage load. We help you modify rather than simply stop your activity, so the tendon is not repeatedly overloaded — often reducing running temporarily and substituting lower-impact exercise, then grading you back up as your symptoms and strength allow.
Will shockwave therapy help my posterior tibial tendon dysfunction?
It might, in selected cases, but it is not a first-line treatment and we assess suitability individually. The direct research evidence for shockwave in this specific tendon is currently limited to small case series rather than large trials, although it has a stronger evidence base in related conditions such as Achilles tendinopathy and plantar fasciitis. Where it may help is in earlier-stage cases that have not responded to strengthening and orthotics, always as an addition to your exercise programme rather than a replacement for it. It is not suitable where the tendon has ruptured or the flatfoot has become rigid.
This page is for general information only and does not replace professional medical advice.
Reviewed by Lavya Arigalayan, MSc, HCPC Registered Physiotherapist.
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