Tibialis posterior tendinitis

What is Tibialis Posterior Tendinitis?

The tibialis posterior muscle stabilizes the medial longitudinal arch of the foot and supports the supination (inward rotation) of the hindfoot. Its tendon runs behind the inner ankle and attaches, among other things, to the navicular bone. Tendinitis or tendinopathy describes painful overuse, often with inflammation of the tendon sheath in early phases. Over time, tendon degeneration and lengthening can occur, including partial or tearing. This development is described in stages under the term Posterior Tibial Tendon Dysfunction (PTTD).

• Often associated with running and walking stress, longer periods of standing or after increased training
• Pain and swelling along the tendon behind/under the inner ankle
• Weaker arches up to flat feet in advanced stages

Typical symptoms

• Stabbing or pulling pain on the inside of the ankle, often with swelling
• Stress-related complaints when walking, climbing stairs, going uphill or running
• Morning or start-up pain, improvement after warming up, later also pain at rest possible
• Flattening of the arch of the foot, often increasing wear on the outside of the shoe
• Difficulty or inability to stand on one leg on toes on the affected side
• “Too-many-toes” sign: More toes are visible on the sides from behind (rear foot points outwards)

Causes and risk factors

There is usually a combination of mechanical overload and individual factors that make the tendon more vulnerable. Incorrect loading, unusual training increases or unsuitable footwear are often the triggers. Certain underlying diseases can affect tissue quality.

• Overload: strong increase in training, long periods of walking/standing, working on hard floors
• Foot shape: arched arches, hyperpronation, leg axis deviations
• Footwear: little support, cushioned but unstable, worn shoes
• Systemic factors: older age, female gender, obesity, diabetes, rheumatism
• Previous ankle ligament injuries with instability
• Rare anatomical variants, e.g. B. accessory bone (Os tibiale externum)

Anatomy and function of the tibialis posterior tendon

The tibialis posterior muscle arises from the tibia, fibula and interosseous membrane. Its tendon runs behind the medial malleolus in a tendon sheath and inserts primarily into the scaphoid and other metatarsal bones. It is the most important dynamic stabilizer of the medial longitudinal arch and counteracts excessive pronation. A biomechanically vulnerable area is behind the medial malleolus, where the tendon is strongly redirected.

• Function: arch support, hindfoot supination, ankle plantar flexion
• Synergies: Interaction with calf muscles, sole muscles and ligaments (spring ligament)
• Consequence of weakness: collapse of the arch of the foot, hindfoot valgus, forefoot abduction

Staging (PTTD)

The course of tibialis posterior tendinopathy is divided into four stages. The classification helps with therapy planning and prognosis.

Diagnostics in practice

The diagnosis is based on anamnesis, clinical examination and – depending on the findings – additional imaging. Gait analysis, inspection of the arch of the foot and functional tests are important.

• Clinic: Palpation pain along the tendon, swelling, rubbing (crepitation) possible
• Functional tests: one-legged toe stand, rear foot position, “too-many-toes” sign
• Stress x-ray: assessment of the longitudinal arch and axes, signs of arthrosis
• Ultrasound: Dynamic assessment of tendon sheath, thickenings, partial tears
• MRI: Detailed view if higher-grade degeneration or cracks are suspected
• Differential diagnoses: plantar fasciitis, peroneal tendinopathy, tarsal tunnel syndrome, deltoid ligament injuries, navicular stress reactions

Conservative therapy first

The aim is to relieve pain, restore tendon function and protect the arch of the foot. The therapy is tailored individually to the stage, duration of the symptoms and everyday requirements. In many cases, consistent conservative treatment leads to significant improvement.

• Stress control: reduction of pain-causing activities, change of pace, shorter distances; Pain-adapted walking instead of running
• Cooling in acute phases, short-term anti-inflammatory measures after medical consultation
• Taping or functional bandages for temporary guidance of the rear foot
• Insoles supply: medial longitudinal arch support, UCBL or custom-made insoles
• Stable shoes with heel cap and torsional stability; If necessary, rocker soles
• Physiotherapy: Strength building tibialis posterior, calf and foot muscles, mobility and coordination
• Weight management and optimization of training planning (progression, regeneration)

Cortisone injections into or on the tendon are generally avoided due to an increased risk of rupture. A short-term immobilizing orthosis can be useful in acute, painful phases, but is quickly converted into active therapy.

Physiotherapy and exercises

A structured exercise program strengthens the tendon and improves arch control. Exercises should be pain-adapted, regular and progressive. The following selection serves as a guide and is dosed individually in physiotherapy.

Stress criteria: Exercise pain up to a maximum of 3/10 can be tolerated, but should subside within 24 hours. If symptoms increase, adjust training.

Insoles, shoes and orthoses

Mechanical relief of the tibialis posterior tendon is central. Targeted insoles and shoe advice reduces the peak loads on the tendon and supports the arch of the foot.

• Insoles: medial wedge/longitudinal arch support, correction of the rear foot if necessary; Individual production in cases of significant misalignment
• Shoes: stable heel cap, good torsional rigidity, sufficient width in the forefoot; Rocker soles may be required for longer journeys
• Orthosis (e.g. AFO/Richie Brace) in stage II for hindfoot control; limited in time and combined with training
• Tape/low-dye taping as a short-term aid during sporting or work-intensive phases

Regenerative procedures – carefully indexed

Regenerative approaches such as PRP (platelet-rich plasma) or focused shock waves are sometimes being discussed for tendinopathies. The evidence is heterogeneous and dependent on stage, tissue quality and concomitant factors. We only discuss these options if conservative basic measures have been exhausted for several months and stress tolerance has stagnated.

• PRP: may be considered for chronic tendinopathy; Benefits are individual and not guaranteed
• Shockwave therapy: option for pain modulation in selected cases
• Important: realistic goal setting, combination with structured training and mechanics correction

When does an operation make sense?

Surgical procedures are considered if conservative therapy does not bring sufficient improvement over a sufficiently long period of time or if there is advanced structural damage. The choice of procedure depends on the stage and individual anatomy.

• Stage I–II: tendon sheath revision/debridement, if necessary tendon suture or augmentation
• Stage II with malposition: combination of tendon replacement (often transfer of the flexor digitorum longus) and bony corrections (e.g. medializing calcaneal osteotomy), if necessary spring ligament reconstruction
• Stage III: Joint stiffening in the hindfoot (arthrodesis) with rigid flat feet and osteoarthritis
• Stage IV: additional stabilization of the upper ankle joint or deltoid reconstruction

We provide neutral advice on opportunities and risks and plan follow-up treatment with a focus on safe mobilization, gradual increase in load and long-term function.

Course and prognosis

With early diagnosis and consistent conservative treatment, symptoms often improve within 6-12 weeks; stabilization of the tendon usually takes 3-6 months. The longer symptoms persist and the further the stage is, the longer the rehabilitation will be. Persistent risk factors (e.g. unsuitable footwear, untreated misalignments) increase the risk of relapse.

• Early stages: good chances of reducing symptoms with insoles, orthoses and training
• Advanced stages: longer course, some structural measures necessary
• Regular follow-up helps to avoid over- or under-treatment

Prevention and everyday tips

• Increasing the load in sport slowly and systematically, especially when running
• Replace sturdy footwear in a timely manner; Use individual insoles consistently
• Regular foot and calf strength training (“Foot Core”)
• Check your workplace: interrupt long periods of standing with micro-breaks and variable loads
• Weight management and compensatory training (e.g. cycling, swimming) to relieve stress
• Take early warning signals seriously and temporarily reduce stress

First aid for acute complaints

• Activity adjustment: reduce steps that cause pain, choose flat terrain
• Cool briefly, protect skin; Elevate if there is swelling
• Temporary tape/bandage for better guidance
• Gentle isometric exercises instead of complete immobilization
• Make an appointment early for clarification and insoles/shoe advice

When should you see a doctor?

• Sudden shooting pain with an audible clicking sound and significant loss of function
• Increasing misalignment or rapidly flattening arch of the foot
• Severe pain at night when resting or persistent swelling
• Redness, overheating, fever or problems with wound healing
• Unsteadiness when walking, repeated twisting

Your orthopedics in Hamburg-Winterhude

In our practice at Dorotheenstrasse 48, 22301 Hamburg, we clarify inner ankle and arch pain in a structured manner. We combine clinical examination with modern imaging and create an individual therapy plan with a focus on conservative measures. Appointments can be easily arranged via Doctolib or by email.