Tibialis Posterior Tendinopathy: Understanding the Signs, Symptoms and Management
By APA Physiotherapist Ben Howie
Pain along the inside of the ankle or foot is a common complaint among runners, walkers and active individuals. While many people assume this pain is caused by a sprain or plantar fasciitis, another common cause is tibialis posterior tendinopathy.
The tibialis posterior tendon plays an important role in supporting the arch of the foot and controlling foot movement during walking and running. When this tendon becomes overloaded, it can become painful and less tolerant to activity.
Understanding the signs and symptoms of tibialis posterior tendinopathy can help you recognise the condition early and seek appropriate advice before it begins to impact your daily activities or exercise.
What Is Tibialis Posterior Tendinopathy?
Tibialis posterior tendinopathy is a condition involving pain and reduced load tolerance of the tibialis posterior tendon. The tibialis posterior muscle sits deep within the calf, with its tendon passing behind the inside of the ankle before attaching to several bones of the midfoot.
Its primary role is to support the medial arch of the foot, assist with turning the foot inward (inversion), and help control foot motion during walking, running and jumping.
Like many tendon conditions, tibialis posterior tendinopathy develops when the demands placed on the tendon exceed its ability to adapt. Rather than occurring after a single injury, symptoms usually develop gradually over weeks or months as repetitive loading exceeds the tendon's current capacity.
If left unmanaged, ongoing overload may lead to progressive weakness of the tendon and reduced support of the arch, highlighting the importance of early recognition and appropriate rehabilitation.
Common Signs and Symptoms
Tibialis posterior tendinopathy commonly causes pain along the inside of the ankle or foot, although symptoms vary between individuals.
Common symptoms include:
Pain behind or just below the inside ankle bone (medial malleolus)
Pain along the inside of the foot or arch
Tenderness when pressing on the tendon
Swelling around the inside of the ankle
Stiffness when first getting out of bed or after prolonged sitting
Pain during or after walking, running or prolonged standing
Difficulty performing a single-leg calf raise due to pain or weakness
Many people notice that symptoms fluctuate depending on their activity levels. Pain may initially improve as they warm up before becoming more noticeable afterwards or later in the day.
What Can Aggravate Symptoms?
The tibialis posterior tendon works hardest during activities that require the foot to control body weight and support the arch.
Common aggravating factors include:
Running, particularly hills or longer distances
Walking for extended periods
Hiking
Stair climbing
Jumping and landing activities
Prolonged standing
Sudden increases in walking, running or training volume
Returning to activity after a period of reduced exercise
Symptoms often vary considerably between individuals, and activities that aggravate one person may be well tolerated by another.
Who Is More Likely to Develop Tibialis Posterior Tendinopathy?
Several factors may increase the likelihood of developing tibialis posterior tendinopathy, including:
Rapid increases in physical activity
Reduced calf and lower limb strength
Limited ankle mobility
Previous foot or ankle injuries
Higher body weight
Increasing age
Repetitive activities involving prolonged walking or running
Often, multiple contributing factors combine to increase stress on the tendon rather than one single cause.
How Is Tibialis Posterior Tendinopathy Managed?
Management focuses on improving the tendon's ability to tolerate load while addressing factors contributing to ongoing overload. Recovery is usually gradual and requires a consistent rehabilitation approach.
1. Load Management
One of the first steps is identifying activities that are placing excessive demand on the tendon.
This may involve temporarily reducing running volume, limiting hill running, modifying walking distances or adjusting gym exercises while symptoms settle. Complete rest is generally not recommended, as tendons typically respond better to appropriate loading than prolonged inactivity.
2. Progressive Strengthening
Exercise is considered the cornerstone of rehabilitation for tibialis posterior tendinopathy.
A physiotherapist may prescribe a progressive strengthening program targeting:
Tibialis posterior
Calf muscles
Foot intrinsic muscles
Hip and lower limb muscles
Strengthening aims to improve the tendon's capacity to tolerate everyday activities before gradually progressing to higher-demand tasks such as running, jumping or sport.
3. Foot Orthoses
For some people, foot orthoses may help reduce symptoms by decreasing load through the tibialis posterior tendon during walking and standing.
Current evidence suggests orthoses may provide short- to medium-term symptom relief when used alongside an exercise-based rehabilitation program, rather than as a standalone treatment.
Whether orthoses are appropriate depends on the individual and should be determined following a thorough assessment.
4. Addressing Contributing Factors
Management may also include identifying factors that contribute to ongoing tendon overload, such as:
Training errors
Sudden changes in activity levels
Lower limb strength deficits
Reduced ankle mobility
Running biomechanics where appropriate
Footwear considerations
Addressing these contributing factors can help optimise recovery and reduce the likelihood of recurrence.
5. Return to Activity
As pain settles and strength improves, higher-demand activities can be gradually reintroduced.
Return to running, hiking or sport should be based on improving strength, function and symptom response rather than a fixed timeframe. Gradually increasing load allows the tendon to adapt while reducing the risk of symptom flare-ups.
When Should You Seek Professional Advice?
It is worth seeking assessment if you experience:
Pain that persists despite reducing activity
Increasing pain during walking or running
Swelling along the inside of the ankle
Difficulty performing a single-leg calf raise
Progressive flattening of the arch
Symptoms lasting several weeks
Pain that interferes with work, exercise or everyday activities
Early assessment can help identify tibialis posterior tendinopathy before symptoms progress and guide an individualised rehabilitation program.
Practical Tips for Managing Symptoms
If you are experiencing symptoms of tibialis posterior tendinopathy, consider the following:
Reduce activities that significantly increase pain
Avoid sudden increases in walking or running volume
Wear supportive footwear where appropriate
Begin a progressive strengthening program under professional guidance
Maintain general fitness with alternative activities if required
Progress exercise gradually as symptoms improve
Recovery often occurs over weeks to months, and consistency with rehabilitation is usually more effective than trying to push through pain or relying on prolonged rest.
Key Takeaways
Tibialis posterior tendinopathy is a common cause of pain along the inside of the ankle and foot.
Symptoms usually develop gradually and may worsen with walking, running or prolonged standing.
Progressive strengthening and appropriate load management are the mainstays of treatment.
Foot orthoses may benefit some individuals when combined with exercise-based rehabilitation.
Early assessment and rehabilitation can help improve symptoms and reduce the risk of progression.
Understanding tibialis posterior tendinopathy can help you recognise symptoms early and make informed decisions about your recovery. If you're experiencing persistent pain along the inside of your ankle or foot, a physiotherapy assessment can help identify the underlying cause and guide an evidence-based management plan.
References
Alvarez, Richard G., et al. “Stage I and II Posterior Tibial Tendon Dysfunction Treated by a Structured Nonoperative Management Protocol: An Orthosis and Exercise Program.” Foot & Ankle International, vol. 27, no. 1, Jan. 2006, pp. 2–8, 10.1177/107110070602700102. Accessed 19 July 2026.
Gómez-Jurado, Isabel, et al. “Orthotic Treatment for Stage I and Ii Posterior Tibial Tendon Dysfunction (Flat Foot): A Systematic Review.” Clinical Rehabilitation, vol. 35, no. 2, 11 Oct. 2020, p. 026921552096012, 10.1177/0269215520960121.
Milani, Carlo, et al. “Evidence-Based Diagnosis and Treatments of Posterior Tibialis Tendinopathy.” Current Physical Medicine and Rehabilitation Reports, vol. 10, no. 4, 12 Aug. 2022, pp. 273–281, 10.1007/s40141-022-00366-3.
Rhim, Hye Chang, et al. “Characteristics and Future Direction of Tibialis Posterior Tendinopathy Research: A Scoping Review.” Medicina, vol. 58, no. 12, 16 Dec. 2022, p. 1858, 10.3390/medicina58121858.
Ross, M., et al. “Using the International Classification of Functioning to Characterise Tibialis Posterior Tendinopathy.” Journal of Science and Medicine in Sport, vol. 24, Nov. 2021, p. S40, 10.1016/j.jsams.2021.09.103. Accessed 19 July 2026.
Ross, Megan H, et al. “Characterising Tibialis Posterior Tendinopathy Using the International Classification of Functioning, Disability and Health: A Cross Sectional Study.” Brazilian Journal of Physical Therapy, vol. 27, no. 2, 1 Mar. 2023, pp. 100498–100498, 10.1016/j.bjpt.2023.100498.