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Tibialis posterior tendinopathy

What is it?

Tibialis posterior tendinopathy (also known as tibialis posterior dysfunction) is a common condition. It develops when the tendon of tibialis posterior becomes injured. The tibialis posterior tendon is an important structure that works, with other structures, to hold up the arch of the foot. It runs behind the ankle bone on the inside of your ankle (medial malleolus), across the instep and attaches to the bottom of the foot.

Picture of the right ankle showing some of the muscles that help to support the instep include tibialis posterior

  1. Tibialis anterior
  2. Tibialis posterior
  3. Flexor digitorum longus
  4. Flexor hallucis longus

This is often injured due to the tendon being overloaded. Pain is on the inside of the ankle. This will often cause pain when walking and possibly swelling to the inside of your ankle. This tendon is a load bearing tendon that provides stability and support for the arch of your foot therefore if it is significantly injured and left untreated it can lead to a flat foot.

How to manage it

Modifying activity

Initially resting the foot by reducing weight bearing activity can be helpful in reducing pain and inflammation as well as the use of ice with other simple pain medication

High impact activities such as running and jumping create large forces to be controlled by the load bearing tendons in the foot and are best avoided during a period of active inflammation and pain.

Footwear

Modifications to your footwear with the use of simple insoles and supportive shoes, ankle boots or trainers will help to reduce the loading of the tendon. It is advisable to avoid walking barefooted as this will increase the load on the tendon and may further pain and dysfunction.

See the footwear section for further advice.

Orthotics/insoles

A combination of these exercises and using a support in your shoe will provide support for your arch of your foot.

Here is an example of a medial arch support. These are widely available online and in a number of shops.

Please speak with a health care professional should you need any further advice.

Simple painkillers

Painkillers like paracetamol will ease the pain, but need to be taken regularly in order to control the pain. Always follow the instructions on the packet.

Anti-inflammatories like ibuprofen can help with swelling, and therefore help you move more freely. Topical (applied directly on the affected body area) anti-inflammatories are recommended initially. Follow the instructions on the packet and discuss using them safely with a pharmacist, especially if you have any underlying health conditions

However, you should not take ibuprofen for 48 hours after an initial injury as it may slow down healing.

Up to date guidelines can be found on the NHS website:

Ibuprofen

Paracetamol

Other medicines can help to reduce inflammation, swelling and pain. You should discuss this with your GP if the simple pain relief advice does not help or if you are needing to take ibuprofen for more than 10 days.

Ice or heat therapy 

Heat may be helpful in the form of a hot water bottle, wheat pack or hot shower. This can help to relax the muscles around your ankle and may allow exercises to be more effective.

For ice therapy use a damp cloth containing an icepack (or bag of frozen peas) over the top of the painful area to help numb the pain. Leave it on for up to 20 minutes and use up to three times a day.

  • You should be cautious using these treatments if you have altered skin sensation or circulatory problems.
  • Check the skin regularly during and after the ice pack application
  • Stop if there is excessive pain, numbness or tingling
  • Do not put ice directly on to the skin as this may cause a burn.

Exercises

Treating this condition will involve a combination of approaches that incorporate exercises to strengthen the muscles and tendon and supports.

Click here for a video of strengthening exercises for the tibialis posterior muscle and tendon.

Reducing the tightness in you calf muscles can help the management of tibialis posterior tendon. Stretches for your calf muscles can be found here:

Stand in a walking position with the leg to be stretched straight behind you and the other leg bent in front of you. Take support from a wall or chair.

Lean your body forwards and down until you feel the stretching in the calf of the straight leg. 

Hold approx.  30 secs. relax. Stretch the other leg. Repeat 3 times.

Stand in a walking position with the leg to be stretched behind you. Hold on to a support.

Bend the leg to be stretched and let the weight of your body stretch your calf without lifting the heel off the floor.

Hold approx.  30 secs. – relax. Repeat 3 times.

Click ‘Exercises to stretch tight Gastrocnemius muscles’ and ‘Stretches for tight Soleus muscles’ for a video of the exercises.

Strengthening exercises

Strengthening of the muscles around ankle has been found help plantar fascia pain. Try some heel raises, as shown below, as you pain allows. Start with a small number and gradually build up.

Heel and toe tapping 3 minutes 3 times / day 20 second hold three times 3 minutes 3 times / day.

Stand tall, with your weight distributed evenly on both feet, and take support if needed.

Rise up onto your toes and in a controlled manner return to the starting position.

Repeat 10 times x 3.

Please click here for a video of strengthening exercise for the calf.

Physiotherapy 

If you find that you are not improving, some advice or treatment from a physiotherapist can be helpful in managing ankle pain. Click here to self-refer to a physiotherapist.

How to prevent and manage future flare ups

High impact sports certainly increase exposure of high force loading to the foot and increase risk of injury to tibialis posterior. It is important to build up to these activities gradually, especially if you are new to them.

The condition is more commonly caused by poor footwear and natural age related changes to the tendon that develop with time. It is important to wear supportive footwear to help prevent future flare ups.

Weight gain is considered to be a significant contributing factor into the development of this condition. Maintaining a healthy wait can help in both treating and preventing this condition.

It is not likely that this condition will be treated surgically although this is possible as a last resort.

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