The tibialis posterior tendon runs behind the inside of the ankle and helps control the medial arch during walking and single-leg loading. Tendinopathy can produce pain and tenderness behind the medial ankle or toward the navicular, often with reduced tolerance for walking, running or heel-rise loading.
Posterior tibial tendon pain does not automatically mean the arch is collapsing. Early tendon disease can occur without major deformity, while more advanced cases may become part of progressive collapsing foot deformity, a broader mechanical problem involving the hindfoot, arch, forefoot and supporting ligaments.
At Novo Soft Tissue in the Denver Tech Center, Dr. Scott King first determines whether the tendon is actually the pain generator, then evaluates tendon capacity and foot alignment before selecting progressive loading, temporary mechanical support, shockwave therapy, imaging or referral.
Posterior Tibial Tendon Dysfunction, PTTD and PCFD
The historical term posterior tibial tendon dysfunction (PTTD) is still widely used, but advanced arch collapse is now more accurately described as progressive collapsing foot deformity (PCFD). PCFD reflects a broader three-dimensional failure pattern rather than a problem involving the posterior tibial tendon alone.
A 2020 expert consensus group recommended the name progressive collapsing foot deformity for what had been called adult acquired flatfoot deformity, describing it as a complex three-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction and midfoot varus. The group noted that many, but not all, of these deformities are associated with posterior tibial tendon rupture.
Posterior Tibial Tendinopathy Is Not Automatically a Collapsing Arch
Painful tibialis posterior tendinopathy and progressive collapsing foot deformity overlap, but they are not synonymous.
| Early tibialis posterior tendinopathy | Progressive collapsing foot deformity |
|---|---|
| Pain behind the medial malleolus | Loss of medial arch height |
| Tenderness along the tendon | Hindfoot valgus (heel drifting outward) |
| Pain near the navicular attachment | Forefoot abduction |
| Reduced heel-rise tolerance | Progressive asymmetry between feet |
| Reduced inversion and plantarflexion capacity | Impaired single-leg heel rise |
| Little or no visible deformity | Ligament involvement and, later, rigid deformity |
A naturally low arch is not the same thing as progressive collapsing foot deformity. The concern is acquired or progressive change combined with pain, loss of function or mechanical instability. Once the foot is collapsing, treatment cannot focus exclusively on the tendon because the problem has become a multiplanar mechanical deformity.
Not All Medial Ankle or Arch Pain Is the Posterior Tibial Tendon
- Plantar fasciitis: pain under the inner heel at the plantar fascia attachment, often with first steps after rest. See plantar fasciitis.
- Tarsal tunnel and tibial nerve symptoms: burning, tingling, numbness or pain that radiates into the sole.
- Flexor tendon pain: the flexor digitorum longus and flexor hallucis longus run in the same medial ankle corridor.
- Navicular or midfoot bone pain: focal bony tenderness, a stress or traumatic history, or an unusual load pattern.
- Ankle or subtalar joint pain: joint-line pain, swelling, restricted motion or a previous sprain or injury.
How tendon pain differs from heel and other medial foot pain is explained in posterior tibial tendinopathy vs. plantar fasciitis. Pain behind the outside of the ankle instead is more often related to the peroneal tendons; see peroneal tendinopathy. Pain along the front of the ankle toward the inner midfoot may instead involve tibialis anterior tendinopathy.
What We Examine
- Exact pain location, palpation along the tendon and swelling where present
- Single-leg heel-rise quality and endurance
- Inversion and plantarflexion strength
- Standing foot posture, hindfoot alignment and forefoot abduction, compared side to side
- Walking mechanics and how symptoms respond to load
- Calf capacity and ankle dorsiflexion where relevant
- Neurologic symptoms where the history suggests nerve involvement
Compared with pain-free controls, patients with posterior tibial tendon dysfunction show large deficits in heel-rise endurance, inversion-related strength and arch height. A 2018 systematic review reported pooled standardized differences of −1.52 for heel-rise endurance, −1.19 for forefoot adduction-inversion strength and −1.76 for arch height, along with more self-reported stiffness, foot-related difficulty and social restriction. Not every early-stage patient shows all three deficits, which is why each is measured.
The single-leg heel-rise test is particularly useful because it assesses the tendon’s ability to function under load. In a clinical reliability study it was the most reproducible examination test and had the strongest association with ultrasound tendon changes, although clinical and imaging findings did not perfectly agree. An inability to heel-rise is an important finding, but it does not on its own prove a tendon rupture. Diagnosis is not one test, and it is never made from flat-foot posture or a single imaging finding.
When Is Imaging Needed?
Usually not for early tendon pain that matches the examination. MRI is particularly useful when a significant posterior tibial tendon tear is suspected. A 2024 systematic review found MRI sensitivity up to 95%, specificity up to 100%, and accuracy of 96% for detecting posterior tibial tendon tears. Ultrasound remains useful for tendon assessment, especially when a dynamic and lower-cost examination is appropriate.
Imaging helps answer structural questions, but tendon structure alone does not replace the clinical examination.
How Treatment Is Selected
Load Management
Provocative walking, running or hiking demand is modified where needed. Prolonged complete rest is usually avoided unless there is another medical reason for it.
Progressive Tendon Loading
Progressive loading is the foundation for isolated early tendinopathy. Depending on irritability, it progresses heel-rise capacity, inversion and plantarflexion strength, foot intrinsic function, walking, running and sport demand. In a randomized trial of 36 patients with early-stage disease, all groups improved with orthotic support and stretching, but adding progressive resistance exercise, particularly eccentric loading, produced greater improvement in pain and function.
Temporary or Longer-Term Orthotic Support
Support is used only when the examination shows a mechanical reason for it. It is more useful when hindfoot valgus, arch collapse or progressive collapsing foot deformity meaningfully increases tendon load, and less important when alignment is normal and tendon capacity can be rebuilt without it. Orthotics are selectively indicated rather than automatically prescribed.
When We Use Custom Orthotics
Novo does not prescribe orthotics automatically for posterior tibial tendon pain. When the examination shows meaningful arch collapse, hindfoot valgus or progressive collapsing foot mechanics, external support may reduce load on the tendon while strength and walking capacity are rebuilt.
When custom support is appropriate, Novo uses Sole Supports custom orthotics. They are fabricated through a healthcare provider and can be customized to the patient’s foot, body weight, flexibility, activity demands and footwear. Learn about Sole Supports →
When orthotics help, and when they may not be needed, is covered in when do orthotics help posterior tibial tendon dysfunction?
Radial Shockwave
Radial shockwave may be considered for selected persistent tendon pain. Direct evidence is limited to small case-series-level research, so it is used as an adjunct, not as the automatic first step. Shockwave may be directed to symptomatic tendon tissue. It does not mechanically realign a collapsing foot. Protocol choice, including focused shockwave, depends on the diagnosis and target.
Manual Treatment
Manual treatment may address relevant calf, ankle mobility or adjacent soft-tissue restriction where clinically appropriate. It does not repair the posterior tibial tendon.
Imaging and Referral
Imaging is used selectively. Referral to a foot and ankle specialist is appropriate with progressive collapse, fixed deformity, a substantial tendon tear, major weakness, inability to heel-rise, rapid progression, or when well-structured conservative management fails.
You do not need to decide which treatment you need before your visit. All four tools are compared on the services page, and shockwave at Novo is explained on shockwave therapy in Denver.
What Research Says
- Exercise: a systematic review found a moderate signal favoring eccentric strengthening when combined with orthoses and stretching, but the number of randomized trials was small and exercise prescriptions were poorly standardized (Ross, 2018). Clinical improvement does not require imaging normalization. In a small 10-patient study, symptoms, function and heel-rise performance improved after eccentric rehabilitation despite persistent ultrasound tendon abnormalities (Kulig, 2009).
- Orthoses in early disease: a systematic review of four randomized trials involving 186 patients found that orthoses can reduce pain in early-stage posterior tibial tendon dysfunction. Personalized arch support appeared more effective than flat insoles, and orthoses generally performed better when combined with exercise rather than used as the entire treatment (Gómez-Jurado, 2021).
- Orthoses in PCFD: a 2026 systematic review and meta-analysis of 14 studies in progressive collapsing foot deformity found orthotic interventions improved pain and function and measurably altered foot mechanics, reducing hindfoot eversion by roughly 3–5° (Khaliliyan, 2026). These findings apply to PCFD, not to isolated tendon pain with normal alignment.
- Structured nonoperative care: in a prospective series of 47 stage-I/II patients treated with an orthosis plus structured strengthening, 83% achieved successful subjective and functional outcomes and only 11% progressed to surgery (Alvarez, 2006). The study was not randomized.
- Shockwave: a 10-patient case series combining radial shockwave with foot-core exercise after failed conservative care reported clinically important function gains in 9 of 10 patients for daily activities and 8 of 10 for sport, with no adverse effects observed. With no control group, the effect of shockwave itself cannot be isolated (Robinson, 2020).
Read the posterior tibial shockwave evidence review → · When orthotics help →
Sources: Myerson et al., Foot Ankle Int 2020 · Ross et al., J Foot Ankle Res 2018 · Ross et al., J Orthop Sports Phys Ther 2021 · Rehman et al., Eur Radiol 2024 · Kulig et al., Phys Ther 2009 · Ross et al., BMJ Open Sport Exerc Med 2018 · Kulig et al., Foot Ankle Int 2009 · Gómez-Jurado et al., Clin Rehabil 2021 · Khaliliyan et al., Foot Ankle Surg 2026 · Alvarez et al., Foot Ankle Int 2006 · Robinson et al., J Foot Ankle Surg 2020
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