Tibialis Posterior Tendonitis

Pain on the inside of the ankle when running? Maybe just at the start and end of a run? Or not even a pain – just a niggle? Don’t overlook it. It could be Tibialis Posterior Tendonitis.

What is Tibialis Posterior Tendonitis?

Well, the Tibialis Posterior muscle is one of the deep calf muscles found in the back of the leg. It helps your Gastrocnemius and Soleus muscles to plantarflex the ankle (i.e. point the foot away, or lift up on to tip toes when standing). It also acts to invert the foot (also known as supinate) – meaning to turn the sole of the foot inwards.

Whilst the belly of the muscle is located deep in the calf, the Tibialis posterior tendonitistendon passes down to run behind the inner ankle bone (medial malleolus). It then travels down below it and on to the Navicular and Medial Cuneiform bones of the foot. It is this area which becomes injured in cases of Tibialis Posterior Tendonitis.

As with many conditions labelled ‘Tendonitis’, this name is now thought to be inaccurate as the ‘itis’ suffix suggests an inflammatory element. Research has shown inflammation to not be the main pathology of the injury. Degeneration of the tendon’s collagen fibres is a more likely culprit. A better term to use when describing this and similar conditions is Tendinopathy.

Symptoms

  • Niggly pain on the inside of the ankle and into the foot
  • Initially at the start of a run and again when finishing
  • Tender to press around the inner ankle bone
  • As it progresses pain lasts longer into runs and may be continuous
  • Discomfort turn the sole of the foot outwards (eversion) as this stretches the tendon
  • There may be some pain on contracting the Tibialis Posterior against resistance in more severe cases – plantarflexion with inversion.
  • The calf muscles may feel ‘tight’ and there may be less dorsiflexion (pulling the foot upwards) than on the other ankle.

Causes of Tibialis Posterior Tendonitis in Runners

As mentioned above, Tibialis Posterior (tib post) acts to plantarflex and invert (supinate) the foot. These are the actions the muscle performs whilst shortening as it contracts. This is known as a concentric contraction.

However, muscles can also perform what’s known as an eccentric contraction and these are much harder work for the muscle and tendon as a unit. What happens with this type of contraction, is that as the muscle contracts, it lengthens. Eccentric contractions occur to help control and slow down a movement against gravity or momentum for example.

So in the case of our feet when running, Tibialis Posterior will act to slow down the movement of eversion (also known as pronation) as we go from heel strike to toe off. So, in those of us who overpronate, or pronate very rapidly – Tib post has to work pretty hard to help control this movement. The result in many cases is degeneration of the tendon.

Treatment

As with pretty much all running injuries, the first step is to rest. Continuing to run on it will only make it worse and mean you need an extended rest period in the long run. However, rest alone won’t be enough. The injury happened for a reason and you need to establish what that reason is and correct it BEFORE returning to running.

In order to help the tendon rest, if you are on your feet all day, I would recommend taping the foot to unload the tendon by reducing the amount of pronation available. Also wearing good supportive shoes will help with this. No flip flops, ballet shoes or Ugg boots please!

So, as mentioned above, Overpronation is one of the biggest causes of this condition. If you already know you overpronate, then consider if you have been wearing the right type of running shoes? Or if you might be overdue a new pair or if anything else has changed in your training and lifestyle which could put extra stress on that tendon. A new job where you walk more maybe? Less supportive shoes on a daily basis?

If you are not sure, or didn’t think you did overpronate, then I would recommend a gait analysis. This will show you how much your pronate and if it is excessive. It may be as simple as a new pair of running shoes or inserts in your current ones.

Strengthening for Tibialis Posterior Tendinopathy

Strengthening is really key to this injury in order to prevent it coming back. And it really is the type of strengthening you are doing that is important. As the tendon is overworked in an eccentric manor, it is this type of contraction you should be working on strengthening.

Tibialis Posterior is a plantarflexor and inverter when it works concentrically, which means that in order to work it eccentrically we must control movements in the opposite direction. This is why eccentric heel drops and eversion on a step are great exercises for this condition:

Eccentric Heel Drop:

  • Stand on a step with the heels hanging off the back
  • Lift up on to the toes (using both legs)
  • Take the weight onto the injured leg only
  • Slowly lower the heel back down below the step under as much control as possible
  • Put the other foot on the step and lift back up onto the toes and repeat.
  • To make it even more specific, you can reduce the effect that Gastrocnemius has by performing this exercise with the knee slightly bent.

Eversion on a Step:

  • Stand sideways on a step so that the inside of the foot is just over the edge
  • Very slowly roll the arch of the foot inwards, as if trying to get the big toe down to the floor
  • Reverse the movement to bring you back up to the starting position.

Resistance (rehab) bands are also good for Tibialis Posterior strengthening as the foot can be moved into inversion to strengthen concentrically and then controlled very slowly back to the starting position to work the eccentric element.

Stretching Tibialis Posterior

Tight calf muscles (and so Tib Post too) can increase the amount and speed of pronation (inversion). Stretching the calf muscles on a regular basis (minimum x3 a day) can really help with reducing pronation whist running.

Make sure you stretch Soleus and Tibialis Posterior by performing a calf stretch with a bent knee. You can also place more emphasis on Tib post by adducting the knee slightly (moving it inwards towards the other leg) when in a Soleus stretch position.

Returning to Running

Only return to running following Tibialis posterior tendinopathy when:

  • you have absolutely no pain day-to-day;
  • It is no longer tender to press around the inner ankle bone
  • There is no pain on stretching or contracting the Tib Post muscle
  • You have addressed any running shoe issues
  • You have seen good improvements in your eccentric strengthening exercises
  • You have full ankle range of motion (especially dorsiflexion with the knee bent)

At this point, you are able to try a very short run. I would advise trying on a treadmill first as they allow you to stop immediately if you do feel any discomfort. When running outside, you need to get back to where you started from so there is always a temptation to just carry on.

Start with a 10 minute jog, provided everything feels ok. Don’t be tempted to do more than this. Then I would always advise you to have at least one full day’s rest to ensure there is no delayed response to the run before trying again – another 10 minute run. If this is ok, try a little longer the next time – 20 minutes max. Continue to increase in this manor whilst continuing exercises. If you feel are recurrence of the injury, then stop immediately and re-assess.

10 thoughts on “Tibialis Posterior Tendonitis

  1. Gordon

    Very interested to read your article on Posterior Tibialis Tendonopathy as the symptoms you describe match my experience very well – developed the condition 18 months ago after ramping up the miles too quickly for a half marathon.
    Are you suggesting that you need to rest until all pain is gone before starting any strengthening exercises? I still have some pain when inverting against an exercise band and don’t know whether to keep going with the exercises or stop and rest further.

    Reply
    1. Heidi Dawson Post author

      Sorry for the slow response!
      You should rest until there is no ‘sharp’ pain. A dull, aching sensation is generally ok, anything more than that is just aggravating the tendon further.

      Reply
  2. Darren

    When I run, the right foot on toe-off turns outwards (like stubbing a cigarette but out action) I’ve tried to improve ankle dorsiflexion but I get a pinching feeling at the talar. I think this is causing all sorts of problems throughout the rest of the chain. Btw there is no pain but it does not feel right and I tried running in sand near the sea tonight to see my footprints and the left one is straight ahead (12 o’clock) and the right one is (about 1 o’clock..maybe a little less) Any ideas why the right side is turning out like this?

    Reply
    1. Heidi Dawson Post author

      Hi Darren. This turning out of the foot is usually due to a restriction higher up the chain. It is the bodies way of compensating for another problem. Common issues are reduced ankle range of motion and reduced hip range of motion. I would suggest you have tight hip external rotators such as Piriformis, which would explain why that foot turns outwards.

      Reply
  3. Darren

    Or it could be a medial ankle ligament impairment (deltoid)…this is normally a source of valgus and rotational ankle instability..I suppose a contribution of abnormalities of the posterior tibial tendon and the spring ligament complex to the rotational or valgus instability of the hindfoot must also be assessed? There is little to no pronation on that side but a rotational instability on toe-off…Your comments are appreciated.

    Reply
  4. Warren

    I am an avid distance runner who has been a running for years. I was finishing up a five mile run. As I was running up a hill I experienced what I thought was a calf cramp. I decided to run through it with less than a 1/4 mile to go. I ended up limping around for the next two days before being able to walk normal again. After resting a couple more days I tried a slow jog but could only go one mile before the calf cramping in the belly of the calf. Quit running for two weeks rode the recumbent bike at the gym with no pain. Tried running again can only go for about four miles with the pain returning in the calf. I have noticed the pain on the inside of my left ankle from the calf down now aches. Does that sound like posterior tibial tendinitis? Thank you for any helpful information.

    Reply
    1. ray

      I am on my second bout of this. The second time came exactly 1 year to the month of my previous one. I did not feel pain in my calf at all. Only in the area under my inside ankle. I thought I had beat this thing or was ill advised. Haven’t run for a month now and I amclimbing the walls.

      Reply
  5. JC

    “Returning To Running” I was diagnosed with P T Insufficiency last year. I did not return to running until I had achieved all 6 of the criteria listed. A year later, almost to the day. The pain returned. I need reconstructive surgery now as my insufficiency has turned to tendonosis. The return came on suddenly and without warning. I was running fine with no pain, the suddenly it came back and I literally hobbled home. That as May 29th. I haven’t run since. Good luck if you get this and be careful. This is to runners like kryptonite is to Superman.

    Reply
  6. Makenzie Cothran

    I’ve had this since February 2015. Over the summer, I stopped running for a month and when I ran a mile, it started hurting the next day. I haven’t ran in about three weeks and the pain is gone. When I ran before I ran a half mile once a week for about a month and it hurt then even when I didn’t have any pain before. Currently, as I’ve said, I haven’t ran in three weeks but I’m scared to run a half mile because I don’t want it to start hurting again. What would y oh recommend? Try running a half mile and then rest a few days and continue or wait a while longer?

    Reply

Leave a Reply