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Dancers, especially women, are prone to Posterior Tibial Tendonitis, an overuse injury

What is Posterior Tibial Tendonitis or PTTD? What Can I Do about It?

Luke Ferdinands

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What is Posterior Tibial Tendonitis (or PTTD), and what can I do?

Posterior Tibial Tendonitis (PTT), also known as Posterior Tibial Tendon Dysfunction (PTTD), is a condition that goes by many names and can cause significant pain and limit mobility. It's a relatively common condition affecting 3-10% of the population. However, a lot of people who visit the in-person physical therapy practice of Luke, our co-founder, don't know they have it until they work with him, because Posterior Tibial Tendonitis is very much underdiagnosed.


Understanding this condition, its causes, risk factors, and symptoms can help you manage and treat it effectively, regardless of what you call it. Let's dive in, so you can leverage effective at-home PTTD treatments to take control of your recovery.

So many names for one foot and ankle pain condition

Posterior Tibial Tendonitis is a condition with multiple names, each highlighting different aspects of the same injury and its impact on the foot and ankle. The posterior tibial tendon maintains the arch of the foot. When this tendon becomes inflamed or damaged, it can lead to a host of structural problems in the foot.


Posterior Tibial Tendon Dysfunction (PTTD) refers to the dysfunction of the posterior tibial tendon. When this tendon cannot perform its role properly, the arch of the foot can collapse, leading to what’s often termed as Flatfoot or Adult Acquired Flatfoot Deformity (AAFD). This arch collapse can make the foot appear flat or fallen, hence the terms Fallen Arches or Flat Feet.

Posterior Tibial Tendonitis can cause overpronation of the foot

Another term, overpronation, is a more general term that describes the inward rolling of the foot when walking or running. Overpronation is a common symptom of posterior tibial tendon dysfunction. (As an independent condition, it's also a risk factor for Posterior Tibial Tendonitis.) This inward roll can exacerbate the condition and lead to further problems throughout the chain of movement, like knee pain, if not addressed.

Mechanism of Posterior Tibial Tendonitis

The posterior tibial tendon is essential for maintaining the arch of the foot and providing shock absorption and stability when walking or running. This tendon runs along the inside of the ankle and helps with the push-off phase of the gait cycle.


However, when the posterior tibial tendon is injured or inflamed, its ability to support the arch diminishes. As a result, the arch can flatten or collapse, leading to decreased shock absorption and increased strain on other parts of the foot and ankle. This additional strain can cause pain and discomfort as the muscles and tendons work harder to compensate for the compromised posterior tibial tendon.

What causes Posterior Tibial Tendonitis?

We've learned that PTTD happens when the posterior tibial tendon (or tibialis posterior tendon) is damaged or inflamed. But how does that happen?


Essentially, Posterior Tibial Tendonitis is an overuse injury, where repetitive stress placed on a tissue leads to soft tissue injury. At the most basic level, the cause of Posterior Tibial Tendonitis is simple: it's a mismatch between load and capacity.


When you have a weak point somewhere in the kinetic chain that goes from your foot all the way up to your hip, the tibialis posterior tendon has to work harder to support the load with every step you take. When that load exceeds the capacity of the tendon, it develops microtears and inflammation, which leads to pain around the tendon, typically felt inside the ankle.

Fallen arches due to PTTD

Top 4 causes of PTTD

Several factors can contribute to the development of PTTD. If you think of the root cause as the load and capacity mismatch, the list should make sense. Common causes of Posterior Tibial Tendonitis include:

  1. Increased Activity: Longer hours on your feet due to job change, or more frequent running to train for a race can overwork the tendon.
  2. More Intense Activities: Pursuing high-impact sports or activities or increasing the intensity without proper conditioning can strain the tendon beyond its capacity.
  3. New Activities: Sudden changes in your activity level, like walking hours on uneven surfaces during a vacation or picking up a fun new sport, can trigger PTTD.
  4. Weight Gain: Increased body weight puts additional stress on the posterior tibial tendon, making it more susceptible to injury. Studies have found that a 25-lb weight loss (granted, this is no easy feat!) can relieve pain by 30% - imagine the impact if the scale was tipping the other way.

Risk factors for Posterior Tibial Tendonitis

Understanding the risk factors can help you prevent and manage PTTD. You might be at higher risk if:

  • You tend to walk on the inside of your feet: This gait pattern (overpronation) can strain the tendon. The telltale sign of overpronation is extra wear on the inside of your shoes.
  • Your knees come together (Knock Knees): This alignment issue not only exacerbates overpronation but also increases the stress on the posterior tibial tendon.
  • You have low or no arch: A naturally flat foot places more demand on the tendon to absorb the shock and stress.
  • You are overweight or recently gained weight: Excess weight increases the load on your feet, especially if your weight gain didn't come with a corresponding increase in strength.
  • You stand for long periods at work: Jobs that require prolonged standing, such as nursing, teaching, or factory work, can overburden the tendon.
  •  Your activity levels increased or you took up a new activity recently: Sudden increases in physical activity can trigger PTTD.

How to tell if it's Posterior Tibial Tendonitis or PTTD

Figuring out if you have Posterior Tibial Tendonitis can be tricky even for podiatrists and physical therapists, but here are some clues to see if your foot or ankle pain is from PTTD:

  • Take the Foot and Ankle Pain Quiz: We built the quiz so you can pick the right treatment for you, using the tried-and-true diagnostic tools from physical therapy.
  • Pain Location: Focus on where the pain is most intense. Pain inside the ankle, usually below it, suggests PTTD.
  • Heel Raise Test: Trying to raise your heels off the ground while standing can indicate PTTD, if you feel pain or have difficulty performing the movement. Watch the video to see how to perform this test.

Telltale symptoms of Posterior Tibial Tendonitis

Recognizing the symptoms of PTTD early is key to finding the right treatment and avoiding progression of the condition. If you are seeking a healthcare professional's help, it can be especially helpful, since this is a condition that your doctor or PT may overlook or misdiagnose.


Look out for these three telltale signs:

  • Burning sensation or dull ache on the inside of your ankle: This pain usually occurs below the ankle but can extend above it. The discomfort may be persistent or come and go.
  • Worsening pain after activity: The pain tends to get worse after being active for a while, especially after prolonged walking or standing.
  • Increased discomfort when going uphill or up stairs: Activities that put more strain on the tendon through push-off movements, like climbing stairs or walking uphill, often exacerbate the PTTD pain.
  • Swelling around the ankle: Inflammation associated with Posterior Tibial Tendonitis often causes fluid accumulation and swelling around the ankle. This restricts the smooth movement of the tendon, worsening the pain and further reducing function.

What should you do about Posterior Tibial Tendonitis?

The gold standard of non-invasive, active treatment for Posterior Tibial Tendonitis incorporates four components that work together:

  • Load management: Wear a brace to help maintain the arch and reduce the load that the injured tendon has to support
  • Venous return: Wear compression socks to encourage fluid drainage and reduce ankle swelling
  • Progressive strengthening: Gradually increase strength throughout the kinetic chain by following a program of eccentric strengthening exercises
  • Soft tissue mobilization: Massage the small muscles and tendons that support the arch to reduce pain, release tension, and encourage the growth of healthy tissue

This is the basis of the Alleviate Method, developed to bring the effective treatment methodology and tools to everyone's home. Our PTTD System uses the Alleviate Method to get you back to doing what you love, without a visit to a doctor's office. Check it out, and let us know if we can answer any questions!

Key Takeaways

Repetitive Stress Injury: Posterior Tibial Tendonitis (or PTTD) is a chronic pain condition that affects the tibialis posterior tendon. It develops when the tendon is subjected to more load and stress than it can handle.

Risk Factors: Being on your feet for long periods of time, weight gain, low arch, overpronation, and increase in your activity level can trigger this condition.

Symptoms: PTTD pain often feels like a dull ache inside of your ankle, or a burning sensation. It usually gets worse after activity, and going uphill or up stairs feels worse than walking on a flat surface. You might have swelling around the ankle, too. 

Treatment: Physical therapists use a four-pronged approach to treat Posterior Tibial Tendonitis. Alleviate PTTD System replicates this gold standard of PT treatment with a support brace, medical-grade compression socks, a PTTD exercise program, and a deep tissue foot massager.

Luke Ferdinands, physical therapist and Alleviate co-founder

Luke Ferdinands, Physical Therapist & Co-Founder


A New Zealand-trained physical therapist with over 20 years of experience, Luke developed the Alleviate Method to bring the gold standard of physical therapy care to everyone's home. Luke leads the development of physical tools and digital physical therapy content, focusing on driving clinical outcomes for people with chronic musculoskeletal pain conditions like Tennis Elbow, Plantar Fasciitis, Runner's Knee, and more.