Question 1

What is tibialis posterior tendinopathy?

Accepted Answer

Tibialis posterior tendinopathy (or tendonitis) is one of the most common causes of inner ankle pain in runners. It is an overuse injury, usually caused by excessive inward rolling of the foot or ankle (overpronation) or by increasing training intensity too quickly.

Question 2

Symptoms of tib post tendinopathy

Accepted Answer

The tibialis posterior muscle is located deep inside your calf, with its tendon running along the inner ankle, behind the ankle bone (medial malleolus), and attaching to the inside of the foot arch as well as underneath the foot. A tendinopathy can develop in any of these areas.

If you have tibialis posterior tendinopathy:

Pain is typically felt around the inside of the foot and ankle. In some cases, it can cause an intense ache or burning sensation higher up the leg (lower quarter).
Swelling may develop on the inner side of the ankle and foot.
Pain often sets in gradually during the day or a training session. Sometimes, it is not noticeable at the time but is felt the next morning.
It usually does not hurt while sitting still or sleeping.
In most cases, the tendon feels stiffest and most painful in the morning or after sitting still for long periods. However, as you move, it warms up, and the pain eases. In some cases, it may remain sore throughout the day and cause limping.
Symptoms may be most noticeable at the start of a run but subside as the tendon warms up, only to return, often more intensely, a few hours later.
If the tendon continues to be irritated, pain may become persistent, preventing running and even making walking painful.
Calf stretches may feel good while being performed but often worsen symptoms later in the day.
Standing for long periods usually increases pain.
Walking up and down hills is often more aggravating than walking on flat surfaces.
Walking on a sloped surface may affect symptoms: placing the injured foot on the lower side of the slope may reduce pain, while having it on the higher side usually worsens it by increasing pronation.

Not everyone experiences the same symptoms, and the severity can vary. However, if your pain is severe, it doesn’t necessarily mean you have a serious injury — it just means your tendon is really irritated and needs a break.

If you experienced a sudden pain when taking a step or felt something snap, you may have torn the tendon and should get it checked immediately.

Question 3

When to see a doctor

Accepted Answer

You should consult your doctor or physical therapist before using the app to ensure you have the correct diagnosis and are ready to start rehab exercises.

If you have any concerns about your injury after starting rehab, schedule a review with your doctor, especially if:

You experience sudden, sharp pain, a popping sensation, or feel like someone kicked you in the ankle or foot — this could indicate a tendon strain or tear, and the app’s program isn’t designed for tendon tear rehab.
You notice bruising — tibialis posterior tendinopathy doesn’t cause bruising.
Your leg (thigh, calf, or foot) is swollen, red, hot, or throbbing — these could be signs of a blood clot, which requires urgent medical attention.
You have pain at night that keeps you awake or disrupts your sleep.
You experience pins and needles or tingling in your leg — this may indicate a nerve injury, and our rehab plan might not be right for you.
Your symptoms are getting worse.
Your injury isn’t recovering as expected (see expected recovery times below).

If you have a chronic condition, e.g., osteoporosis, heart disease, or an inflammatory condition, the rehab plans in the app are likely not appropriate for you. Please check with your doctor before using the app.

Question 4

What causes tibialis posterior tendinopathy?

Accepted Answer

The tibialis posterior muscle helps prevent excessive inward rolling of the foot and ankle (overpronation) while standing, walking, and running. It also assists the plantar fascia in supporting the foot arch.

Tibialis posterior tendinopathy is an overuse injury that can develop suddenly after a single strenuous training session or gradually over time.

Sudden overuse typically occurs during training sessions that are much harder than usual, such as those that are significantly longer, hillier, or faster than normal.

Gradual overload usually happens due to:

Not allowing enough recovery time between training sessions, or
Doing too many high-intensity training sessions in quick succession.

Other contributing factors include:

Poor ankle stability — Lax foot and ankle ligaments or weak ankle and foot muscles may lead to excessive inward rolling of the foot.
Poor trunk and hip stability — Weak core and hip muscles can cause excessive inward rotation of the legs and feet.
Overstriding while running — Increases impact forces and places greater strain on the tibialis posterior tendon.
High, rigid foot arches or stiff ankle joints — May limit dorsiflexion (upward foot movement) and lead to compensatory overpronation.
Switching to more flexible or minimalist shoes — Reduces passive support, requiring your ankle muscles and tendons to work harder.
Ankle sprains — Can injure the tibialis posterior tendon and lead to tendinopathy if not treated correctly.
Menopause — Lower estrogen levels reduce the body's ability to produce and repair collagen, increasing the risk of tendon injuries.
Fluoroquinolone antibiotics — These medications can cause tendon injuries, including tendinopathy and tears.
Inflammatory conditions — Conditions like gout, rheumatoid arthritis, and psoriasis can cause tendon pain and may be mistaken for tendinopathy.

Some people think tight calf muscles contribute to tibialis posterior tendinopathy by limiting ankle movement, but research doesn’t strongly support this. In our experience, aggressive calf stretching too early in rehab often makes symptoms worse.

Question 5

What's the best treatment?

Accepted Answer

A combination of rest and targeted exercise is usually the most effective treatment. Research supports the following approaches:

Relative rest — Avoid aggravating activities and modify training to allow healing.
Progressive strength training — Gradually rebuild foot and ankle strength.
General strength and control exercises — Strengthen the core and other leg muscles to better distribute load during running and jumping.
Mobility exercises — Gain and maintain good mobility in all your lower body joints and muscles. Calf stretches can be helpful but should only be introduced once the injury has settled.
Movement retraining — Learn how to use your whole kinetic chain (all the interconnected parts of your body) optimally while running, specifically during the landing phase

The app’s rehab plan incorporates all these elements, starting with low-load exercises to reduce pain and gradually increasing intensity as healing progresses.

Other treatments you may encounter:

Supportive insoles — May help if you overpronate
Complete rest — May calm your pain initially, but prolonged rest is not advised as it can cause a loss of strength
Massage — May help with pain, but overly vigorous massage can worsen symptoms
Electrotherapy (such as ultrasound) — Not recommended by current research
Shockwave therapy — May help in some cases, but research shows contradictory results
Non-steroidal anti-inflammatory drugs (NSAIDs) — May be helpful in some cases during the early stages but are not recommended for ongoing tendinopathy (pain present for more than six weeks)

Question 6

How long does tib post tendinopathy take to recover?

Accepted Answer

Your recovery time depends on how long your tib post tendinopathy has been present before starting rehab:

Symptoms for less than 4 weeks: 12–16 weeks
Symptoms for 4–12 weeks: 4–6 months
Symptoms for more than 3 months: 9 months or longer

Question 7

How can I stop this injury from coming back?

Accepted Answer

You can reduce your risk of developing tibialis posterior tendinopathy by keeping your body strong and avoiding common training mistakes. We recommend that you:

Invest in supportive running shoes and insoles if needed.
Allow enough recovery time between hard training sessions.
Avoid sudden increases in training volume or intensity.
Do strength training twice a week — the stronger your core and leg muscles, the less strain your lower legs take.
Add balance exercises to your training plan — they help improve your control and movement patterns.
Get plenty of sleep and adjust your training intensity when you're feeling tired — you’re more likely to get injured when you're physically or mentally fatigued.

Once you’ve completed your rehab, switch to one of the run training plans in the app — we’ve designed them with all of these elements in mind.

Question 8

Research references

Accepted Answer

Houck, J., Neville, C., Tome, J., & Flemister, A. (2015). Randomized controlled trial comparing orthosis augmented by either stretching or stretching and strengthening for stage II tibialis posterior tendon dysfunction. Foot & ankle international, 36(9), 1006-1016.
Kulig, K., Burnfield, J. M., Requejo, S. M., Sperry, M., & Terk, M. (2004). Selective activation of tibialis posterior: evaluation by magnetic resonance imaging. Medicine & Science in Sports & Exercise, 36(5), 862-867.
Kulig, K., Reischl, S. F., Pomrantz, A. B., Burnfield, J. M., Mais-Requejo, S., Thordarson, D. B., & Smith, R. W. (2009). Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Physical Therapy, 89(1), 26-37.
Milani, C., Vyas, K., & Malik, G. (2022). Evidence-Based Diagnosis and Treatments of Posterior Tibialis Tendinopathy. Current Physical Medicine and Rehabilitation Reports, 10(4), 273-281.
Robinson, D., Mitchkash, M., Wasserman, L., & Tenforde, A. S. (2020). Nonsurgical approach in management of tibialis posterior tendinopathy with combined radial shockwave and foot core exercises: a case series. The Journal of Foot and Ankle Surgery, 59(5), 1058-1061.
Ross, M. H., Smith, M. D., Mellor, R., & Vicenzino, B. (2018). Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines. BMJ open sport & exercise medicine, 4(1), e000430.

Strong Feet: Tibialis Posterior