If you’ve been feeling a sharp, pulling ache along the inside of your ankle, especially after a long day of walking, you might be dealing with more than just tired legs. You tried to ignore it, but the achy feeling in your ankle keeps haunting you when you’re shopping along Orchard Road or after exercising. If this sounds like your symptoms, you could be having posterior tibial tendonitis: an inflammation of a key tendon that supports your arch and helps you push off.
Posterior tibial tendonitis is one of the most common chronic causes of medial ankle pain, particularly in Singapore and across Asia, and it often follows a sharp rise in daily step count (e.g. a recent holiday trip) or an intense session such as HIIT or Muay Thai. Most of our patients dismiss it as tired legs at first, but over time the pain creeps up until everyday activities from walking to climbing stairs become uncomfortable. Importantly, leaving it untreated can progressively change your foot shape into an adult-acquired flatfoot deformity, the late stage of which can make walking itself difficult.
Functions Of The Posterior Tibial Tendon
The posterior tibial tendon runs along the inside of your ankle and attaches to the navicular bone in the foot. When the tendon contracts, it helps lift your foot arch and your heel off the ground, making your foot a stable lever and allowing you to propel forward effectively.
When there is too much load or stress on the tendon, it becomes inflamed or irritated. In severe cases, the tendon becomes weakened or even torn, leading to posterior tibial tendon dysfunction (PTTD). Without a healthy functioning posterior tibial tendon, your arch will then collapse, and your foot will lose its stability when you walk. That’s why recognising and addressing the condition early is so important.
Symptoms of Posterior Tibial Tendonitis
At the start, most people will just feel a pulling ache along the inside of the ankle after long periods of walking or exercise. However, as the condition advances, you will notice that the time or distance needed to trigger the pain becomes shorter.
Besides pain after walking or other activities, most people also find that taking the first step after rest is quite painful. As such, some patients will mistakenly assume that they have plantar fasciitis instead. However, the reason for the first-step pain is that, at rest, the tendon is not under tension. As soon as you stand up, the sudden tendon traction will flare the pain instantly.
Generally, the symptoms of posterior tibial tendonitis come “on and off” in the early stages, making it easy for most people to dismiss them. However, once the tendon damage starts to worsen, the other significant symptoms will appear:
- Pain and swelling along the inside of the ankle or arch.
- Pain when taking every step, especially during push-off.
- Difficulty balancing on the affected foot.
- Difficulty standing on tiptoe with the affected foot.
- Gradual flattening of the arch or asymmetrical foot posture of both feet.
Causes and Risk Factors
Like every other tendon in our body, the posterior tibial tendon becomes inflamed when subjected to sudden, high stress or repeated strain. For most of the time, there isn’t just one single reason for developing posterior tibial tendonitis. Instead, it’s often linked to a combination of lifestyle and physical factors.
What increases load on the posterior tibial tendon?
- Frequent high-impact activities that involve running or jumping, such as HIIT or basketball.
- Sudden rise in step count or prolonged walking, such as during a recent overseas holiday.
- Wearing minimalistic footwear (e.g. ballet flats, barefoot shoes) or shoes that are worn out.
- Tight calf muscles, which cause your foot to compensate by pronating more
- Leg length difference, which causes one foot to pronate more.
Who carries a higher baselink risk?
- Age between 40 to 60, especially ladies after menopause.
- Higher BMI.
- Sudden weight gain due to pregnancy.
- Jobs that require long hours of standing.
- Persons with flat feet, which will place more strain on the posterior tibial tendon.
- Persons with congenital bony deformities, such as having an os navicular bone
Treating and Preventing Posterior Tibial Tendonitis
Posterior tibial tendonitis is a load problem, so recovery hinges on taking stress off the tendon and giving it the chance to heal before it fails progressively into a flatfoot deformity. Care is conservative-first and staged to how advanced the condition is: early cases settle with load reduction and footwear changes, while persistent cases add orthoses and rehabilitation to correct the underlying mechanics. We generally do not recommend over-relying on anti-inflammatories, as they mask the pain without addressing the underlying cause. Your podiatrist should first determine how advanced the condition is, because that drives the plan.
Conservative treatment
Most cases respond well to conservative measures, layered according to how the tendon is coping.
- Activity modification and footwear: In the early stage, avoid or reduce high-impact sports and long hours of standing to take strain off the tendon. Switch away from slippers or barefoot shoes to proper, supportive, and stable sports shoes that hold the arch.
- RICE and pain control: Applying the RICE (rest, ice, compression, elevation) technique helps control swelling in a symptomatic flare. Anti-inflammatories, if prescribed, should not be taken for more than 2 weeks in a row.
- Custom orthotics: For cases persisting beyond 2 to 3 months or not responding to early measures, custom orthotics can be designed to help realign the foot, support the arch, and reduce stress on the posterior tibial tendon.
- Rehabilitation and physical therapy: Physical therapy or a structured rehabilitation programme can help strengthen the posterior tibial tendon and the surrounding muscles, addressing the tight calf and altered mechanics that overload the tendon.
- Focused shockwave therapy and EMTT: Where symptoms have stalled or the tendon is more damaged, advanced therapies such as extracorporeal magnetotransduction therapy (EMTT) and focused shockwave therapy (ESWT) can help signal the body’s natural response and trigger healing processes.
When conservative care isn’t enough
For advanced cases with a significant flat foot deformity or more extensive tendon damage, an ankle-foot orthosis (AFO) or ankle brace is often introduced late-stage to stabilise and realign the collapsing foot and offload the posterior tibial tendon. Where the tendon has failed beyond what conservative care can restore, surgery becomes the last resort: flatfoot correction or tendon repair are among the surgical options for late-stage posterior tibial tendon dysfunction, and referral to an orthopaedic colleague is arranged where that pathway is indicated.
Given how detrimental PTTD can be, your main goal should be to prevent yourself from getting it. While not every case is preventable, you can reduce your risk by:
- Wearing supportive shoes, especially if you stand or walk a lot.
- Increase your physical activity gradually and build up your training.
- Take sufficient rest and breaks.
- Stretching and strengthening the calf and ankle muscles.
- Maintaining a healthy weight to reduce strain on the tendon.
Simple lifestyle adjustments like the ones above can make a big difference in preventing PTTD injury or in preventing recurrence after you recover.
Have Your Posterior Tibial Tendonitis Managed at Straits Podiatry
When ankle discomfort starts to hinder your daily activities, it is a sign that your leg needs help. At Straits Podiatry, we emphasise obtaining the right diagnosis and then consider all factors, including your activities, shoe selection, calf flexibility, and foot mechanics, to determine the cause of your pain.
From there, we design a management plan that fits your life. This will include footwear recommendations, custom insoles, activity guidance, and simple home exercises to ease strain. If symptoms continue to persist, we can also explore EMTT and focused ESWT as part of a comprehensive approach. Speak with our team today or book a consultation for a thorough assessment by our podiatrist in Singapore, and a personalised recovery plan to get back to comfortable movement.
Frequently Asked Questions About Posterior Tibial Tendonitis
Is posterior tibial tendonitis the same as flat foot?
No, it is not. Posterior tibial tendonitis is an injury caused by the inflammation of the tendon. In contrast, flat foot is a foot deformity condition. However, having a flat foot can increase the risk of posterior tibial tendinitis. Vice versa, an untreated case of posterior tibial tendon injury can also progress to posterior tibial tendon dysfunction and result in a flat foot deformity. Simply put, one can lead to the other, but they are not the same condition.
How long does recovery take?
If you manage to detect the issue and start conservative treatment for posterior tibial tendonitis early, you may feel better within 4 to 8 weeks. However, advanced tendon dysfunction may take significantly longer, especially if surgery is necessary.
Can I still exercise if I have posterior tibial tendonitis?
Yes, you can. However, we recommend switching to lower-impact activities such as swimming and flat-terrain cycling to keep tendon stress low until you recover. You should also avoid an incline treadmill walk, as it puts the posterior tibial tendon under high stress despite the activity being lower-impact.
Do orthoses really help?
Yes. Orthoses are proven in research to be one of the standard non-surgical treatments because they directly reduce stress on the tendon by restoring proper foot alignment and gait pattern.
When should I see a podiatrist?
If you experience persistent ankle or arch pain, swelling, or difficulty with mobility for more than 2 weeks, it’s time to consult a podiatrist. Early intervention is critical as it prevents progression into posterior tibial tendon dysfunction.