The tibialis posterior is a muscle that attaches from the tibia and fibula (bones in the lower leg) to many small bones of the inside of the foot. It helps stabilise around the ankle and point the foot inwards. Tibialis posterior tendinopathy is an overload of this tendon, causing pain and discomfort where the tendon wraps under the bony knob on the inside of the ankle, called the medial malleolus. The condition is also often associated with tenosynovitis—an irritation of the sheath (covering) that wraps around the tendon. When this is involved, it may feel like you have subtle crackling or squeaking (called crepitus) of the tendon as you move your foot. 

What causes tibialis posterior tendinopathy?

As with other tendinopathies, it is thought that tibialis posterior tendinopathy is caused by excessive load beyond a tendon’s capacity. Compression of the tendon at the ankle is linked to pathology in the tendon and sheath (covering). Exact causes of this condition are not known; however, some consider rolling in of the foot (pronation) as an important factor to address. Tibialis posterior tendinopathy is most often seen in people over the age of 40 and is not common in younger patients.

How do I know if I have tibialis posterior tendinopathy?

Tibialis posterior tendinopathy is characterised by pain and sometimes associated creakiness (crepitus) and swelling under the bony knob on the inside of your ankle (medial malleolus). Your physiotherapist or podiatrist will be able to assess and manage this injury. Your physiotherapist will examine the strength and function of the muscles around your ankle, often by asking you to perform a single or double-leg heel raise, which may be painful or difficult to complete if the condition is present. Imaging and scans are not used in the diagnosis of tibialis posterior tendinopathy.

How can physiotherapy help with tibialis posterior tendinopathy?

Physiotherapy management can improve pain and symptoms of tibialis posterior tendinopathy. Exercises can be used to improve the strength of the tibialis posterior muscle, as well as other associated muscles, such as those of your calf and foot. For these to be effective, they will need to be challenging to improve the strength of the muscle and capacity of the tendon. Orthotics may be helpful to provide extra support to the foot, which in turn may offload the tendon. A heel raise or wearing shoes with heels can decrease the compression and therefore the pain.

No evidence supports the use of techniques such as soft tissue massage or joint mobilisation—these should be considered adjuncts to an adequate loading program and never used alone. If your treating physiotherapist suspects an associated irritation and inflammation of the covering of the tendon (tenosynovitis), they may refer you to a GP for a course of non-steroidal anti-inflammatory medication.

How effective is physiotherapy for tibialis posterior tendinopathy?

Treatment for this condition is poorly researched. A recent randomised controlled trial showed adding resisted strengthening exercises to prescribing orthoses and stretching had better results than orthoses alone. These findings are supported by other smaller studies. Further research is required to better understand this complex condition. 

Source: Choose.physio