Have you been feeling pain on the inside of the ankle during or after your run?
You could be suffering from posterior tibial tendonitis – this is inflammation of the tendon in the lower leg and foot.
It’s a common running overuse injury, and the sooner you treat it the sooner you can get back to running pain-free.
So if you have inner ankle pain while running, here’s how to identify and treat posterior tibial tendonitis, as well as how to prevent it from happening again.
What Is Posterior Tibial Tendonitis?
Posterior tibial tendonitis—also known as posterior tibial tendon dysfunction—is when the tendon on the inside of the ankle that extends to the foot becomes inflamed.
While it may not be as well known as plantar fasciitis, Achilles tendonitis, or ankle sprains, posterior tibial tendonitis is a common ankle injury among runners.
What Does the Posterior Tibial Tendon Do?
The posterior tibial tendon attaches to the navicular bone in the middle of your foot and to the posterior tibialis muscle on the back of your calf.
It plays a vital role, as it helps to hold up the foot’s arch, stabilizes the ankle, and provides support as you walk and push off the toes.
The posterior tibial tendon also prevents the navicular bone from moving out of position, which prevents the arch from dropping or falling flat.
The tendon will also invert your foot during your gait cycle, rolling your ankle so that your body weight shifts to the outside of your foot.
What Causes Posterior Tibial Tendonitis?
One of the main causes of posterior tibial tendonitis is overuse of the tendon. Symptoms usually occur after exercising.
The tendon can become inflamed, or have tears from repetitive use. This usually results from high-impact activities like running, tennis, basketball, or soccer.
It can also be injured by doing activities that involve sudden movements, like jumping or when you start to sprint.
You can also develop posterior tibial tendonitis from doing work that requires a lot of bending at the ankles and knees.
There are several risk factors that can increase your risk for developing posterior tibial tendonitis, like overpronation. When your feet roll inwards, this causes your arch to flatten out more than normal, which places excessive strain on the tendon.
If you’re overweight, this would add increased stress on the tendon.
Injuries like a sprained ankle or a fall can cause tears in the tendon, which can increase your risk of developing posterior tibial tendonitis.
You may also be at a higher risk of developing posterior tibial tendonitis if you have flat feet or low arches.
While it seems that people who have high arches are less likely to develop posterior tibial tendonitis, the tendon can still become inflamed through overuse.
Posterior Tibial Tendonitis Symptoms
If you have posterior tibial tendonitis, you’ll feel pain approximately 2 cm above the inside ankle bone. But you may also feel pain along the inside of your arch, underneath, or at the back of your heel.
The pain will be worse when you walk, try to run, or stand for long periods. You may also notice swelling and tenderness along the tendon towards the foot.
Some people may even experience spasms of the peroneal tendons, which are on the outside of your foot and ankle.
The posterior tibial tendon will feel warm to the touch and there may be redness along the inside of the ankle and foot.
Depending on the severity or stage of posterior tibial tendonitis, you may notice progressive flattening of the arch of the foot.
Stages of Severity
Posterior tibial tendonitis is classified into 4 stages of severity, which indicates the abnormal shape of your foot as the condition progresses.
The first stage is where your foot shape hasn’t changed, but you’re experiencing pain and swelling along the tendon.
During this stage, the posterior tibial tendon becomes elongated and the arch of your foot gradually begins to flatten. You may find that you have difficulty walking or that your ankle doesn’t feel stable.
Fortunately, during this stage, it may still be possible to correct the flattened arch.
Once the posterior tibial tendon has weakened, it will no longer be able to support the arch of the foot. This leads to a condition called adult-acquired flatfoot deformity, which is also known as a “fallen arch”.
Treatment becomes more difficult during this stage, as joints and bones in your foot may no longer line up correctly.
This is the most severe and challenging stage, as not only is the foot involved, but your adjacent ankle joint will be affected by the condition.
During this stage, you can develop arthritis either in your foot, ankle, or both. With arthritic changes to the ankle, surgery is often necessary to restore foot function and alleviate pain.
Can You Still Run With Posterior Tibial Tendonitis?
If you’re experiencing any symptoms of posterior tibial tendonitis, then you definitely shouldn’t run.
Running can lead to progressive damage to the tendon, causing the arch of foot to fall. This can lead to you needing surgical intervention to correct, which will leave you on the sidelines for months.
If you’re experiencing pain in your inner arch, ankle, or heel, you should seek medical attention as soon as possible.
It’s important to treat the condition early before it gets worse, as surgery is usually needed in the later stages. While surgery can help, you may still lose some of your foot’s function.
How to Treat Posterior Tibial Tendonitis
Treatment of posterior tibial tendonitis will depend on the severity of the condition. But the initial treatment will be to immobilize the ankle or foot and rest the tendon so that it can heal.
Unfortunately, even normal walking can aggravate the tendon and prevent it from healing adequately.
Your doctor may recommend that you wear a walking boot, hinged ankle-foot orthosis, or that you use crutches.
You’ll need to wear supportive, motion control shoes that provide a stiff platform for the foot, as this will prevent movement between the back and middle of your foot.
This will help to reduce the pressure that’s placed on the posterior tibial tendon, which will allow the tendon to heal.
You should avoid wearing flat shoes, flip-flops, and walking around barefoot, as this will aggravate the tendon and delay the healing process. Instead, shoes for posterior tibial tendonitis are a better option.
You can add firm arch support insoles to your shoes. This will help to correct any biomechanical imbalances and relieve the stress that’s being placed on your tendon.
Elevate the affected foot above your heart level and ice the tendon 2 to 3 times per day for 20 minutes.
Start icing the area where you feel the most tenderness along the tendon. This will help to alleviate the pain and reduce the swelling.
You can use anti-inflammatory medications—NSAIDs—like ibuprofen, Motrin, Aleve, or Tylenol to alleviate pain, discomfort, and swelling.
In some cases, your doctor may recommend a steroid injection into the foot or ankle joints.
You should avoid walking, running, and the elliptical while your tendon is healing! To maintain your fitness and activity level, you’ll need to look at activities such as swimming or aqua jogging. Both these activities won’t place the tendon under excessive strain.
Your doctor may recommend physical therapy, which can include stretching and strengthening exercises. This will help to alleviate pain and strengthen the muscles and tendons in your foot.
Maintain a healthy weight, as this will help to reduce the amount of pressure that’s placed on your ankle and foot.
How to Prevent A Posterior Tibial Injury
The best way to prevent a posterior tibial injury is to reduce the stress that’s placed on your tendon.
Look for shoes that provide firm arch support for your foot shape. Avoid wearing shoes that can increase your risk of developing posterior tibial tendonitis, such as flip-flops or high-heeled shoes.
Add supportive orthotics to your shoes that provide extra arch support, as this will reduce the stress that’s placed on your posterior tibial tendon. If over-the-counter insoles aren’t providing enough support, then look at getting custom-made orthotics.
Incorporate stretch and strengthening exercises into your daily routine. These exercises can help improve your balance and correct muscle imbalances that lead to poor foot mechanics.
Make sure to stretch your calves often, as this will help to loosen the muscles and stretch the tendon.
Stretch before and after your training session. This can reduce your risk of injury, as well as improving overall mobility in all the muscles of your lower legs.
Foam roll your legs to address any lower leg tightness or restrictions, with a focus on trigger points along the tibialis posterior.
Apply ice to any area where you feel pain or discomfort. This will reduce swelling and help to alleviate pain.
If you notice any pain during your run, stop what you’re doing when you first notice any discomfort. Don’t try and push through the pain, as you will cause further damage to the tendon.
How Long Is Recovery From Posterior Tibial Tendonitis?
The posterior tibial tendon is slow to heal, especially as the part of the tendon that connects to the bump—medial malleolus—has poor blood supply.
Depending on the severity of your posterior tibial tendonitis and when you start the recovery process, it could take 6 to 8 weeks or 6 to 9 months for the tendon to heal.
If you return to running before your tendon has healed, this can double the recovery time and possibly lead to you having surgery.
Posterior Tibial Tendonitis Exercises
Incorporating the following exercises into your daily routine will help improve the overall strength of the surrounding muscles, your ankles range of motion, and improve your balance.
By strengthening the muscles that surround the posterior tibial tendon, you’ll also reduce the load and stress that’s placed on the tendon.
Resistance Band – In, Out, Up, and Down
When you first begin to do this exercise, start with a light resistance band and over a few weeks increase the strength of the resistance band. You should also do this exercise in your shoes and orthotics.
Loop one end of the resistance band around a post and the other end around the instep of your foot.
Then start by rotating your foot inwards against the resistance, while keeping the resistance band at a 45-degree angle. Make sure that all of the movement comes from your ankle and that you’re not rotating your leg while doing the exercise.
Repeat this movement for three sets of 15 reps.
Then, with the resistance band around the outside of your foot, rotate outwards against the resistance. Again, you’ll want to make sure that all of the movement comes from your ankle.
Repeat this movement for three sets of 15 reps.
For the last movement, loop the resistance band across the top of your foot and flex your foot towards you against the resistance.
Repeat this movement for three sets of 15 reps.
All movements should be done slowly and the movement must come from the ankle. You can do these exercises twice a day, and try to build up to doing 50 reps per movement.
When the exercise feels easy, increase the intensity of the resistance band that you’re using.
Tennis Ball Strength
When you first start these exercises, it’s recommended that you start by sitting and as your strength increases, you can move to standing. This will also help to increase the intensity and pressure that’s placed on the ball.
While you’re sitting, place your heel on the ball and use your heel to push down on the ball. Do this “pumping” action slowly for up to 1 minute on each foot.
Then place the ball under your toes and use your toes to curl it towards you.
Do this movement for 10 reps on each foot.
Stair Calf Raises
When the pain has subsided, you can start to add this to your daily foot exercises. This is a single leg exercise and you’ll repeat the movement on each leg for 10 to 20 reps.
Stand on your forefoot, with your heel off the back of a step. Then, slowly lower your heel down towards the floor, then raise up onto your toes.
Make sure that you do this exercise slowly so that you can make sure that you get a full range of motion.
Start by raising yourself up onto your tip toes and then walk forwards on your toes for 10 steps. Once you’ve taken 10 steps, rock back onto your heels, and walk back to the start point.
Repeat this exercise 3 to 5 times.