If you’ve got a constant ache or swelling along the inside of your ankle or foot, especially after walking or running, you might be dealing with Posterior Tibial Tendon Dysfunction (PTTD). It’s a common cause of adult-acquired flatfoot and often starts with pain or weakness in the arch.

Over time, your foot may flatten, making everyday movement harder. Shockingly, PTTD causes over 80% of adult flatfoot cases, yet many people have never heard of it¹.

As a physiotherapist in Sandton, I treat this often. The good news? You don’t need surgery to get better. With the right Posterior Tibial Tendon Dysfunction rehab—including posterior tibial tendon exercises, ankle strengthening, and hands-on therapy—you can ease pain, build strength, and get back on your feet.

What is Posterior Tibial Tendon Dysfunction (PTTD)?

Posterior Tibial Tendon Dysfunction is when the posterior tibial tendon—the tendon that helps hold up your foot’s arch—gets weak, stretched, or torn. This tendon runs along the inside of your ankle and foot and plays a key role in foot stability.

When it stops working well, the arch drops and the foot begins to flatten. This can lead to pain, swelling, and what’s known as adult-acquired flatfoot².

Who’s Most at Risk?

PTTD mostly affects adults over 40, especially:

Women
People with obesity, diabetes, or arthritis
Those with a history of ankle injuries or overuse
Anyone who spends long hours on their feet with poor support

If you live an active lifestyle and notice posterior tibial tendon pain, foot arch pain, or swelling near your ankle, it’s worth looking into PTTD physiotherapy.

How Common Is It?

Posterior Tibial Tendon Dysfunction is the number one cause of adult-acquired flatfoot. In fact, over 80% of adult flatfoot cases are directly linked to this condition.

Despite being so common, Posterior Tibial Tendon Dysfunction is often missed or misdiagnosed until the symptoms get worse—when the foot has already started to collapse and pain becomes harder to manage.

It’s also a frequent reason for medical visits, showing up in up to 10% of foot and ankle specialist appointments³.

Common Signs and Symptoms of Posterior Tibial Tendon Dysfunction (PTTD)

Pain on the inside of your ankle or foot: A dull or sharp ache just behind the bony bump on the inner ankle, especially after walking or standing.
Swelling along the tendon: Puffy or tender area around the inside of your ankle that feels sore to touch.
Pain after standing or walking for long periods: Extended time on your feet can make your ankle or arch ache, especially without support.
Pain when walking uphill or downhill: Slopes make the foot feel unstable or painful, particularly around the arch and ankle.
Fallen arch on one foot: You may notice one arch is lower than the other or that your foot looks flatter when standing.
Trouble doing a single heel raise: Lifting your heel off the ground while standing on one foot feels weak, painful, or unsteady.
Foot rolls inward more than usual: Overpronation becomes more obvious—your foot leans inward, especially when walking barefoot.
Pain after running or exercising: Common in active people; ankle pain after running is a frequent early warning sign.
Harder to wear flat or unsupportive shoes: Sandals, flip-flops, or flats may feel uncomfortable or worsen symptoms.
One foot looks different: You might notice that one foot points outward or collapses more compared to the other.
Pain reaching into your arch or heel: The ache may spread down into your arch or even your heel, especially during long walks.
Foot stiffness or fatigue: Your foot feels tired, stiff, or heavy, even with everyday tasks like grocery shopping or housework.

Why Does Posterior Tibial Tendon Dysfunction (PTTD) Happen?

As a physiotherapist, I often get asked: “Why is this happening to my foot?” The answer lies in what’s going on inside your body—particularly with one very important structure: the posterior tibial tendon. Let’s break it down in a simple way:

The Role of the Posterior Tibial Tendon

This tendon runs down the inside of your lower leg, behind the bony bump on the inside of your ankle, and attaches to bones in your foot. It plays a key role in:

Supporting your arch
Controlling how your foot rolls when you walk
Helping you push off when you walk, run, or climb stairs

When it’s working well, you likely don’t even think about it. But once it weakens or gets damaged, things start to fall apart—literally. Your arch collapses, your foot rolls inward, and pain starts creeping in⁴.

How the Damage Begins

Posterior Tibial Tendon Dysfunction often starts from overuse, poor foot mechanics, or repeated strain. Think about how often you walk, run, or stand every day. That tendon can only handle so much. If it’s under constant pressure—like from long hours on your feet, poor footwear, or past injuries—it starts to wear out.

Here’s what happens:

Tiny tears form in the tendon
Blood flow in the area is limited, especially behind the ankle bone (a known “weak spot”)
The tendon becomes inflamed or stretched
Over time, it can’t support the arch anymore

This “weak zone” behind the medial malleolus (that inner ankle bump) is where most damage starts. Studies show this area gets poor blood flow, making it harder for your body to repair the tissue once it’s injured⁵.

Why It Gets Worse Over Time

Posterior Tibial Tendon Dysfunction is a progressive condition, meaning it slowly gets worse if it’s not treated early. As the tendon weakens:

The arch flattens more
The heel rolls out
Other foot structures like ligaments and joints start to get overloaded
Eventually, you may develop a progressive collapsing foot deformity

Your foot simply loses its natural support system. That’s why PTTD rehab—including posterior tibial tendon exercises, manual therapy for flatfoot, and proper PTTD orthotics in Sandton—is so important in slowing or stopping this breakdown².

Why You Feel the Pain

The pain you feel is your body telling you that your tendon is under too much stress. It often shows up:

Around the inside of the ankle
Deep in the arch
When standing, walking, or going uphill

As your tendon stretches or tears, your muscles and joints try to pick up the slack, which only makes things worse. That’s why early PTTD physiotherapy in Sandton makes such a big difference—we treat the cause, not just the symptoms.

How Bad Can Posterior Tibial Tendon Dysfunction (PTTD) Be?

Posterior Tibial Tendon Dysfunction can start off as something small—like a bit of pain on the inside of your ankle after a walk—but if left untreated, it can lead to real problems with how your foot works.

Stage 1: Early Pain and Irritation

In the beginning, the tendon is inflamed but still intact. You might feel pain and swelling along the inside of your ankle or arch, especially after walking or running. At this stage, your foot still looks normal, but you may notice a bit of weakness.

This is when Posterior Tibial Tendon Dysfunction physiotherapy can be most effective. With proper rest, targeted ankle strengthening exercises, and supportive footwear, we can help the tendon recover and stop things from getting worse⁶.

Stage 2: Arch Begins to Drop

Now the tendon may be stretched or partially torn. The arch of your foot starts to flatten and your foot may turn outward. Walking, especially for long periods, might feel tiring or unstable. You may not be able to stand on your toes on one foot.

At this point, we focus on PTTD rehab to support your foot, manage pain, and strengthen the surrounding muscles to take pressure off the tendon⁷.

Stage 3: Stiff and Flattened Foot

By stage 3, the tendon no longer supports the foot, and the arch is fully collapsed. The joints may become stiff, and walking may be painful even for short distances.

Daily activities like climbing stairs or standing for long periods may feel harder. Physiotherapy at this stage focuses on pain relief, joint mobility, and helping you stay active with the help of orthotics or bracing where needed⁸.

Stage 4: Ankle Starts to Collapse

In the final stage, the ankle joint becomes affected too. You may feel pain around the whole ankle, and walking becomes difficult. The foot and ankle may look visibly deformed.

What Other Conditions Could It Be?

Pain along the inside of your ankle and a flattening arch might make you think it’s Posterior Tibial Tendon Dysfunction (PTTD), but a few other conditions can feel very similar.

As a physiotherapist, I always look out for these common alternatives to make sure we’re treating the right issue. Here are five conditions that are often confused with Posterior Tibial Tendon Dysfunction, from most to least likely:

Flexor Tendonitis

This also causes pain along the inside of the ankle but involves the flexor tendons, not the posterior tibial tendon. Pain tends to be closer to the back of the ankle and improves faster with rest. Unlike PTTD, the arch usually stays normal⁶.

Tarsal Tunnel Syndrome

This is a nerve issue, not a tendon problem. It causes burning or tingling in the foot and often gets worse at night. Posterior Tibial Tendon Dysfunction pain is more mechanical and linked to movement, while tarsal tunnel pain can happen even at rest³.

Plantar Fasciitis

Pain is felt under the heel or through the arch, especially first thing in the morning. Unlike Posterior Tibial Tendon Dysfunction, it doesn’t usually involve swelling or pain along the inside of the ankle, and the arch stays stable⁴.

Ankle Arthritis

Arthritis causes joint stiffness, swelling, and deep pain. It often affects both ankles and doesn’t change your arch or foot shape like PTTD does⁸.

Medial Malleolus Stress Fracture

This causes sharp, focused pain in the inner ankle, especially during high-impact activity. Unlike Posterior Tibial Tendon Dysfunction, there’s no arch collapse or tendon weakness. It usually needs imaging to confirm⁵.

Common Mistakes When Treating Posterior Tibial Tendon Dysfunction (PTTD)

Ignoring the First Signs

Many people ignore pain on the inside of the ankle or arch, hoping it will go away. But this early pain is a red flag. Without treatment, the tendon can weaken more, and the foot starts to collapse. Early care means better recovery.

Resting Too Much

Rest can ease pain, but it doesn’t fix the problem. Posterior Tibial Tendon Dysfunction needs movement, support, and strengthening. Without posterior tibial tendon exercises, the tendon stays weak and the arch keeps dropping.

Wearing Unsupportive Shoes

Flat shoes, sandals, or old trainers often make symptoms worse. Proper footwear and orthotics are key to reducing strain on the tendon and slowing progression.

Skipping Physiotherapy

Trying to manage it on your own often isn’t enough. Posterior Tibial Tendon Dysfunction physiotherapy focuses on specific exercises, movement correction, and pain relief. Without it, many people see little improvement—or get worse.

Waiting Too Long

PTTD gets harder to treat over time. If left too long, the tendon may tear completely, the foot flattens, and surgery may be your only option. Starting PTTD rehab early can help you avoid that.

What If You Don’t Treat It?

If ignored, Posterior Tibial Tendon Dysfunction can lead to permanent arch collapse, arthritis, and ongoing pain. Walking and daily activity become difficult, and long-term damage is likely.

The Outlook with Treatment

The good news? With the right care—including physiotherapy, strengthening, and supportive treatment—most people improve. Early treatment gives you the best chance to avoid surgery and stay active.

Types of Scans for Posterior Tibial Tendon Dysfunction (PTTD)

Here are the three most common scans used and what we’d look for:

Ultrasound

An ultrasound is often the first scan used. It’s quick, safe, and shows soft tissues like the posterior tibial tendon. With this scan, we’re looking for signs of swelling, small tears, or thinning in the tendon.

It can also help us see if the tendon is still moving properly when you point or flex your foot.

MRI (Magnetic Resonance Imaging)

An MRI gives a detailed view of the tendon and surrounding structures. If we suspect a serious tear or you’re not getting better with normal PTTD treatment, this scan can help.

It shows if the tendon is torn, inflamed, or has lost its normal shape. It can also show damage in nearby joints and ligaments if the condition is more advanced.

X-ray

X-rays don’t show the tendon, but they help check your foot alignment. If your arch has dropped or your heel is tilting outwards, this scan will confirm it. In later stages of PTTD, an X-ray can also show if any joints in the foot are starting to wear down or shift out of place.

Scans aren’t always needed for early Posterior Tibial Tendon Dysfunction, especially if symptoms are clear. But if pain is getting worse or treatment isn’t helping, they give us a better idea of how much the tendon has changed—and help guide the next step in your PTTD rehab.

Is Surgery Needed?

If your posterior tibial tendon dysfunction (PTTD) hasn’t improved with rest, rehab, and orthotics, you might start to wonder: “Do I need surgery?” The short answer is—maybe, but only if everything else hasn’t worked. Surgery is usually a last resort.

Most people with early-stage PTTD do well with physiotherapy and orthotics, but if your arch is collapsing more or you’re still in pain after months of treatment, surgery may be the next step.

Surgery is typically only recommended if:

You have ongoing pain or trouble walking after months of rehab.
Your foot shape continues to change, especially if the arch collapses further.
The tendon has torn or ruptured completely and isn’t responding to non-surgical care.
You’re in stage II or higher of the condition, where the foot is no longer flexible¹³.

Surgeons may do a tendon transfer, repair, or even fuse some of the foot bones depending on how much damage there is. While it sounds intense, many people find that surgery gives them back their ability to walk without pain¹⁴.

What Happens After Surgery?

This is where foot and ankle physiotherapy becomes your best friend again. After surgery, rehab helps you:

Regain ankle and foot strength
Improve flexibility and balance
Learn to walk properly again
Avoid long-term stiffness or weakness

Recovery takes time. Most people start gentle rehab within a few weeks and continue for several months⁸. You’ll likely use crutches, a boot, or both early on. As your strength returns, your exercises will shift from healing to strengthening and stabilizing your foot.

Treatment Options for Posterior Tibial Tendon Dysfunction (PTTD)

As a physiotherapist, my goal is to help you recover from Posterior Tibial Tendon Dysfunction without surgery when possible.

With the right care, most people can manage the condition well using proven, hands-on techniques and a focused rehab plan. Here’s what that may include:

Posterior Tibial Tendon Exercises

These are targeted movements to strengthen the muscles that support your arch and ankle. They:

Build strength in the foot, calf, and ankle
Support the arch and improve foot control
Reduce pain and help prevent arch collapse

We’ll start with foot activation and ankle mobility, then progress to resistance work as your foot gets stronger. These ankle strengthening exercises are key to improving your Posterior Tibial Tendon Dysfunction recovery time⁶.

Myofascial Release

This is a hands-on technique used to release tension in the soft tissues around the foot, arch, and calf. It:

Relieves tension in the calf, arch, and ankle
Improves circulation and foot flexibility
Eases pain caused by stiffness or overuse

This is especially helpful when your foot feels tight, locked up, or sore after walking or standing for long periods¹⁰.

Orthopedic Manual Therapy

This includes gentle joint movements to restore proper motion in the foot and ankle. It:

Restores movement in stiff foot and ankle joints
Improves walking mechanics and reduces stress on the tendon
Speeds up results when combined with exercise

It’s often used in early stages of PTTD, especially when walking feels uneven or restricted¹¹.

Laser Therapy

This involves using low-level laser light to target inflammation in the tendon. It:

Reduces inflammation and pain in the tendon
Speeds up healing in chronic cases
Boosts blood flow to support recovery

It’s a helpful tool when pain is lingering and healing is slower than expected⁹.

Dry Needling

This technique uses very thin needles to release tight or overworked muscles around the foot and calf. It:

Releases tight muscles in the calf and foot
Improves movement and reduces tension
Relieves deep pain from overuse or stress

It’s commonly used when massage or stretching isn’t enough to ease deep muscle tightness¹⁰.

Strapping and Taping

This involves applying supportive tape to lift the arch or control ankle movement. It:

Supports the arch and ankle during daily activity
Reduces strain on the tendon and relieves pain
Boosts stability and confidence when walking

It’s especially useful in the early phases of rehab or during flare-ups when the tendon feels unstable¹².

Combining the Right Treatments

Managing Posterior Tibial Tendon Dysfunction (PTTD) works best when we combine the right treatments. A mix of posterior tibial tendon exercises, manual therapy, laser therapy, dry needling, and supportive strapping can ease your pain and get you moving better.

When delivered by a skilled physiotherapist in Sandton, this approach gives you a stronger, more stable foot—without needing surgery.

Conclusion

As a physiotherapist, I want you to know that posterior tibial tendon pain doesn’t have to control your life. With the right care and a focused Posterior Tibial Tendon Dysfunction rehab plan, you can walk, train, and stay active again—without pain holding you back.

I’ve worked with many clients frustrated by ongoing medial ankle pain or foot weakness. But with smart exercise, proper treatment, and consistent support, they’ve returned to full strength—often without needing surgery.

If you’re looking for expert help—whether it’s personalised PTTD treatment in Sandton, guidance on the right rehab plan, or support from a trusted foot and ankle physio—I’m here to help you move better, feel stronger, and stay pain-free.

Make Your Booking

Send a WhatsApp Message

References

Adukia, V., Trivedi, R., Houchen-Wolloff, L., Mangwani, J., O’Neill, S., Divall, P., et al., 2025. Non-operative and operative management of posterior tibialis tendon dysfunction – A systematic review and meta-analysis. Journal of Arthroscopic Surgery and Sports Medicine, 6, pp.3–15. https://doi.org/10.25259/JASSM_43_2024
Knapp, P.W. and Constant, D., 2022. Posterior Tibial Tendon Dysfunction. StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542160/scholarlyworks.lvhn.org
Ross, M.H., Smith, M.D., Mellor, R. and 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. https://doi.org/10.1136/bmjsem-2018-000430
Houck, J., Neville, C., Tome, J. and 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), pp.1006–1016. https://doi.org/10.1177/1071100715579906
Kulig, K., Reischl, S.F., Pomrantz, A.B., Burnfield, J.M., Mais-Requejo, S., Thordarson, D.B. and Smith, R.W., 2009. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Physical Therapy, 89(1), pp.26–37. https://doi.org/10.2522/ptj.20070242
Yao, K., Yang, T.X. and Yew, W.P., 2015. Posterior Tibialis Tendon Dysfunction: Overview of evaluation and management. Orthopedics, 38(6), pp.385–391. https://doi.org/10.3928/01477447-20150603-06
Easley, M.E. and Harston, B.J., 2018. Current concepts review: adult acquired flatfoot deformity. Foot & Ankle International, 39(3), pp.252–265. https://doi.org/10.1177/107110070602700113
Hintermann, B. and Knupp, M., 2010. Injuries and dysfunction of the posterior tibial tendon. Orthopade, 39(12), pp.1148–1157. https://doi.org/10.1007/s00132-010-1692-3
Koltak, A. and Yurt, Y., 2021. Comparison of the effects of low-level laser and insoles on pain and function in patients with posterior tibial tendon dysfunction: A randomized clinical trial. Journal of Back and Musculoskeletal Rehabilitation, 34(4), pp.679–685. https://doi.org/10.3233/BMR-200199
Poppen, O., Feder, P. and Gorman, C., 2021. Stage III posterior tibial tendonitis and dysfunction leading to acquired flat foot in a 49-year-old male. Journal of Contemporary Chiropractic, 4(1), pp.107–111. https://journal.parker.edu/article/78004-stage-iii-posterior-tibial-tendonitis-and-dysfunction-leading-to-acquired-flat-foot-in-a-49-year-old-male
Alvarez, R.G., Marini, A., Schmitt, C. and Saltzman, C.L., 2006. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: An orthosis and exercise program. Foot & Ankle International, 27(1), pp.2–8. https://doi.org/10.1177/107110070602700102
Bek, N., Şimşek, T.T., Atar, D. and Korkusuz, F., 2012. Home-based general versus center-based selective exercise program in patients with stage I posterior tibial tendon dysfunction. Turkish Journal of Physical Medicine and Rehabilitation, 58(4), pp.331–336. https://doi.org/10.4274/tftr.82755
Erard, U. E., Sheean, A. J., & Sangeorzan, B. J. (2019). Triple arthrodesis for adult-acquired flatfoot deformity. Foot & Ankle Orthopaedics, 4(3), 2473011419849609. https://doi.org/10.1177/2473011419849609

Posterior Tibial Tendon Dysfunction: 5 Essential Facts

Share This: