Posterior Tibialis Pain. The Unusual Suspect

Jul 9, 2020

Medial (inside) Ankle Pain

If you have experienced inside calf, ankle and foot pain, posterior tibialis tendonopathy may be the culprit. This is often misdiagnosed or missed out completely. Yet it is a common structure that is irritated particularly in running – due to the biomechanics.

Posterior Tibialis Anatomy

It is important to understand the muscle, in order to better understand the injury, and then effectively treat the condition. Posterior tibialis originates from the upper 2/3 posterior (back) of the tibia and also the upper 2/3 medial (inside) surface of the fibula.

The tendon then is formed and travels down the back and medial (inside) malleolus (ankle bone) within a groove and then it splits into a medial and lateral portion. These tendons then attach underneath the midfoot.

Posterior tibialis | Run Life


Posterior Tibialis is a key muscle for stabilisation of the foot. It contracts, together with other muscles, to produce inversion (turning foot inwards) and plantarflexion (pushing foot downwards).

Its major role is supporting the medial (inside) arch of the foot.

Differing Diagnoses

Posterior tibialis is best assessed by a Physiotherapist in order to confirm, or rule out, this condition. There are other conditions, which may have similar symptoms:

  • stress fracture
  • nerve impingement
  • medial ankle joint dysfunction
  • plantar fasciitis
  • shin splints/ medial tibial stress syndrome (MTSS)
  • circulatory conditions
  • calf pain

Similar…but not the same

Plantar fasciitis can be experienced together with posterior tibialis tendonopathy. They are closely linked and you need a careful diagnosis to:

  • Distinguish between the two
  • Recognise if you are experiencing BOTH conditions
  • Treat appropriately depending on the findings.

Tips to prevent posterior tibialis pain

  1. Catch it early. Be aware if you are experiencing pain on the inside of your ankle that is worse at the beginning of your run, usually if you are pushing hard and then after your run/ activity, once you have cooled down. This could be the start of posterior tibialis pain.
  2. Recognise possible causes. With training – a sudden increase in load of training, speed, hills, intensity or type (road to trail or trail to road) could aggravate this tendon. Gym work, such as ballistics and plyometrics (example – burpies and skipping), places more load on your legs. Other possible causes may be wearing high heels, sudden change in shoe from supported to minimalist or the minimal to supported, prolonged standing and lastly a change in training style.
  3. Reduce or stop what is irritating your pain. You are experiencing pain as a warning that it your body is not coping with the load.

Management of posterior tibialis

Once you have identified what may be aggravating the tibialis posterior, reduce or stop the activity. However, it is important that you are able to find an alternative so that fitness is maintained and the surrounding structures are strengthened. Most importantly, so you don’t go crazy!

Low impact activities are a good choice with some cardio and then some strength training. A full assessment by a Physiotherapist can determine which structures may need strengthening as well as some manual therapy initially, to ease the pain.

If you are in a painful phase, the suggestion is to AVOID stretches until the pain calms down. Strengthening can be started, however this should be guided by a Physiotherapist who has fully assessed you and can treat you appropriately.

Training changes

  • Try to increase your step rate (cadence) as this will decrease the pressure through the legs and possibly prevent over striding and over pronation.
  • Quieter running is preferred – ensure your feet aren’t “slapping” the ground.
  • Initially a flatter running terrain may be more beneficial and then progress to hills.

Dawn Nunes

Dawn Nunes is an enthusiastic Physiotherapist with over 15 years experience. Her passion is to help everyone lead an Active lifestyle preventing and rehabilitating injuries. She is also known as “Physiotrailrunner” and enjoys blogging about the local trails. Find out more about Dawn here.

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