Tib Post Exercises: The Three Moves, and Why the Arch Matters

Posterior tibial tendon dysfunction produces pain, swelling and stiffness in the tendon and along the inside of the foot. The mechanism is thought to be an accumulation of tiny injuries, known as microtraumas, which trigger inflammation and later degeneration, and can go on to tear the tendon partially or completely. The pain makes walking, standing and high-impact activity such as running difficult.

Holding up the arch of the foot during walking is the tendon's main job. Once it weakens it stops delivering that stability and support, and the arch flattens. The risk of tendon trouble rises with a flat foot posture, higher bodyweight, a jump in activity, high-impact loading, or injury. Given time, those injuries produce muscle weakness and changes within the tendon itself. Severe pain and restricted movement are the point at which to speak to your therapist for advice.

Non-surgical management covers adjusting activity levels to keep pain down; strengthening work, both general and targeted, to bring the pain down; a cold pack such as a gel ice pack for 20 minutes with something protecting the skin; supportive footwear, orthotics, strapping, bracing or a short leg cast where needed; and non-steroidal anti-inflammatory drugs or a steroid injection.

One item on that list deserves a caveat. A steroid injection into or around this particular tendon is approached with more caution than its place on a standard list implies, because the tendon carries body weight and steroid is associated with tendon weakening. It is a decision for the clinician who has examined you.

The first exercise is the one most people do wrong. Lifting the arch without letting the big toe or the heel come up is a small, precise movement, and it is easy to substitute by rolling the whole foot outwards. Done properly you should feel the work along the inside of the shin rather than under the foot.

The most directly relevant trial randomised adults with stage I or II tibialis posterior tendinopathy to three groups: orthoses and stretching alone, orthoses plus concentric progressive resistive exercise, or orthoses plus eccentric progressive resistive exercise. All three groups improved on the Foot Functional Index. The eccentric exercise group improved most and the orthoses-only group improved least.

A subsequent systematic review of randomised trials and clinical guidelines for exercise in PTTD reported moderate effects on pain and disability from eccentric strengthening combined with stretching and orthoses. The consistent theme across the evidence is that the insole is worth having and is not the treatment on its own. Strengthening is what changes the outcome, and slow lowering under load is the version of strengthening that does most.

In practical terms, that argues for progressing the sheet above rather than staying on it. Heel raises with the ball, lowered slowly over a four-second count, and eventually performed on one leg, are the natural next step once 15 repetitions three times a day are comfortable. Single-leg heel raises are the benchmark most clinicians work towards.

Most tendon problems hurt and then settle. This one can change the shape of your foot while it does so, and that part does not reverse on its own.

As the tendon loses its ability to hold the arch, the heel drifts outwards and the forefoot turns out. Seen from behind, more toes become visible on the outside of the affected foot than the other one, which is the classic "too many toes" sign. Left long enough the change becomes fixed, and treatment moves from loading the tendon to bracing or reconstructing the foot.

Two tests worth doing at home. Stand in bare feet and look at both arches in a mirror: is one visibly lower? Then try a single-leg heel raise on each side, holding a wall for balance. Difficulty lifting the heel on the painful side, or a heel that does not turn inwards as it lifts, is a meaningful finding and a reason to get it assessed sooner rather than later.

Our guide to foot pain covers how this is separated from plantar fasciitis, which produces pain in a nearby area but behaves quite differently.

The Cuckoo Trail and the South Downs Way produce a particular version of this every summer: someone who has gone from occasional walking to fifteen or twenty miles a week over a few weeks, usually in shoes chosen for comfort rather than support, and who now has an ache on the inside of the ankle that is worst at the end of a long day.

What testing separates is a tendon that is merely overloaded from one that has already lost its hold on the arch. A tendon that hurts but still passes a single-leg heel raise is a loading problem with a good outlook, and the sheet above plus a graded return to distance usually resolves it. A tendon that cannot lift the heel, or a heel that stays turned out as it rises, has moved further along and needs supporting while it is loaded. In the Uckfield clinic, the people who do worst are the ones who rested it completely for six weeks: the pain settles, the strength does not return, and the first long walk restarts the whole thing.

If the inside of your ankle aches after walking and you are unsure how far it has gone, booking an assessment is what tells you which of those two situations you are in.

What does "tib post" mean?
It is shorthand for tibialis posterior, the muscle and tendon that supports the arch of the foot. Tib post dysfunction and PTTD are the same thing.

How long does PTTD take to settle?
Early-stage problems typically improve over three to six months of consistent loading. Tendon change is slow, and progress is measured in months rather than weeks.

Do I need insoles?
The trials used orthoses in every group, so they are a reasonable part of the plan. On their own they produced the least improvement, so treat them as support for the strengthening rather than a substitute.

Can I keep running with tib post pain?
Often, at reduced volume, if pain stays low and settles within 24 hours. Pain that builds across the week means the load is too high.

Is a flat foot always PTTD?
No. Plenty of people have low arches and no symptoms at all. What matters is an arch that has changed, particularly on one side.