# Posterior tibial tendon dysfunction > Posterior tibial tendon dysfunction is a strained tendon on the inside of the ankle that helps hold up the arch, and over time the arch can flatten. It's most common in women over 40. Supportive insoles, often with exercise, are the usual first step, and early checking matters. Guide in [Heel and arch pain](https://footanklelowerlimb.com.au/learn/topics/heel-and-arch-pain), from Foot Ankle Lower Limb: https://footanklelowerlimb.com.au/learn/posterior-tibial-tendon-dysfunction Reviewed by Andrew Schox, BSc(Hons) PGradDipPod MPod (Podiatrist) on 27 October 2026. Next review by 27 October 2027. - **It's a strained tendon on the inside of your ankle.** The tendon helps hold up your arch, and over time the arch can flatten. - **It's most common in women over 40,** and most people who get it already have flat feet. - **Supportive insoles are the first step,** often with exercise and sometimes a short rest for the tendon. - **Early checking matters,** because left alone it can lead to a stiff, fixed flatfoot. - **Injections into the tendon aren't recommended.** ## What is posterior tibial tendon dysfunction, and how common is it? Posterior tibial tendon dysfunction (PTTD) is a painful, strained tendon on the inside of your ankle. The tibialis posterior tendon runs behind the inside ankle bone, attaches under the sole of your foot and helps hold your arch up [1]. When it's strained it causes pain and inflammation, and over time the arch along the inside of your foot becomes flatter [2]. That's why PTTD is a common cause of adult acquired flatfoot (a flat foot that develops in adulthood) [3]. You may also see it called tibialis posterior tendinopathy. Adult acquired flatfoot affects about 3% of adults [4]. PTTD is usually thought of as a condition that progresses, though how it plays out over time isn't fully known [3]. ## What causes it, and who gets it? It most often starts when the tendon wears down and becomes inflamed or torn [5]. Extra load on the tendon can cause tiny tears. Examples are flat feet or feet that roll inwards, very flexible joints, being overweight, a sudden change in exercise, a change of shoes, and stiff or weak calf muscles [6]. Most people who develop it already have flat feet [7]. Anyone can get it, but it's common in women over 40 [2], and it's reported as about 3 times more common in females [8]. High blood pressure, obesity, diabetes, rheumatoid arthritis and a past injury to the tendon are also listed as risk factors [5]. These are links rather than proven causes, so having one doesn't mean you'll develop it. ## What does it feel like, and how is it diagnosed? You'll typically feel pain and mild swelling along the tendon behind your inner ankle bone, sometimes spreading into the inner arch. It's usually felt during activity and after rest [5]. Running or other high-impact activity can become very difficult, and some people find long periods of walking or standing hard [9]. Later, the heel can roll inwards, the foot looks flatter and you may notice a 'too many toes' sign [6]. As the foot collapses, pain can also appear on the outside of the ankle [9]. Diagnosis is based on an examination. A podiatrist or doctor will look at your standing arch and heel, press along the tendon and ask you to rise onto your toes on one leg. Tenderness, pain and swelling around the tendon point to early disease. Difficulty with that single-leg heel raise, with a flexible flatfoot, points to a later stage [10]. A flat foot caused by rheumatoid arthritis may not respond to treatment in the same way, which is one reason a proper examination matters [10]. ## What helps first? Supportive insoles or orthoses (shoe inserts made to support the arch) are the core of first-line care. Personalised arch-support orthoses eased pain more than flat insoles in early-stage disease, and adding exercise seemed to improve the effect [11]. They also reduce forces on the tendon [2]. How much they help, and which exercises work best, isn't clear yet [11], so it helps to have a podiatrist guide you and review progress. For a painful early-stage tendon, a short period in a boot or cast lets it rest [2]. > [!tip] Try this > If the inside of your ankle is sore after activity, ease back on high-impact activity such as running for now, and have it checked early rather than waiting to see if your arch flattens. Injections into the tendon aren't recommended [12]. Injecting the inner side of the tendon carries a major risk of it rupturing [13]. A steroid injection is unlikely to be a first choice unless the problem is linked to an inflammatory condition [8]. ## What helps if that isn't enough? If self-management and first-line care haven't settled it, your podiatrist or GP can refer you to an orthopaedic foot and ankle surgeon [5]. A referral is for an opinion. It isn't a promise that surgery is the right option [8]. It helps to note what you've tried, for how long and what happened, so the referral is clear. ## How long does it take to settle, and can it come back? How long recovery takes isn't clear yet, and no best way to stop it returning has been shown, whether footwear, exercise or weight loss. What is clear is that early care is worthwhile. Left unmanaged, the condition can lead to a fixed flatfoot [5]. As it progresses, painful arthritis, stiffness and pain at rest or at night can develop, and the foot shape can no longer be corrected [13]. Untreated, the tendon can also rupture and need surgery [6]. Having new inner ankle or arch pain checked early, and reviewed over time, is a sensible step. Keep an eye out for an arch that's becoming less flexible, new night or rest pain, or a foot shape that's getting worse. ## When to see a podiatrist See a podiatrist if you have new pain on the inside of your ankle or along your arch, an arch that's flattening, or pain that isn't settling with the care above. This guide is about adults: if a child or teenager under 16 has these symptoms, see your GP [12]. See your GP soon if: - you have pain at rest or pain that keeps you awake at night, especially with a stiff foot that no longer corrects [12][13]; - your foot shape is getting worse [13]; - you notice a lump in the foot or ankle, unexplained weight loss, or night sweats that are out of the ordinary [12]. See your GP or a podiatrist the same day if: - you have diabetes and a wound, sore, blister or colour change on your foot, or it's red, swollen or warm (it could be a Charcot foot) [13][6]; - your foot or ankle is hot, red and swollen, which can be a sign of infection [1], or swelling or colour change spreads up your leg [12]; - you have a high temperature or feel hot and shivery along with foot pain [6]; - you can't put weight on your foot or ankle, or you have sudden pain with a pop or snap, or a new significant injury, or a flat foot that appears after an injury [12][13]. For urgent advice when it isn't an emergency, call healthdirect on 1800 022 222 (24 hours a day), or go to a Medicare Urgent Care Clinic. ## Common questions ### Is posterior tibial tendon dysfunction the same as adult acquired flatfoot? They're closely related. Adult acquired flatfoot is the broader term, usually meaning a flat foot that becomes more painful and flatter over time. PTTD is used when the main problem is the tibialis posterior tendon. Your podiatrist may use either name, or 'progressive collapsing foot deformity', for the same picture. ### Should I rest or keep exercising? A short period of rest can help an irritated tendon in early disease, but rest alone isn't the whole answer. Exercise is usually added alongside supportive insoles rather than instead of them. Exactly which exercises and how hard isn't clear yet, so a podiatrist can guide you and adjust the plan as you go. ### Can it get better without surgery? Surgery isn't the usual starting point. Care normally begins with supportive insoles, exercise and sometimes a short rest for the tendon, and a podiatrist can review how you're going. No result can be promised, and if it isn't settling, a referral is for an opinion rather than a decision to operate. ## Further reading - [Posterior tibial tendon dysfunction on Clindice](https://clindice.com/posterior-tibial-tendon-dysfunction) - [Tibialis posterior tendinopathy - My Joint Health Hub](https://myjointhealthhub.bnssg.nhs.uk/foot-ankle-pain/tibialis-posterior-tendinopathy/), NHS - [Posterior tibialis tendon dysfunction (PTTD)](https://www.esht.nhs.uk/wp-content/uploads/2025/05/1166.pdf), NHS - [Surgery to repair / reconstruct the tibialis posterior tendon](https://www.royalberkshire.nhs.uk/media/izjjlzxg/tibialis-posterior-tendon-repair-or-reconstruction-surgery_mar25.pdf), NHS - [Tibialis posterior tendon dysfunction or insufficiency or adult acquired flat foot deformity](https://www.wsh.nhs.uk/CMS-Documents/Patient-leaflets/TraumaandOrthopaedics/6112-1-Tibialis-Posterior-Tendon-Dysfunction-or-Insufficieny-or-Adult-Aquired-Flatfoot-Deformity.pdf), NHS - [A Patient's guide to Adult Acquired Flatfoot Deformity Tibialis Posterior Tendon Dysfunction :: Royal National Orthopaedic Hospital](https://www.rnoh.nhs.uk/patients-and-visitors/patient-information-guides/adult-acquired-flatfoot-deformity-tibialis-posterior-tendon-dysfunction), NHS ## Sources 1. Patients & visitors · NHS. https://www.nhsborders.scot.nhs.uk/patients-and-visitors/our-services/allied-health-professionals/physiotherapy/physiotherapy-msk-services/foot-and-ankle-pain/ 2. Posterior Tibial Tendon Dysfunction (PTTD) · Herefordshire and Worcestershire Health and Care NHS Trust. https://www.hacw.nhs.uk/leaflets-podiatry-pttd/ 3. Posterior Tibial Tendon Dysfunction: An Overview · Ling SK, Lui TH · The Open Orthopaedics Journal · 2017. https://doi.org/10.2174/1874325001711010714 4. Outcomes Following the Use of Subtalar Arthroereisis in the Correction of Adult Acquired Flatfoot: A Systematic Review · Baryeh KW, Ismail H, Sobti A et al. · Foot & Ankle Specialist · 2022. https://doi.org/10.1177/1938640020987775 5. MSK Tibialis Posterior tendon dysfunction (adult acquired flat foot) | Right Decisions · NHS. https://www.rightdecisions.scot.nhs.uk/borders-ref-help-toolkit/podiatry/msk-tibialis-posterior-tendon-dysfunction-adult-acquired-flat-foot/ 6. Posterior tibialis tendon dysfunction (PTTD) · NHS. https://www.esht.nhs.uk/wp-content/uploads/2025/05/1166.pdf 7. Tibialis posterior tendon dysfunction or insufficiency or ... · NHS · 2024. https://www.wsh.nhs.uk/CMS-Documents/Patient-leaflets/TraumaandOrthopaedics/6112-1-Tibialis-Posterior-Tendon-Dysfunction-or-Insufficieny-or-Adult-Aquired-Flatfoot-Deformity.pdf 8. Plantar midfoot | Right Decisions · NHS. https://www.rightdecisions.scot.nhs.uk/ggc-msk-foot-and-ankle/midfoot/plantar-midfoot/ 9. Tibialis Posterior Dysfunction (Acquired Flat Foot) | Right Decisions · NHS. https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/surgery-and-orthopaedics/orthopaedic-and-trauma-surgery/foot-and-ankle-service/tibialis-posterior-dysfunction-acquired-flat-foot/?useNavigation=true 10. Reported selection criteria for adult acquired flatfoot deformity and posterior tibial tendon dysfunction: Are they one and the same? A systematic review · Ross MH, Smith MD, Vicenzino B · PloS One · 2017. https://doi.org/10.1371/journal.pone.0187201 11. Orthotic treatment for stage I and II posterior tibial tendon dysfunction (flat foot): A systematic review · Gómez-Jurado I, Juárez-Jiménez JM, Munuera-Martínez PV · Clinical Rehabilitation · 2021. https://doi.org/10.1177/0269215520960121 12. Tibialis Posterior Tendinopathy · NHS. https://elht.nhs.uk/application/files/1817/3738/1080/Tib_Post_PDF.pdf 13. Acquired Adult Flatfoot Deformity · boa.ac.uk. https://www.boa.ac.uk/static/83bf469d-2c6f-470b-a6ffc7f0fda8eada/acquired%20adult%20flatfoot%20deformity.pdf --- This page is general information, not a diagnosis or a treatment plan for you. For advice about your own feet or legs, see a podiatrist or your doctor. In an emergency, call 000.