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Ankle · Posterior Tibial Tendon Dysfunction (early flexible)

Posterior Tibial Tendon Dysfunction

A tendon runs behind the bony knob on the inside of your ankle and helps hold your arch up. When it struggles with the load, the inside of your ankle can ache and your arch can start to flatten. A flexible arch can still come back when you sit relaxed or stand on tiptoe, even if you cannot do a single-leg heel raise. A weak or impossible heel raise does not mean your foot is rigid. A rigid arch stays flat both on tiptoe and when sitting relaxed. Arch support and gradually building strength can help with the flexible pattern.

The tendon got loaded beyond what it was conditioned for: a lot of standing or walking, extra body weight, a foot that already rolls in, or simply age (it’s the most common cause of adult flatfoot, usually in middle age). As the tendon weakens it stops holding the arch, the arch flattens, and the heel drifts outward, which loads the tendon even more, a vicious circle. Support and strengthen: SUPPORT the arch (an orthotic / arch support takes load off the tendon) AND rebuild the tendon and the muscles that hold the arch up.

How it typically shows up

Gradual pain and swelling along the inside of the ankle and arch, behind the inner ankle knob along the posterior tibial tendon. Standing and walking cause aching and fatigue, the arch may flatten, and more toes may show from behind. A single-leg heel raise may be weak, painful or impossible, including in flexible stage II. Heel-raise strength alone does not determine flexibility. In a flexible foot, the arch comes back when sitting relaxed or on tiptoe. A rigid flatfoot stays flat both on tiptoe and when sitting relaxed.

How long recovery takes

Begin gentle ankle and foot work, then comfortable heel raises, arch control and balance. Arch support and progressive loading can help together. Use two legs when single-leg work is too hard, easing aggravating activity during flares.

The phased recovery approach

  1. Phase 1 · 1–3 weeks

    Calm

    Support your arch and settle inner-ankle tendon irritation before loading.

    What you get back: a comfier day on your feet.

    • Ankle Alphabet: 1 set × 45–60s moving · Complete A to Z for the shown time, drawing large, slow letters within comfortable range. · Sit down and lift the injured foot off the floor.
    • Short-Foot / Arch Raise: 3–4 sets × 20–25s hold · Dome your arch slightly to train foot muscles stabilizing your ankle. · Sit or stand, foot flat on the floor.
    • Toe Curls / Towel Scrunch: 2–3 sets × 10–15 reps · Curl slowly and gently, pain-free, activating small arch muscles. · Sit with your foot flat, on a towel if you have one.
    • Calf Stretch / Knee-to-Wall Mobilizer: 3 sets × 30s hold · Stop at a gentle pull. Do not push into the end of the stretch, that position compresses the tendon that holds your arch. · Face a wall, injured foot forward, toes a few inches away.

  2. Phase 2 · 4–8 weeks

    Rebuild

    Strengthen your inner-ankle tendon, keeping the arch supported.

    What you get back: a heel raise that holds your arch.

    • Calf Stretch / Knee-to-Wall Mobilizer: 3 sets × 30s hold · Stop at a gentle pull. Do not push into the end of the stretch, that position compresses the tendon that holds your arch. · Face a wall, injured foot forward, toes a few inches away.
    • Resisted Band Inversion: 4–10 sets × 25 reps · Move slowly inward, slower back, carefully loading your arch-supporting tendon. · Sit, leg out, band looped around your foot’s ball.
    • Sole-to-Sole Press: 4–10 sets × 25 reps · Bring your soles together and release in a comfortable rhythm, without holding. · Sit with both heels together on the floor and your toes pointing slightly down.
    • Heel Raise with Arch Control: 4–10 sets × 25 reps · Work the slow lowering, building toward one leg. · Stand tall, weight toward each big-toe side, arches lifted.

  3. Phase 3 · 4–8 weeks

    Daily life

    Rebuild all-day standing and walking, maintaining arch and tendon strength.

    What you get back: standing and walking all day, comfortably.

    • Single-Leg Heel Raise: 3 sets × 12–20 reps · Lift and lower slowly with equal control. · Stand and rest a fingertip on a wall for balance, with your weight on the injured leg.
    • Heel Raise with Arch Control: 3 sets × 12–20 reps · Work the slow lowering, building toward one leg. · Stand tall, weight toward each big-toe side, arches lifted.
    • Double-Leg Heel Raise: 3 sets × 12–20 reps · Lift and lower slowly and evenly. · Stand tall, feet hip-width apart, optional fingertip on a wall for balance.
    • Eccentric Band Inversion: 3 sets × 12–15 reps · Control the slow working return smoothly within the pain rule. · Sit, leg out, band looped around your foot’s ball.

Exact exercises, sets and progression depend on your severity, equipment and goal. This is the shape of the program, not a one-size prescription.

What matters while you recover

  • Support the arch: get an orthotic

    An arch support is the best first step, worn about 90% of your waking hours. If you cannot do one heel raise on that side, ask about a braced ankle-foot orthosis instead.

  • Load it, don’t rest it (the tendon rule)

    Tendons recover with load, so pain up to moderate is fine if it settles by next morning and isn’t climbing week to week. If it lingers or rises, ease the load.

  • Start below single-leg load

    You don’t need a full single-leg heel raise to start. Begin with seated or two-leg raises, shifting weight onto the sore side only as the arch stays controlled.

Common questions

How is this different from an ankle sprain?
A sprain is on the OUTSIDE of the ankle from one rolling-in moment. This is on the INSIDE, along the arch, and it comes on gradually as the tendon that holds your arch gets overloaded. The giveaways are the flattening arch and a single-leg heel raise that’s weak or sore on the inside.
Do I really need an arch support / orthotic?
Arch support can reduce strain while you build strength. Studies have combined support, stretching and progressive resistance. The contribution of each part varies between people.
Should I just rest until the arch stops hurting?
Temporarily reduce walking or standing that aggravates the tendon while keeping tolerable movement. Build back gradually as symptoms settle between sessions.
What if I can’t do a single-leg heel raise yet?
Use the two-leg heel raise and steady yourself with a support. Keep that version until the single-leg option feels manageable. Do not force a difficult single-leg repetition.

Related ankle conditions

Sources