What is the treatment for posterior tibial tendonitis?

Treatment of Posterior Tibial Tendonitis

Start with relative rest, ice therapy, NSAIDs, and eccentric strengthening exercises for 3-6 months, combined with custom foot orthoses with longitudinal arch support—this conservative approach resolves symptoms in approximately 80% of patients. 1, 2

Initial Conservative Management (First 6-8 Weeks)

Core Treatment Components

• Relative rest: Avoid activities that reproduce pain while maintaining some activity to prevent deconditioning—complete immobilization is not recommended initially 1
• Ice therapy: Apply to reduce acute pain and swelling 1
• NSAIDs: Use oral or topical formulations for acute pain relief; topical NSAIDs eliminate gastrointestinal bleeding risk 1
• Custom foot orthoses: Personalized insoles with internal longitudinal arch support are more effective than flat insoles or standard treatments for pain reduction 2
• Eccentric strengthening exercises: These stimulate collagen production and guide proper alignment of newly formed collagen fibers 1

Important Caveat About Terminology

The condition is often mislabeled as "tendonitis" implying inflammation, but most cases presenting to primary care are chronic degenerative conditions better termed "tendinosis" or "tendinopathy" 1. This distinction matters because anti-inflammatory treatments have limited long-term benefit in degenerative conditions.

Adjunctive Therapies (If Initial Treatment Insufficient)

Second-Line Options

• Immobilization: Consider a cast or fixed-ankle walker-type device for particularly acute or refractory cases 1
• Corticosteroid injections: May provide better acute pain relief than NSAIDs but do not alter long-term outcomes; use with caution as they may inhibit healing, reduce tensile strength, and potentially predispose to rupture 1
• Radial shockwave therapy: Combined with foot core exercises showed clinically important improvements in 80-90% of patients who failed standard conservative treatment 3

Monitoring and Progression

Continue initial treatments if improvement occurs within 6-8 weeks until symptoms fully resolve 1. The natural history shows gradually increasing load-related localized pain coinciding with increased activity 1.

Referral Criteria

Refer to a podiatric foot and ankle surgeon if no improvement occurs after 6-8 weeks of conservative treatment 1. Early recognition and treatment is critical to prevent debilitating long-term consequences, as this condition represents a spectrum of pathologic changes involving associated tendon, ligament, and joint structures 4.

Surgical Considerations

Surgery becomes necessary when conservative care fails after 3-6 months of well-managed treatment 1. Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 5.

Common Pitfalls to Avoid

• Avoid corticosteroid injections directly into the tendon substance: These can weaken the tendon and increase rupture risk 1
• Do not rely solely on orthoses without exercise: Foot orthoses combined with exercise programs are more effective than orthoses alone 2
• Do not continue ineffective treatment beyond 6-8 weeks: Delayed referral can lead to progression requiring more invasive interventions 1, 4

Underlying Pathophysiology Context

Posterior tibial tendonitis results from increased stress on the tendon as it compensates for excessive subtalar joint pronation during physical activity 6. The tendon is relatively hypovascular proximal to its insertion, predisposing it to hypoxic degeneration 1. This microtrauma causes fiber rupture leading to the clinical presentation 6.