Posterior tibial tendinopathy: this is the search made by people who have pain on the inner side of the ankle when walking for a long time or standing all day, and who have noticed that the foot seems to "give way" inwards. Before giving you the programme, though, I will tell you straight away the thing that almost no article on this topic puts in writing: that exercises and insoles stop the arch of the foot collapsing is not proven. What the evidence supports is more modest, and it is still the best reason to start there.
In this guide you will first find the signs that should make you stop, then what the research really says about posterior tibial tendinopathy, how it is recognised, why the staging system you see everywhere has changed, and what to include in a programme with which expectations.
⚠ Important: read this before continuing
The exercises and advice in this article are general guidance and may not suit your situation. Everyone has a unique clinical history: what works for others could be counterproductive for you.
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First of all: the signs that come before any exercise
The inner side of the ankle is a crowded area: tendons, nerves, small bones under heavy load. Several things can hurt in the same spot, and some of them should not be managed with exercises. Check these signs before reading the practical part.
You felt a sudden give, a snap, and now you cannot bear weight on the foot. An acute tendon injury or a fracture cannot be trained: it needs assessment promptly.
The pain is focused on the bone, the inner ankle bone or the inner top of the foot at the level of the navicular bone, and appeared after an increase in running, jumping or a change of surface. The medial malleolus and the navicular are two of the sites classified as "high-risk" stress fractures: high-load areas under traction with poor blood supply, where a delayed diagnosis leads to delayed healing and failed union. In those cases the literature recommends a high index of suspicion, early imaging and offloading, not a strengthening programme.
The foot is warm, swollen and red, perhaps without pain proportionate to the swelling, and you have diabetes or peripheral neuropathy. This is the picture that should bring Charcot arthropathy to mind: here time matters, and the right thing is to remove load and be seen straight away, not to strengthen.
You have fever, chills, redness that is spreading, or a wound nearby. Infection first, then everything else.
You feel tingling, burning or numbness on the sole of the foot or towards the toes. This points to nerve involvement (for example a tarsal tunnel syndrome), which is managed differently.
The calf is swollen and painful, and the pain is not linked to movement of the foot. Suspected deep vein thrombosis must be ruled out by a doctor before anything else.
You have prolonged morning stiffness and pain in several joints, or a diagnosis of inflammatory arthritis. Rheumatic diseases can damage this tendon directly: the assessment should be made together with a rheumatologist.
And one sign that is not an emergency but does change the strategy: if, looking at both feet from behind, you notice that the arch of one is lower and the heel is more deviated outwards, you are no longer in the phase where it is enough to "rest a little". Get assessed early.
What the research really says (the part that is usually missing)
This is the honest core of this article, and I ask you to read it before the list of exercises.
First: the natural history is not really known. The main review on posterior tibial tendon dysfunction states this explicitly: the natural history of the condition is not fully understood, although there is broad agreement that it is a progressive disorder. That difference matters. "Everyone agrees it tends to get worse" is not the same as "it has been shown that, if untreated, it evolves into flat foot". The first is clinical consensus, the second would be a finding nobody has in hand. For the same reason, the claim that circulates everywhere, that this is the most common cause of acquired flat foot in adults, appears in sources in a more cautious form: a common cause.
Second: the evidence for exercise is thin, and the effects are modest. The systematic review that searched for all randomised trials of exercise in posterior tibial tendinopathy found 3, for a total of 93 people. Eccentric strengthening, combined with stretching and insoles, showed moderate effects (standardised mean differences between 0.6 and 1.2) in reducing pain and disability compared with concentric strengthening with stretching and insoles, and compared with stretching and insoles alone. The authors conclude by referring to a scarcity of good-quality research and to prescription parameters reported minimally: in the studies, often, the only constant was the number of sets and repetitions and the duration of the trial period.
Two clarifications that are usually skipped, and that change the weight of that result. The first: the eccentric advantage comes from only one of the three studies, with twelve people per group, and the review authors describe it as "marginally more effective" than the other types of strengthening; in the same comparison, concentric and isotonic strengthening did not do better than stretching and insoles alone on the Foot Function Index at 12 weeks. The second: the strengthening did not improve the strength measures, either at 6 or at 12 weeks, and the distance covered in the 5-minute walk test was not different between groups. What moves in the data is pain and the patient-reported score, not measured strength.
Third: in almost all the studies the exercises were added on top of insoles. In two of the three studies the comparison was "insoles + stretching + exercises" against "insoles + stretching": what is measured there is not exercise against nothing, it is which ingredient to add on top of the insoles. In the most cited randomised study, 36 adults with an early-stage picture were divided into three groups for 12 weeks: insoles and stretching; insoles, stretching and progressive concentric strengthening; insoles, stretching and progressive eccentric strengthening. Foot Functional Index scores improved in all three groups, with the eccentric group improving the most and the group with insoles and stretching alone improving the least. Pain straight after the 5-minute walk test decreased in all groups.
The only study in which exercises were tested without insoles (stretching, ankle strengthening and balance against no treatment) is also the smallest of the three: 14 people in total, 7 against 5. There, pain fell much more than in the group left untreated at 6 weeks, and ankle dorsiflexion mobility improved. With numbers like these it is an encouraging hint, not proof: but it is right to know that an "exercise against nothing" comparison exists, and it went well.
Fourth: the insoles offer a hint, not strong proof. The systematic review on orthotic treatment in the early stages included 4 randomised studies and 186 people, with 75% at high risk of bias due to lack of blinding of participants and practitioners. The conclusion is framed in the conditional: orthotic treatment may be effective in reducing pain in the early stages, and insoles with a custom support for the longitudinal inner arch were found to be more effective than flat insoles or standard treatment. The authors call for more research.
Fifth, and most important: arch shape is not among the outcomes of these studies. The reviews report pain, patient-reported function scores, strength and distance walked, measured at 6 and 12 weeks: there is no measurement of arch height or of progression of the deformity over time. If you are looking for proof that insoles and exercises stop the deformity, that proof does not exist today, either for or against.
What do you do with all this? Not that conservative treatment of posterior tibial tendinopathy is useless: it remains the first route, it costs little and does no harm. But it changes two concrete things: what you expect (a reduction in pain and better tolerance of walking, not a guarantee about the arch) and what you monitor (not only how you feel, but also whether the shape of the foot is changing, because nobody can reassure you in advance about that).
What the posterior tibial tendon is and what it does
The posterior tibial muscle starts from the deep and back part of the lower leg. Its tendon runs behind the inner ankle bone, changes direction at that point like a rope around a pulley, and inserts into several bones of the foot, mainly the navicular.
Its work is twofold: it turns the foot inwards (inversion) and, above all, actively supports the inner arch with every step. When you rise onto your toes, it is what locks the hindfoot and turns the foot into a rigid lever. If it weakens, stretches or tears, that support is lost and the passive structures, ligaments and capsules, are left to bear a load they are not built for. From there the progressive flattening can begin.
The point where the tendon turns behind the malleolus is also where the blood supply is poorest: it is the area where pain most often concentrates.
Why it happens
Overuse degeneration. This is the most frequent mechanism: over time the tendon tissue changes and loses its capacity to bear load. What we call posterior tibial tendinopathy is therefore, in most cases, a degenerative tendinopathy rather than a classic inflammation: the term "tendinitis" is convenient but imprecise.
Overload. Rapid increases in walking, running, work on your feet, return to activity after a break, changes of footwear or surface.
Inflammatory diseases. Rheumatoid arthritis and other arthritides can attack the sheath and the tendon directly.
Factors that are often found together with the problem. Here it is better to be precise about what is known. The case series that examined the clinical histories of 67 people with a rupture of the posterior tibial tendon (average age 57) found that 52% had hypertension, diabetes or obesity, with a statistical association for obesity and, to a lesser extent, for hypertension. It is a study without a comparison group: it says these factors are often found together with the problem, not that they cause it. Added to this, based on clinical experience more than dedicated studies, are older adult age, a foot that is already tending towards flatness, or a hindfoot that is valgus from the start. Repeated cortisone injections in that area are also considered a risk: in the literature they are associated with worsening of the local blood supply of the tendon, which is already poor.
Trauma. Significant sprains or direct injuries in that area.
An important piece of advice: before trying these exercises, make sure you have received a correct diagnosis. People often think they have one problem when the real cause of the pain is another. Doing the wrong exercises can make the situation worse instead of better.
How it is recognised
Pain on the inner side, below and behind the inner ankle bone, extending towards the centre of the foot. It gets worse with prolonged walking, standing, climbing and uneven ground.
Swelling along the course of the tendon, often cord-shaped, behind the inner ankle bone.
A dropping arch, most evident when comparing the two feet while weight-bearing.
Heel deviated outwards. Looking at the person from behind, more toes are visible sticking out laterally on the little-toe side than on the other foot.
Difficulty rising onto the toes of one foot. This is the sign clinicians look for most: on a healthy foot, when you rise onto your toes on one leg, the heel turns inwards and the arch lifts. If the tendon is not working, the movement is weak, painful, or the heel does not turn. Note one detail that changes the interpretation: in the early stages a single rise can still be substantially normal, and what gives way is the repetition, that is, you cannot do several in a row. It remains a useful clinical test, but without a certified predictive value: on its own it does not make a diagnosis.
Tiredness and heaviness of the foot at the end of the day, even before frank pain.
The stages, and why the classification has changed
Almost all articles report the four classic stages: tenosynovitis without deformity (I), flat foot that is still flexible with a stretched or torn tendon (II), flat foot that has become rigid with arthritis of the joints of the foot (III), involvement of the ankle (IV).
It is a useful map for understanding the direction of travel, but it should be used knowing something that is usually not said: none of these classification systems has ever been validated. The international consensus group that revisited the topic in 2020 writes this plainly: from the first classification in 1989 onwards, later versions added anatomical variants but were never put through validation. The same group unanimously proposed abandoning the old names and calling the condition progressive collapsing foot deformity (PCFD), describing it as a complex three-dimensional deformity that combines hindfoot valgus, forefoot abduction and midfoot varus.
The practical message is twofold. On one hand, the problem is almost never just the tendon: when the arch gives way, ligaments and joints are also involved, and focusing only on the "inflamed tendon" misses the picture. On the other, if you hear that you are "in stage II", take it as a reasoned description of the state of your foot, not as an objective measure. The new classification, after all, comes from expert consensus, which is the lowest level of evidence, not from a study.
If in your case the picture is already that of a collapsed arch, the guide on adult flat foot and exercises to strengthen the plantar arch may also be useful to you.
How the diagnosis is reached
Clinical examination. This is the part that carries the most weight: observing the foot under load from the front and from behind, comparing the two sides, palpating the course of the tendon, assessing strength in inversion, the single-leg heel-raise test, checking ankle mobility and whether the deformity is rigid or not.
Ultrasound. It shows the superficial tendon well: thickening, fluid in the sheath, degenerated areas, partial tears. It has the advantage of being dynamic and is usually the first test.
MRI. It is needed when the picture is unclear, when an extensive lesion is suspected or when ligaments and cartilage must also be assessed.
Weight-bearing X-rays. These are the ones that really show alignment: X-rays taken lying down do not tell you what is needed.
On the choice of tests, it is worth knowing that in the 2020 consensus group the proposal to include MRI within the classification was rejected (three votes in favour out of nine). Not because MRI is useless, but because staging remains first of all clinical: what you see the foot doing matters more than what appears on an image.
Treatment: what to include, and in what order
The shared principle is that in the early stages of posterior tibial tendinopathy one always starts with non-surgical treatment. Here is how I would set it up, with honesty about what supports each choice.
Reduce the load that causes pain, without stopping altogether. Not "absolute rest": remove the activities that trigger the symptom (running, long walks on asphalt, long periods standing) and keep those the foot tolerates. A tendon kept completely at rest does not become stronger.
In the more irritated pictures, a period of immobilisation. A brace or boot for a few weeks is a common clinical choice when pain is high: it serves to calm the tissue and allow you to restart, not to cure.
Insoles. They are the intervention with the most studies behind it in this condition, and it is reasonable to consider them part of the programme from the start. But remember the real level of the evidence: 4 randomised studies, 186 people, most at high risk of bias, with a pain advantage for custom arch supports compared with flat insoles. It is worth using them, knowing that they help the symptom and are not a structural correction.
Footwear. A closed shoe, with a rigid heel counter and a sole that is not too flexible, gives the foot a support that is often felt straight away. It is common-sense clinical advice more than a recommendation based on dedicated studies.
Progressive strengthening. To be introduced once the most irritable phase has calmed down. The documented additional benefit concerns only the eccentric version and comes from a single study with twelve people per group: in the same comparison, concentric and isotonic strengthening did no better than insoles and stretching alone. It is worth doing, since it is the lever over which you have direct control, while knowing this is the real level of the evidence.
Cold and anti-inflammatories can help manage an acute phase. They do not change the course and should not be used to silence pain and carry on loading as before.
In advanced stages, when the foot has become rigid or the ankle is involved, the discussion changes: one moves to more structured braces that include the ankle (such as an AFO) and surgery is evaluated, which the literature describes as a "tailored" reconstruction, with different combinations of soft-tissue procedures, osteotomies and arthrodeses depending on the deformity. This is not a personal failure: it is a different condition from the one treated with exercises.
The exercises for posterior tibial tendinopathy, one by one
First, a clarification that will spare you frustration. You will not find precise dosages here of the kind "3 sets of 15, twice a day". This is not an oversight. The systematic review assessed how well prescription parameters are described in the studies: sets, repetitions and programme duration are the only items reported by all of them, while load, rest between sets, time under tension and range of movement are missing almost everywhere. Copying "3 sets of 15" therefore gives an idea of precision that the studies do not have, because half of the parameters that decide the effect are not even written down. The good criterion is not a number, it is how the foot feels the next day.
Inversion against elastic resistance. Seated, leg straight, elastic band around the forefoot and anchored on the opposite side. Turn the foot inwards and downwards, then, and this is the part that matters, let the band return very slowly, resisting. That slow return phase is the eccentric work, the ingredient that gave the largest advantage in the studies. The movement starts from the ankle, not from the hip rotating.
Heel raises. Start standing on both feet, move to one leg when the movement is clean and the foot does not protest the next day. Rise in a controlled way and lower even more slowly. A useful variant when the hindfoot tends to fall outwards is to squeeze a small ball between the heels, to encourage them to stay aligned.
Short foot (arch activation). Foot resting on the floor, heel and base of the big toe fixed: try to "shorten" the foot by bringing the forefoot towards the heel while lifting the arch, without curling the toes. It is the hardest exercise to learn and the easiest to get wrong: if the toes bend into a hammer shape, you are not doing it.
Toe strengthening. Scrunching a towel or picking up small objects trains the intrinsic muscles of the foot. It is a sensible complement, not the pivot of the programme.
Single-leg balance. It serves to re-educate control of the foot under load. Natural progression: eyes open on a stable surface, then eyes closed, then a soft surface. The rule is to stay where you can keep the arch lifted and the heel aligned: if the foot collapses, you are training the wrong pattern.
Calf stretching. A stiff calf increases the load on the inner side of the foot, and from there comes the logic of stretching it. It is worth doing in two variants, with the knee straight and with the knee bent, because they involve different muscles. If the ankle moves poorly, it may make sense to work on it separately with ankle dorsiflexion exercises.
On why so much emphasis is placed on the slow return phase, we covered it more fully in the guide to eccentric exercises.
How to progress without invented numbers. You increase when the movement is clean and the foot is no worse the next morning. Moderate discomfort during the exercise is acceptable in a tendinopathy; pain that increases from day to day, or that appears at rest, is the signal to step back one rung. And if the deformity keeps increasing despite everything, the problem is not your consistency: it is that a re-assessment is needed.
What you can control to reduce the risk
There are no studies showing that this condition can be prevented, so what we are discussing here are reasonable choices, not guarantees. Increase loads gradually, in running, walking and hours on your feet, rather than in jumps. Keep an eye on body weight and metabolic conditions, which appear consistently in the literature among the associated factors. Use footwear that genuinely supports the hindfoot when you are on your feet for long periods. Maintain strength and mobility of the ankle and foot. And above all do not ignore pain on the inner side of the foot that lasts for weeks: posterior tibial tendinopathy is one of those conditions in which getting seen early, even just to know where you stand, changes the options available.
Where online physiotherapy fits
Telerehabilitation does not add a magic ingredient. Here it serves three concrete purposes, which are the three areas in which self-management most often fails.
The first is understanding whether the picture really is this one: the list of signs at the top of this article is checked in an assessment, and the comparison between the two feet under load can be made by looking, even on a video call. The second is seeing how you perform the movement: the short foot and eccentric inversion are exercises that almost everyone gets wrong on the first attempt, and they are corrected in a few minutes. The third is deciding when to change: when to add load, when to stop, when it is time to ask for an ultrasound or a specialist assessment instead of persisting.
In summary
Posterior tibial tendinopathy is the suffering of the tendon that supports the arch of the foot, and it should be taken seriously because the overall picture, which experts now prefer to call progressive collapsing foot deformity, tends to get worse. "Tends to get worse", however, remains an agreement among clinicians, not a progression demonstrated by studies, and this also applies in reverse: nobody has shown that insoles and exercises stop the collapse of the arch.
What the evidence supports is narrower than how it is usually presented: in a single study of 36 people, eccentric strengthening added to insoles and stretching reduced pain and disability more than insoles with stretching alone, while the other forms of strengthening made no difference and measured strength did not improve in any of the three studies in the review (93 people in total). That is little, and you should know it. It is still enough to start from there, because it costs little, does no harm, and the alternative is waiting.
The practical rule I leave you with: start as soon as possible, measure your progress on pain and walking, but keep an eye on the shape of the foot too. If the arch keeps dropping while the pain improves, you are not finished: you have only changed the problem to solve.
Sources
- Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines, BMJ Open Sport & Exercise Medicine, 2018
- Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial, Physical Therapy, 2009
- Orthotic treatment for stage I and II posterior tibial tendon dysfunction (flat foot): A systematic review, Clinical Rehabilitation, 2021
- Classification and Nomenclature: Progressive Collapsing Foot Deformity, Foot & Ankle International, 2020
- Posterior Tibial Tendon Dysfunction: An Overview, The Open Orthopaedics Journal, 2017
- High-Risk Stress Fractures: Diagnosis and Management, PM&R, 2016
- Possible epidemiological factors associated with rupture of the posterior tibial tendon, Foot & Ankle, 1992
Last check of the sources: August 2026.
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