The purpose of this blog is to discuss the anatomy and function of the tibialis posterior, describe tibialis posterior tendinopathy, and outline exercises and management strategies for rehabilitation.
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Anatomy & Function
The tibialis posterior is located in the deep posterior compartment of the lower leg, originating from the tibia, fibula, and interosseous membrane. Its long tendon then travels behind the medial malleolus, passes through the tarsal tunnel, and inserts on the navicular, cuneiforms, cuboid, and bases of metatarsals 2-4, although the exact attachments may vary a bit. In a non-weight bearing position, the tibialis posterior is a plantar flexor (pointing the foot downward), invertor (turning the sole of the foot inward), and adductor (bringing the foot toward midline). Klein 1996 reported the tibialis posterior as having the greatest inversion moment arm.
The tibialis posterior’s main functions are highlighted in weight bearing, particularly during the stance phase of gait. As one of the primary supinators of the foot and ankle, it helps to support and control the medial longitudinal arch of the foot. For simplicity, think of supination in weight bearing as the raising of the navicular and arch, while pronation is the lowering of those same structures.
During the first half of stance, pronation occurs to help create a flexible foot for attenuating forces and accommodating uneven terrain. This is partially controlled by the eccentric contraction of the tibialis posterior.
During the second half of stance, supination occurs to help create a rigid foot as we progress over the limb (“push-off”). This is aided by the concentric contraction of the tibialis posterior.
Tibialis Posterior Tendinopathy
According to the PhD thesis by Dr. Megan Ross, “tibialis posterior tendinopathy is the preferred terminology for the condition of a painful, dysfunctional tibialis posterior tendon.”
Although tibialis posterior tendinopathy is multifactorial, it’s easiest to think of it as a load-related issue. The tendon is being loaded more than it can currently handle. And this occurs along a continuum.
On one end, this might happen in a young, healthy runner who recently had a spike in mileage which resulted in an acute overload of the tendon. Toward the other side of the continuum, this might be a chronic issue in an older, sedentary individual with a higher body mass, resulting in a significant decrease in function.
In addition to pain along the medial aspect of their foot and/or ankle, individuals diagnosed with tibialis posterior tendinopathy may present with a more pronated foot posture. This too may occur along a continuum and progress as the condition worsens. Someone like the older, sedentary individual with the higher body mass may present with a flexible flatfoot deformity which is “characterized by forefoot abduction, a lowered medial longitudinal arch and/or hindfoot eversion.” A rigid flatfoot deformity would represent a more fixed posture of the foot in weight bearing and non-weight bearing, and would likely coincide with a significant progression of the condition (along with other comorbidities).
Please understand that having “flat”, or “flatter”, feet does not necessarily mean you’re going to develop tibialis posterior tendinopathy. You can have flat feet and be the fastest runner in the world (Usain Bolt).
Lastly, according to Ross 2021, the most reliable test for diagnosing tibialis posterior tendinopathy is a single leg heel raise.
A person would either report pain along their medial ankle and/or foot, or be unable to perform a single repetition. The young, healthy runner would likely have pain and decreased endurance, but would still be able to perform a single leg heel raise. On the other hand, the older, sedentary individual might not be able to perform a single leg heel raise because of that loss in function.
Load Management & Activity Modification
The most important aspect of rehabilitation for tibialis posterior tendinopathy is load management. You need to reduce or modify aggravating activities initially to reduce the overall load experienced by the tibialis posterior tendon before gradually reloading it through exercises and functional activities to build up its capacity.
If you’re the runner in this example, load management here is fairly straightforward – you need to manipulate your mileage (duration), speed (intensity), and/or frequency so that you’re able to run without a worsening of symptoms. If you have to scale back significantly, you can implement other forms of training like biking, swimming, and resistance training to maintain fitness while symptoms calm down.
I highly recommend tracking daily steps for anyone experiencing tibialis posterior tendinopathy because it helps you understand your baseline level of function and tolerance. You don’t necessarily have to hit a certain step count; you just need to determine how much is too much right now and very gradually build that up over weeks and months.
There are also strategies for reducing symptoms during walking and running. For example, a 2019 paper by Maharaj and colleagues demonstrated that walking with a wider step width may decrease the demand on the tibialis posterior during gait. If you normally walk with a very narrow stance, you can increase the distance between both feet so it feels like you’re walking on train tracks. I don’t recommend this as a permanent change. This is something you might do if you’re experiencing symptoms while walking from point A to point B, don’t have time to sit and rest, and want to try to offload the tendon a bit.
A similar thought process could be applied to running based on a 2014 study by Brindle et al. If you run with your feet really close together, or even crossing over one another, you can increase your cadence by 5-10%, imagine running on train tracks, or even place some white tape on a treadmill to use as a visual cue. To learn more, check out our podcast episode with Chris Johnson – Spotify, iTunes, iHeart, Amazon.
Finally, weight loss may be an option for contributing to a decrease in symptoms by reducing the load on the tibialis posterior and positively affecting other comorbidities you may have such as diabetes. If that is a goal of yours, I recommend working with licensed professionals who can assist with that process.
Shoes and Foot Orthoses
Most people want to know if they should wear specific shoes or foot orthoses, and I think it’s an important consideration if you’re experiencing symptoms associated with tibialis posterior tendinopathy.
A different study by Maharaj in 2018 found that supportive, athletic footwear may be beneficial in this scenario because the shoes help decrease the amount of work done by the tibialis posterior during walking compared to a barefoot condition in individuals with flat feet. Another study by Williams and colleagues in 2003 demonstrated that inverted foot orthoses may reduce the loads experienced by the tibialis posterior without actually changing the foot mechanics.
I want to highlight that last point again – the purpose of foot orthoses or shoewear isn’t to change how your feet look or move necessarily. The goal of either is to reduce the demand on the tibialis posterior. To learn more, check out our podcast episode with Ian Griffiths – Spotify, iTunes, iHeart, Amazon.
This also doesn’t mean that you have to wear a specific shoe or use a certain device for the rest of your life.
And it definitely doesn’t mean that you have to pick a shoe based on the appearance of your foot, especially if you’re asymptomatic.
I have extremely flat feet and I wear barefoot, or minimalist shoes, because they’re comfortable for me in the activities that I perform on a daily basis.
Research on tibialis posterior tendinopathy in general is somewhat limited, but even more so when it comes to exercise therapy.
Therefore, the exercise progressions that I have outlined in this video are based on the available evidence, what is known about the diagnosis, the anatomy and function of the tibialis posterior, and common impairments seen in patients.
A systematic review by Ross and colleagues in 2018 and research conducted for her PhD thesis determined that individuals with tibialis posterior tendinopathy may present with decreased single limb heel raise strength, endurance, and height, weakness related to plantar flexion, inversion, and forefoot adduction, impaired hip extensor strength and endurance, poorer hip abductor endurance, deficits in weight bearing ankle dorsiflexion range of motion, and difficulties with single leg balance.
This information is not based on prospective data which means that we cannot say that these changes are the cause of tibialis posterior tendinopathy. In fact, it’s very possible that function worsens due to pain and decreases in physical activity. Nonetheless, the exercise progressions will aim to address these deficits.
Exercise Progression #1: Foot Adduction
The first exercise comes from two papers by Kulig et al in 2004 and 2009. To familiarize yourself with the movement, you can just practice pointing your foot down and in in a seated position while your foot is not in contact with the ground. Next, sit on a chair with your knees flexed approximately 80 degrees with your feet on the floor. Stabilize your legs by placing your forearm between your knees and slide your foot along the ground toward the midline of your body. Finally, the actual exercise involves using an elastic band attached to your foot and maintained at a 45 degree angle to the floor. Based on the research by Kulig, it might be helpful to wear shoes while practicing this exercise initially.
Aim for 3-4 sets of 12-15 repetitions, 2-3 times per week. You may experience cramping in your foot or leg from the novel movement so take rest breaks as needed.
Exercise Progression #2: Heel Raise
A heel raise trains the tibialis posterior in a manner that may carry over to its role during the second half of the stance phase of gait.
The initial focus of a heel raise should be on the execution of the movement. As you perform a double leg heel raise, your heels should invert, or slightly point toward one another, which is indicative of that supination action of the tibialis posterior.
A lacrosse ball or tennis ball squeezed between your heels as you rise up on your toes can help guide the movement.
The next thing you want to do is ensure that you’re maximizing the height of the heel raise. Similar to the last exercise, your calves might feel like they’re going to cramp if you’re rising up as high as possible.
Aim for 3 sets of 20-25 repetitions with 2-3 minutes of rest between sets.
Once you can accomplish that, begin practicing with a single leg until you can accomplish 3 sets of 20-25 repetitions.
Next, add a weight in the same hand as the working leg while using the opposite hand to assist with balance.
Lastly, introduce a deficit or incline if tolerable while continuing to progress weight. There is no end goal once you’ve started adding weight and increased the range of motion. You just want to get progressively stronger while maintaining appropriate technique and staying within comfort.
Aim for 3-4 sets of 8-15 reps with 2-3 minute rests, 2-3 times per week. As you perform the movement, rise up to the count of 3 and lower down to the count of 3.
The next three movements will work on a combination of hip strength and endurance, weight bearing dorsiflexion range of motion, knee strength, foot and ankle strength, endurance, and control, and single leg balance. Altogether, they should carry over to functional tasks like walking, ascending and descending stairs, and other movements.
Exercise Progression #3: Single Leg Balance
There are going to be two camps of thought for how to train single limb balance, and I’m fine with either.
- Single leg exercises should be executed while maintaining the arch of the foot. This might help train the foot intrinsics, tibialis posterior, and decrease symptoms in some scenarios. However, it’s unrealistic, and probably not advantageous, to always train like this because the foot is meant to pronate, supinate, etc. during normal day-to-day activities.
- Therefore, the second way is to just let your foot do what it wants as long as it’s tolerable for you.
I lean more toward #2 because I think the body will adapt to the stressors placed upon it when dosed appropriately. Once again, you can explore both and use a combination of the two if that works for you.
For balance, practice standing on one leg until you can comfortably perform 3-4 sets of 60 seconds, 2-3 times per week. After you’ve accomplished that, there are two routes you can take:
- Y Balance. Stand on one leg and reach your opposite leg as far out in front of you, behind you and to the side, and behind you and to the side in the other direction. Start with short distances and progress over time.
- Single leg rotations. Stand on one leg, rotate your torso as far as you can in one direction, and then rotate as far as you can in the other direction. Same thing – start with small rotations and gradually make them larger.
There are an infinite number of possibilities here, but these two multiplanar exercises are quite challenging for the foot and ankle. Aim to eventually perform the Y Balance or Single Leg Rotations for 3-4 sets of 45-60 second rounds per leg, 2-3 times per week.
If you want to incorporate a balance pad, you’re welcome to do so. Also, feel free at any point to use a wall or dowel for assistance and use as short of hold times as necessary to make the exercises tolerable for you.
Exercise Progression #4: Squat/Lunge/Split Squat Variation
For this progression, you can start with bodyweight squats to a chair. If you feel comfortable performing 3-4 sets of 12-15 repetitions, 2-3x/week, you can progress one of two ways:
1. Practice single leg sit to stands from a chair. If the chair is too low, place objects down to decrease the difficulty. As you get stronger, you can slowly decrease the height. The progression is a single leg squat where instead of sitting all the way down, you just tap your butt to the chair or object behind you in a slow and controlled fashion.
2. Split squats. You’ll start in a half kneeling position with your back knee on a pad, pillow, or towel, and stand straight up. If rising from the floor is too difficult, place objects down to decrease the distance traveled. Over time, you can work your way back to the floor. The progression is a reverse lunge where you start in standing, take a step back, and drop the back knee to the floor under control.
Either exercise can be progressed to 3-4 sets of 8-15 repetitions, 2-3x/week with added weight as needed.
Exercise Progression #5: Deadlift Variation
The last exercise is a deadlift variation called a single leg RDL. It’ll be helpful to have already practiced the single leg balance mentioned earlier.
You’re going to stand on one leg, kick the other leg straight back so that it’s parallel with the floor, and then return to the starting position. The end goal is to not touch the moving leg to the floor, but it’s completely acceptable as you’re learning the exercise.
You can also use your hands to maintain balance.
A simple way to progress the movement is by adding a knee drive.
Finally, you can add a weight in the opposite hand of the stationary leg.
Aim for 3-4 sets of 6-12 repetitions, 2-3x/week.
Foot Intrinsic Strengthening
Why didn’t I include foot intrinsic strengthening exercises? Because they’re relatively low load and less challenging than the progression of movements that I just outlined. A single leg heel raise and some of the other exercises require you to move and support your entire body weight which will strengthen all of the intrinsic foot muscles. If you want to do a little more, you’re more than welcome to perform toe curls with a towel, toe spreading, toe yoga, and the short foot exercise.
Guidelines, Not Rules
Please recognize that these exercises are recommended based on a theoretical framework and therefore do not have to be followed exactly. This video is providing guidelines, not hard and fast rules. The frequency, intensity, and volume of exercises will be individualized based on your training history, symptoms, goals, etc. Some people may benefit from doing just 1-2 exercises, or no exercises at all (instead focusing on lifestyle factors and activity modifications)!
With regards to other interventions such as stretching, foam rolling, massage, dry needling, acupuncture, etc., you can do them if they feel good, don’t exacerbate symptoms, and don’t hinder progress with the exercises, but they’re not something that I personally recommend.
In summary, the appropriate terminology for pain and dysfunction associated with loading of the tibialis posterior tendon is tibialis posterior tendinopathy. The primary focus of rehab should be load management which includes reducing or modifying aggravating activities, and incorporating a gradual progression of exercises as needed. In addition to performing exercises 2-3 times per week, other forms of training like cycling and swimming may be beneficial if walking and running are limited. Since it can be a long process, tracking steps is helpful for monitoring progress. You may use supportive shoes or foot orthoses to temporarily reduce loads on the tibialis posterior, but the overall goal of rehab should be on improving your function rather than changing the structure or appearance of your foot.