Posterior Tibial Tendonitis vs. Tendonosis: What’s the Difference?

If you’ve been researching posterior tibial tendon pain, you’ve likely encountered two similar-sounding terms: posterior tibial tendonitis and posterior tibial tendonosis. While they affect the same tendon and share some symptoms, these are actually distinct conditions that require different approaches to treatment.

Understanding the difference is crucial for getting the right care and making a full recovery.

Quick Comparison: Tendonitis vs. Tendonosis

Aspect	Tendonitis	Tendonosis
Nature	Acute inflammation	Chronic degeneration
Onset	Sudden	Gradual
Duration	Days to weeks	Weeks to months/years
Primary Issue	Inflammation	Tissue breakdown
Treatment Focus	Reduce inflammation	Stimulate healing
Recovery Time	Weeks	Months

What Is Posterior Tibial Tendonitis?

Posterior tibial tendonitis is an acute inflammatory condition of the posterior tibial tendon. It typically develops quickly, often after a specific event or period of increased activity.

Key Characteristics

• Inflammation of the tendon and surrounding tissues
• Acute onset (hours to days)
• Inflammatory markers present (swelling, warmth, redness)
• Usually related to recent overuse or injury

Common Causes

• Sudden increase in activity
• New exercise or sport
• Acute trauma (fall, twist)
• Wearing improper footwear for a specific activity

Typical Symptoms

1. Rapid onset of pain
2. Visible swelling around the inner ankle
3. Warmth over the affected area
4. Redness (sometimes)
5. Pain with specific movements
6. Symptoms improve with rest and ice

What Is Posterior Tibial Tendonosis?

Posterior tibial tendonosis is a chronic degenerative condition. It develops over time due to repeated stress that exceeds the tendon’s healing capacity, leading to structural breakdown of the tendon tissue.

Key Characteristics

• Degeneration of tendon tissue
• Gradual onset (weeks to months)
• Minimal inflammation (or none)
• Related to long-term overuse and incomplete healing

Common Causes

• Chronic, repetitive stress
• Years of wear and tear
• Previous episodes of tendonitis that didn’t fully heal
• Age-related changes in tendon tissue
• Biomechanical issues (flat feet, overpronation)

Typical Symptoms

1. Gradual onset of pain
2. Chronic, dull ache
3. Morning stiffness that improves with activity
4. Thickened tendon that may feel knotted
5. Weakness when pushing off
6. Long-lasting pain that doesn’t fully resolve with rest

Side-by-Side Comparison

Onset and Duration

Tendonitis:

• Sudden onset (hours to days)
• Typically lasts days to weeks
• Resolves with proper treatment

Tendonosis:

• Gradual onset (weeks to months)
• Persists for months or years
• Requires longer treatment

Pain Pattern

Tendonitis:

• Sharp, acute pain
• Pain with specific movements
• Significant pain with activity
• Pain improves with rest

Tendonosis:

• Dull, aching pain
• Pain throughout activity
• Pain that persists even at rest (in severe cases)
• Morning stiffness that improves with movement

Physical Findings

Tendonitis:

• Visible swelling
• Warm to touch
• Redness
• Tenderness along the tendon

Tendonosis:

• Mild or no swelling
• Normal temperature
• Thickened, nodular tendon
• Deep tenderness

Imaging Findings

Tendonitis:

• Inflammation around the tendon
• Fluid accumulation
• Normal or slightly thickened tendon

Tendonosis:

• Tendon thickening
• Degenerative changes
• Areas of abnormality within the tendon
• Possible partial tears

Why the Difference Matters

Understanding whether you have tendonitis or tendonosis is important because the treatment approaches differ:

Treating Posterior Tibial Tendonitis

Treatment focuses on reducing inflammation:

1. Rest and Activity Modification

   • Avoid activities that cause pain
   • Use crutches if needed
   • Switch to low-impact exercise

2. Ice Therapy

   • Apply ice for 15-20 minutes, several times daily
   • Reduces inflammation and pain

3. Medications

   • NSAIDs (ibuprofen, naproxen)
   • Reduce pain and inflammation

4. Immobilization

   • Sometimes a walking boot or brace
   • Allows inflammation to settle

5. Physical Therapy

   • Gentle stretching
   • Gradual strengthening
   • Modalities (ice, ultrasound)

Recovery: Usually 4-8 weeks with proper treatment

Treating Posterior Tibial Tendonosis

Treatment focuses on stimulating healing and addressing degeneration:

1. Targeted Exercise

   • Eccentric exercises are the cornerstone
   • Slow, controlled lengthening of the tendon
   • Promotes collagen remodeling and healing

2. Activity Modification

   • Reduce stress on the tendon
   • Cross-train with low-impact activities
   • Avoid aggravating activities

3. Physical Therapy

   • Comprehensive rehabilitation
   • Eccentric, isometric, and progressive strengthening
   • Gait analysis and correction
   • Balance training

4. Orthotic Support

   • Custom orthotics
   • Supportive footwear
   • May help address biomechanical issues

5. Advanced Treatments (if needed)

   • Extracorporeal Shockwave Therapy (ESWT)
   • Platelet-Rich Plasma (PRP) injections
   • Surgery (in refractory cases)

Recovery: Typically 3-6 months of dedicated treatment

Can One Turn Into the Other?

Yes, this is a common progression:

Acute Tendonitis → Chronic Tendonosis

This is a well-documented pathway:

1. You develop acute tendonitis
2. You return to activity too quickly
3. The tendon doesn’t fully heal
4. Repeated stress causes ongoing damage
5. Over time, degenerative changes develop
6. You now have tendonosis

This is why proper treatment of acute tendonitis is so important—it’s easier to treat and has a faster recovery.

How to Know Which You Have

Questions to Consider

1. How quickly did the pain start?

   • Sudden = likely tendonitis
   • Gradual = likely tendonosis

2. How long have you had symptoms?

   • Days to weeks = likely tendonitis
   • Months = likely tendonosis

3. Is there swelling and warmth?

   • Yes = suggests tendonitis
   • No or minimal = suggests tendonosis

4. Does the pain improve with rest?

   • Significantly = suggests tendonitis
   • Only partially = suggests tendonosis

5. Do you have morning stiffness?

   • Minimal = suggests tendonitis
   • Significant, lasting >30 minutes = suggests tendonosis

See a Professional

The most reliable way to get an accurate diagnosis is to see a healthcare professional. They can:

• Take a detailed history
• Perform a physical examination
• Order appropriate imaging (MRI or ultrasound)
• Provide the correct diagnosis

Treatment: The Importance of Getting It Right

Getting the right diagnosis matters because the wrong treatment can make things worse:

If You Have Tendonitis But Think It’s Tendonosis

• You might do aggressive strengthening too soon
• Could worsen inflammation
• Delay recovery

If You Have Tendonosis But Think It’s Tendonitis

• You might rely too much on rest and ice
• Missing the key treatment (eccentric exercise)
• Condition may progress

Prevention: Stopping the Progression

Whether you currently have tendonitis or tendonosis (or neither), here’s how to prevent problems:

For Tendonitis

1. Treat it properly

   • Don’t return to activity too quickly
   • Complete your rehabilitation
   • Address any biomechanical issues

2. Gradual progression

   • Don’t increase activity too quickly
   • Follow the 10% rule

3. Proper warm-up

   • Dynamic stretching before activity
   • Gradual intensity increase

For Tendonosis

1. Patience with treatment

   • Eccentric exercises take time to work
   • Expect 3-6 months of treatment
   • Consistency is key

2. Address underlying causes

   • Biomechanical issues
   • Training errors
   • Footwear

3. Maintenance

   • Continue exercises after recovery
   • Regular strengthening
   • Don’t ignore early symptoms

Conclusion

While posterior tibial tendonitis and tendonosis both affect the same tendon and cause similar symptoms, they are fundamentally different conditions:

• Tendonitis = acute inflammation, sudden onset, faster recovery
• Tendonosis = chronic degeneration, gradual onset, longer treatment

The key to proper treatment is accurate diagnosis. If you’re experiencing posterior tibial tendon pain, consider seeing a healthcare professional who can determine which condition you have and guide you to the right treatment.

Remember: treating tendonitis like tendonosis (or vice versa) can delay recovery or make things worse. Get the right diagnosis and follow the appropriate treatment plan.

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Want to learn about early warning signs? Read: Early Signs of Posterior Tibial Tendon Dysfunction