What Is Posterior Tibial Tendonosis? Understanding Chronic Tendon Degeneration

While posterior tibial tendonitis gets more attention, its counterpart—posterior tibial tendonosis—is equally important to understand. This chronic condition affects the same tendon but involves a different pathological process that requires its own approach to treatment.

Understanding Posterior Tibial Tendonosis

Posterior tibial tendonosis (also spelled “tendinosis”) is a chronic, degenerative condition affecting the posterior tibial tendon. Unlike tendonitis, which involves acute inflammation, tendonosis refers to the gradual breakdown of tendon tissue without significant inflammation.

The Key Difference: Tendonitis vs. Tendonosis

  • Tendonitis: Acute inflammation of the tendon, usually from recent overuse or injury
  • Tendonosis: Chronic degeneration of the tendon due to long-term, repetitive stress

Think of tendonitis as a fresh injury, while tendonosis is more like wear and tear accumulated over months or years.

What Causes Posterior Tibial Tendonosis?

Posterior tibial tendonosis develops when the tendon is subjected to repeated stress over an extended period, without adequate time for recovery. The body cannot repair the microdamage faster than it occurs, leading to gradual degeneration.

Primary Causes

  1. Chronic Overuse

    • Repetitive activities that stress the PTT
    • Long-distance running, hiking, or sports with frequent jumping
    • Occupations requiring prolonged standing

  2. Age-Related Degeneration

    • Tendons become less resilient with age
    • Reduced blood supply to the tendon
    • Natural wear and tear over decades

  3. Biomechanical Factors

    • Flat feet (pes planus) creating constant strain
    • Overpronation during walking or running
    • Leg length discrepancies

  4. Incomplete Healing

    • Previous ankle injuries that didn’t heal properly
    • Recurrent episodes of tendonitis that developed into chronic degeneration
    • Inadequate treatment of initial tendon injuries

Risk Factors

  • Age over 40
  • History of ankle or foot injuries
  • Flat feet or fallen arches
  • Obesity
  • Diabetes
  • Participation in high-impact sports
  • occupations involving prolonged standing

Symptoms of Posterior Tibial Tendonosis

The symptoms of posterior tibial tendonosis can be similar to tendonitis but often develop more slowly and persist longer. Understanding these symptoms is crucial for getting the right diagnosis and treatment.

Characteristic Symptoms

  1. Chronic Inner Ankle Pain

    • Dull, aching pain behind the medial malleolus (inner ankle bone)
    • Pain that persists for weeks or months
    • Pain that worsens with activity and improves with rest

  2. Morning Stiffness

    • Significant stiffness in the ankle after periods of rest
    • Pain and stiffness when taking first steps in the morning
    • Improvement after walking for a few minutes

  3. Reduced Strength

    • Weakness when pushing off while walking
    • Difficulty rising on your toes
    • Fatigue in the foot and ankle during activity

  4. Swelling and Thickening

    • Chronic, low-grade swelling
    • The tendon may feel thickened or nodular
    • Possible creaking or grating sensation (crepitus) when moving the ankle

  5. Changes in Foot Structure

    • Progressive flattening of the arch
    • Development of adult-acquired flatfoot
    • Outward tilting of the heel

Symptoms That Differ From Tendonitis

  • Less acute inflammation: Unlike tendonitis, there may be minimal redness or heat
  • Longer duration: Symptoms persist for more than 6 weeks
  • More gradual onset: Pain develops slowly over time rather than suddenly
  • Chronicity: Symptoms may wax and wane but rarely resolve completely without treatment

How Is Posterior Tibial Tendonosis Diagnosed?

Diagnosing posterior tibial tendonosis requires a thorough evaluation, as it can be mistaken for tendonitis or other ankle conditions.

Medical History and Physical Examination

Your healthcare provider will:

  • Ask about your symptoms, their duration, and what aggravates them
  • Review your activity history and any previous injuries
  • Examine your foot and ankle for swelling, tenderness, and weakness
  • Assess your foot mechanics and arch structure

Diagnostic Imaging

  • MRI (Magnetic Resonance Imaging): The gold standard for visualizing tendon degeneration, tears, and abnormalities
  • Ultrasound: Can show tendon thickening, degeneration, and tears in real-time
  • X-rays: Used to rule out bone abnormalities, arthritis, or stress fractures

Key Diagnostic Indicators

Unlike tendonitis, tendonosis often shows:

  • Tendon thickening without significant fluid buildup
  • Areas of degeneration within the tendon
  • Absence of acute inflammatory markers

Treatment Options for Posterior Tibial Tendonosis

Treatment for posterior tibial tendonosis focuses on promoting tendon healing, reducing pain, and addressing underlying biomechanical issues. Because tendonosis involves degeneration (not just inflammation), treatment often takes longer than for tendonitis.

Conservative (Non-Surgical) Treatments

1. Activity Modification

  • Reduce or modify activities that stress the tendon
  • Switch to low-impact exercises (swimming, cycling, elliptical)
  • Avoid walking or standing for prolonged periods
  • Use rest as needed, but complete immobilization is usually not recommended

2. Physical Therapy

This is the cornerstone of treatment for tendonosis:

  • Eccentric exercises: Slow, controlled lengthening exercises that have been shown to stimulate tendon healing
  • Strengthening exercises: Building strength in the posterior tibial muscle and supporting muscles
  • Stretching: Improving flexibility in the calf muscles and Achilles tendon
  • Proprioception training: Improving balance and joint awareness
  • Gait analysis and correction: Addressing biomechanical issues

3. Orthotics and Support

  • Custom orthotics: Provide arch support and correct overpronation
  • Supportive footwear: Shoes with good arch support and stability
  • Ankle braces: For severe cases or during physical activity

4. Medications

  • NSAIDs: May provide temporary pain relief but don’t address the underlying degeneration
  • Topical treatments: Gels or creams that may help with localized pain
  • Note: Unlike tendonitis, corticosteroid injections are generally not recommended for tendonosis as they can potentially weaken the tendon further

5. Other Therapies

  • Extracorporeal Shockwave Therapy (ESWT): Sound waves stimulate healing
  • Platelet-Rich Plasma (PRP) injections: Using your own blood platelets to promote healing
  • Physical modalities: Ultrasound, ice, heat therapy

Surgical Treatment

When conservative treatments fail after 3-6 months, surgery may be considered:

Surgical Options

  1. Tendon Debridement: Removing degenerated tissue and promoting healing
  2. Tendon Repair: Suturing torn or damaged portions of the tendon
  3. Tendon Transfer: Using another tendon (often the flexor digitorum longus) to replace function
  4. Osteotomy: Realigning bones to reduce stress on the tendon
  5. Fusion procedures: For advanced cases with significant joint damage

Recovery After Surgery

  • Initial immobilization (4-6 weeks)
  • Gradual return to weight-bearing
  • Physical therapy for 3-6 months
  • Full recovery may take 6-12 months

Can Posterior Tibial Tendonosis Heal Without Surgery?

Yes, many cases of posterior tibial tendonosis can improve with conservative treatment. However, the healing process is slower than with tendonitis—expect at least 3-6 months of dedicated treatment before seeing significant improvement.

The key is consistency with physical therapy and addressing the underlying causes (biomechanics, activity modification, footwear).

Preventing Posterior Tibial Tendonosis

Prevention is always better than treatment. Here’s how to reduce your risk:

  1. Don’t Ignore Early Signs

    • Address ankle pain promptly
    • Don’t assume pain will “just go away”

  2. Use Proper Footwear

    • Choose supportive shoes with good arch support
    • Replace shoes when worn out
    • Avoid flat sandals or shoes with minimal support

  3. Gradual Training Progression

    • Increase exercise intensity gradually (the 10% rule)
    • Include rest days in your routine
    • Vary your activities to reduce repetitive stress

  4. Strengthen Supporting Muscles

    • Regular calf and foot exercises
    • Balance training
    • Core strength for overall stability

  5. Maintain Healthy Weight

    • Reducing stress on your tendons
    • Lowering your risk of tendon strain

  6. Address Biomechanical Issues

    • Use orthotics if you have flat feet
    • Consider gait analysis if you have recurrent foot or ankle problems

Conclusion

Posterior tibial tendonosis is a chronic condition that requires patience and consistent treatment. Unlike acute tendonitis, it develops over time due to repetitive stress and degeneration of the tendon tissue.

The good news is that with proper treatment—including targeted physical therapy, activity modification, and addressing underlying biomechanical factors—most people can recover from posterior tibial tendonosis without surgery.

If you’re experiencing chronic inner ankle pain that hasn’t responded to rest and basic care, consider seeing a healthcare professional for an accurate diagnosis. Early intervention leads to better outcomes.

Wondering about the specific differences between tendonitis and tendonosis? Read our detailed comparison guide: Posterior Tibial Tendonitis vs. Tendonosis.