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Why arch pain may be posterior tibialis insufficiency in runners - Blog Title Cover for Alliance Regen & Rehab

Preventing and Treating Posterior Tibialis Insufficiency in Runners

Posterior Tibialis Insufficiency (PTI) can be a painful and debilitating condition for runners. It occurs when the posterior tibialis tendon, a key stabilizer of the arch and foot, becomes inflamed or weakened. In this blog, we will delve into the essentials of PTI, including what the posterior tibialis is, the causes of posterior tibialis injuries, and explore effective prevention and treatment strategies for PTI and tendinitis.

The Posterior Tibalis Muscle & Tendon

What is the Posterior Tibalis Muscle?

The posterior tibialis is a vital tendon responsible for supporting the arch and foot. The muscle is located in the lower part of the leg and lies deep to the more superficial muscles that we tend to recognize in our anatomy – the gastrocnemius and soleus. This muscle attaches on the posterior surface of the tibia, which is the bigger bone in the lower leg. It attaches just below the knee joint and extends all the way down the tibia, runs just behind the medial malleolus with the flexor digitorum longus tendon and flexor hallucus longus tendon, and then attaches on multiple bones underneath the foot. 

Structure of skeletal muscle.
What Does the Posterior Tibialis Do?

Because of it’s attachments and it’s action on the foot/ankle, the posterior tib plays an important role in supporting the arch during walking gait and running gait.

If you were to engage the posterior tibialis alone, the muscle would be responsible for inversion of the foot (turning the sole of your foot inward towards midline) and plantarflexion (pointing your foot down or when doing a heel raise). The posterior tib helps to perform those motions with other muscles, but in terms of arch stabilization… the posterior tib is king. 

During running, it plays a crucial role in maintaining proper foot mechanics, specifically when accepting load on each stride, controlling the arch as you roll through and over the foot, and creating a rigid foot for propelling off the forefoot – that is where the plantarflexion and inversion come into play.

Now, when this tendon weakens or becomes inflamed, it can lead to posterior tibialis insufficiency, causing pain and discomfort for runners. Understanding the function and importance of the posterior tibialis is essential in managing PTI..

Achilles tendon.
How can you develop an injury of the posterior tibialis muscle?

A posterior tibialis injury usually occurs at some point in the tendon, which spans from behind the medial malleolus to underneath the sole of your foot. We normally see injuries right underneath the arch or right behind the malleolus. This can occur in the form of tendinopathy or a tendon tear. 

Now, the kicker is that getting an “injury” to this muscle directly is not the only way it can cause problems for runners or for anyone out there with a foot. In fact, this muscle alone can cause problems at the foot, at the knee, in front of the shin, at the hip, and even above that – just by be inactive or weak.

So, having a weak posterior tibialis muscle can cause a lot more problems and that’s our jobs as sports physical therapists and physicians at Alliance Regen & Rehab. We don’t just treat the pain, we fix it by finding the root cause of dysfunction!

Here are some reason why you may be at more risk for posterior tibialis insufficiency or injury:

  • Improper shoe wear
  • Weakness of the flexor hallucis brevis, flexor hallucis longus, gastroc, soleus or flexor digitorum longus
  • Limited amount of time barefoot 
  • Limited ankle joint mobility
  • Improper running form
  • Bunions or Hallux Valgus
  • Dropped Navicular Bone
  • Structural anatomy
  • Lumbar spine injuries affecting the tibial nerve (usually from L4, L5, or S1)
Don’t let all of that scare you! The body can be complicated even for those study it, but this shows why it’s important to get assessed by a licensed professional who understands biomechanics and movement. We believe physical therapists and certainly our physical therapists at Alliance in St. Petersburg, FL are perfectly positioned to help you find out the cause for your injury or movement dysfunction.

Prevention and Treatment For The Posterior Tibialis


Preventing posterior tibialis dysfunction involves a comprehensive approach and plan to do so. Selecting appropriate footwear that provides proper arch support and stability is essential. Runners or walkers should choose shoes that match their foot type, foot needs, and their foots capability. For instance, Runner A who has limited extension in his/her big toe would benefit from a shoe like a Hoka or something similar that doesn’t demand as much big toe extension! This is essential for push-off! Runner B who’s fairly new to running and who only has has some arch discomfort from time to time might benefit from something with more medial arch support while specific foot strengthening and physical therapy is taking place! 

Strengthening exercises play a vital role in preventing posterior tibialis injuries and other running injuries. Focusing on exercises that target the posterior tibialis, as well as other muscles throughout the foot, ankle, and lower leg will help create resiliency and better functionality outside of the gym. Gradual training progression, incorporating rest and recovery, is also crucial to prevent overuse and reduce the likelihood of injury to the posterior tibialis and/or arch.

The best suggestion for any runner is to get an evaluation by a movement specialist or a physical therapist who works with runners specifically. That is why one of our most popular services at Alliance Regen and Rehab is our Medical & Performance Running Analysis! This assessment is great for those who are injured and uninjured as it involves a comprehensive evaluation from head to toe looking to find limitations and strengths based on preferred values for runners! (great toe extension, hip extension, strength, etc). That also involves a discussion on goals, shoe wear assessment, and a video running analysis. You can find out more about our running analysis by clicking here or above! If you’re a runner in the St. Petersburg or Tampa area, we hope to see you!

Here are some exercises to help treat some potential contributing factors to posterior tibialis issues or over-pronation!

Treatment of Injury or Dysfunction in St. Petersburg, FL

When posterior tibialis injury occurs, prompt treatment is highly recommended to alleviate symptoms and promote healing as quickly as possible. Early treatment is vital because of the stages of healing and because it offers guidance/coaching to prevent a potential minor issue from turning into a severe issue! 

Most importantly, determining what is injured and what are the contributing factors for the injury is priority number one! Getting an evaluation by one of our running specialists in St. Petersburg can help uncover what limitations are causing this issue, create a game plan to fix it, and get you back to running quickly… and with proper guidance!

Physical therapy exercises, such as stretching and strengthening the posterior tibialis tendon, are crucial components of rehabilitation. We know how to target this muscle, how to challenge it, how to train the entire kinetic chain, and relate all of that to running or the activity you prefer! Depending on the severity and chronicity of the condition, orthotics or supportive devices, taping, may be recommended to offload stress from the tendon. Shoe wear may be recommended and we typically refer our patients to our trusted partner, St. Pete Running Company where they graciously afford our patients with special discounts!

Diagnostic Ultrasound Imaging is extremely beneficial for getting a real time look at the tissue and the severity of the injury! This helps to guide decision making in deciding which treatment options we need to deploy in order for you to get the most optimal outcome! These treatments may include physical therapy for the posterior tibialis alone, using shockwave therapy, using an orthobiologic like platelet rich plasma, or combining all of the above to get you where you desire to be!

At Alliance Regen and Rehab in St. Petersburg, we develop personalized rehabilitation programs that target your unique needs. If you’re experiencing any tendon-related issues or injuries, don’t hesitate to reach out to us for a consultation. We can help you maintain tendon health while enjoying sports like running, rucking, biking, or just walking!

Sign up for our email list today to learn more about our program and stay up-to-date on the latest news and tips related to pickleball health and wellness.

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