Posterior tibial tendonitis stretches: the exact trial doses, and when surgery rebuilds the arch

Your inner ankle aches and you want a stretch that helps. Here is what the trials did. These are study protocols, not a plan for your foot, so have the diagnosis confirmed first.

Do posterior tibial tendonitis stretches work?

The posterior tibial tendon runs behind the bump on the inside of your ankle and holds up your arch.^[6] When it fails, the foot flattens.

A 2018 review found only three randomized trials, with 93 people, all at stage I or II. Calf stretching was in every treatment group, so no trial can say what stretching adds by itself.^[1] Orthopaedic surgeons still call calf stretching an important part of flatfoot therapy.^[6] A tight calf and flatfoot are linked, though which comes first isn’t clear.^[7]

When does surgery take over from stretching?

Untreated, this problem can progress to a painful flatfoot that needs extensive reconstruction.^[8] The classic stages are:^[9]

• Stage I: pain and mild swelling, no deformity.
• Stage II: the arch flattens, but the foot can still flex.
• Stage III: the deformity becomes fixed (stiff).
• Stage IV: the ankle tilts and wears out.

The exercise trials covered stages I and II only.^[1] For stages III and IV, surgery is the only definitive treatment.^[9] Exercise can also ease symptoms without restoring the tendon: after 10 weeks of eccentric work, pain and heel raises improved, but the tendon still looked abnormal on ultrasound.^[10]

To rebuild the arch, a surgeon can move a neighboring tendon to replace the failing one, shift the heel bone to protect it, repair ligaments, and lengthen a tight calf.^[6,11] The results:

• In that 15-year group, pain fell from 7.3 to 1.3 out of 10.^[3]
• In 102 feet followed about 10 years, 86% of patients were satisfied, some with minor reservations.^[12]
• Patients over 65 improved as much as younger patients.^[13]

Surgery is considered when three to six months of non-surgical care hasn’t worked.^[8] A Foot and Ankle Surgeon decides when that point has come. Once the foot turns stiff, the operation usually becomes a joint fusion,^[8] so an early surgical opinion keeps more options open. Our Center for Lower Extremity Surgery (external site) explains flatfoot reconstruction.

What is the posterior tibial tendonitis test?

It’s the single-leg heel rise. Standing on one leg and rising onto your toes takes a healthy posterior tibial tendon.^[6] You should manage 5 to 10 without difficulty.^[8] Trouble doing it isn’t a diagnosis, but it’s worth an exam. From behind, we also look for “too many toes,” a sign the front of the foot has drifted outward.^[6]

How do you do post tib tendonitis stretches?

Source: Kulig’s trial of 36 adults used a foam wedge near a wall, in shoes.^[9,5] Houck’s used a plain wall calf stretch. We show the wall version with Kulig’s dose: six 30-second stretches, twice a day, in a 12-week program.^[14,9,5]

1. Face a wall in your shoes, hands on the wall. Step the sore leg back with the heel down and the knee straight.
2. Lean forward until you feel a strong but tolerable stretch in your calf.
3. Hold for 30 seconds, 3 times.

1. In the same position, bend the back knee slightly. Keep the heel down.
2. Lean forward until the stretch is strong but tolerable.
3. Hold for 30 seconds, 3 times.

What are the posterior tibial tendonitis exercises with a band?

Slow-lowering band exercise. Family-medicine guidance recommends eccentric over concentric exercise here and shows this technique, but it gives no dose.^[8] The dose below comes from Kulig’s trial, which used a spring-loaded machine, not a band.^[9] That group improved most on pain and disability scores.^[5]

1. Sit and cross your sore foot over the opposite thigh.
2. Wrap a band around that foot and pin the band down with your other foot.
3. With your opposite hand, lift the foot fully inward.
4. Let go, and lower the foot slowly against the band’s pull, for about 5 seconds.
5. Do 3 sets of 15, twice a day, resting 1 to 2 minutes between sets. Add resistance only as tolerated.

Turn-in band exercise. This comes from Houck’s trial of 39 people with stage II disease. The 19 who finished its home strengthening program did this after the stretches as a warm-up.^[15,14]

1. Sit with a band around your forefoot, anchored so it pulls your foot outward.
2. Point your toes slightly down and turn your foot inward through its full range.
3. Return under control.
4. Start with 2 sets of 10, twice a day. Build to 3 sets of 30, and move to stronger bands as tolerated over 12 weeks.^[1,14]

How do you do the heel raises?

Houck’s program used these too, at the same dose.^[1]

1. Stand on both feet. We suggest fingertips on a counter for balance.
2. Rise fully onto your toes, then lower your heels.
3. Start with 2 sets of 10, twice a day, and build to 3 sets of 30.

1. Stand on the sore leg. We suggest fingertips on the counter here too.
2. Rise fully onto your toes, then lower your heel.
3. Use the same dose.

The structured brace program in our short answer set a finish line: 50 single-leg heel rises and 100 feet of walking on the toes, with little or no pain.^[4] See custom orthotics, flat feet and flat feet in adults.

The limits. The review’s authors said no ideal exercise prescription can be named, and neither eccentric nor concentric work improved walking distance beyond orthotics and stretching.^[1] Houck’s home strengthening added little to an orthotic and stretching, and strength didn’t differ between the groups.^[15] The structured brace program had no comparison group.^[4] Surgery is usually complex. Most patients still notice some limits in activity, healing takes six months or more, and bones can fail to heal or wounds can become infected.^[6] The 15-year group was small.^[3]

How we decide

Dr. Efe Ozturk is a Foot and Ankle Surgeon and podiatrist. We examine your foot, watch your heel rise, and take X-rays at the practice to judge the stage. See foot and ankle surgery. We see patients in Lyndhurst, Paramus and Millburn, NJ.

Common questions

What posterior tibial tendonitis exercises should I avoid?

No trial gives a list. The 2018 review warned that holding a calf stretch at full ankle bend squeezes and pulls the tendon behind the ankle bone, which may work against pain relief.^[1] We advise stopping at “strong but tolerable.” Cut back on what worsens pain. Biking, elliptical machines and swimming put less impact on the foot.^[6]

How long do posterior tibial tendonitis exercises take?

The two largest trials ran 12 weeks, and the smallest ran 6.^[1] Patients in the structured brace program took a median of 4 months and 10 therapy visits.^[4] Pain can last beyond 3 months even with early treatment.^[6]

Are post tib tendonitis stretches enough on their own?

No trial tested them alone. Kulig’s group with only custom orthotics and stretching improved, but least.^[9,5]

When to see a Foot and Ankle Surgeon or podiatrist