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1 · SNAPSHOT

Tibialis Posterior Tendinopathy body chart — Illustrative, not diagnostic. Canva body chart for Tibialis Posterior Tendinopathy.

Who: Runners, walkers, people with a pronated foot posture, and middle-aged adults with a gradual onset. Common where load has changed.
What: A painful, load-intolerant tibialis posterior tendon — with or without arch collapse.
How it behaves: Medial ankle and arch ache along the tendon course. Worse with walking, running and single-leg stance. Eased by rest and supportive shoes. Sometimes a described "flattening" of the foot.

The one thing to take from this page:

The tendon problem and the arch-control problem are inseparable. And the arrow only points one way — the job is stopping it moving.

The spectrum	Whose job
Painful tendon, foot posture normal	Yours
Painful tendon, flexible collapse	Yours, with support
Flexible deformity, poor or absent single-leg heel raise	Shared — refer
Rigid deformity	Surgical

The name has changed, and you'll meet the new one first

You'll be taught tibialis posterior tendinopathy or PTTD. The surgical literature now says progressive collapsing foot deformity (PCFD) — and that is what will be written in the report you're handed [1].

It's the same spectrum. What changed is the thinking: from a tendon-only model to multiplanar collapse — hindfoot valgus, forefoot abduction, peritalar subluxation, spring ligament — and from one staging ladder to separating deformity, reactivity and foot type [2].

⚠️ No guideline exists for this condition, anywhere. The PCFD consensus is a surgical nomenclature document, not a physiotherapy guideline — it changes the words, not the loading.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order.

MAIN PROBLEM

"There's an ache on the inside of my ankle when I walk any distance."
"My arch has dropped — look at it next to the other one."
"I can't do a calf raise on that side any more."

That last sentence is close to the diagnosis.

BODY CHART

Map the tendon course — posterior to the medial malleolus, under it, and forward to the navicular. Ache along the course, not a point.
Draw the arch on both sides. Asymmetry is a finding you want on the record and dated.
Mark anything plantar or burning — that is the tarsal tunnel question, not this one.

BEHAVIOUR

	Fits tibialis posterior	Points elsewhere
Aggs	Walking distance, running, single-leg stance, stairs	First steps in the morning → plantar fasciopathy
Eases	Rest, supportive shoes, orthoses	Nothing changes it
Severity	VAS 0–10 at best / at worst / right now	—
Onset	Gradual	Traumatic eversion → deltoid
Quality	Ache, load-related	Burning, tingling, numb → neural

Irritability, three ways — resting symptoms, the vigour needed to provoke it, and how long it takes to settle. That third one sets your loading dose.

HISTORY

Load change — a new distance, new surface, new shoes, a return after a break, weight change.
Foot posture history — have they always been flat, or is this new? New is the one that matters.
Is it progressing? Reducing walking distance over months is a different conversation from a sore tendon.

SPECIAL / SCREENING QUESTIONS

Inflammatory features — morning stiffness >30 min (In), other joints, systemic symptoms. Seronegative arthropathy presents at the tendon insertions.
Diabetes, corticosteroid use, fluoroquinolone exposure — tendon risk factors.
Progressive deformity, or a foot that no longer corrects.

Assessing this region? Download the Ankle & Foot assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Tarsal tunnel syndrome	Burning, tingling or numbness into the plantar foot, positive Tinel's, symptoms on dorsiflexion-eversion. Neural, not tendinous.
Plantar fasciopathy	Sharp heel pain on first steps, tender medial calcaneal tubercle, positive Windlass. Heel, not tendon course.
Deltoid ligament sprain	Traumatic eversion mechanism with bruising, rather than gradual arch collapse.

The one the table can't show

All of them, at once, in a foot that has been collapsing for years. Medial ankle pain in a pronated foot is a region under load, not a single structure, and the reason to map the body chart carefully is that these three sit within centimetres of each other.

And the inflammatory screen. A seronegative spondyloarthropathy presents at the tendon insertion, and it does not respond to loading. Morning stiffness over 30 minutes coded In, other joints, or systemic features send this to a GP, not into a strengthening program.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. Safety is never gated.

Finding	What it suggests	What you do
Absent single-leg heel raise	Advanced dysfunction or tendon rupture	Orthopaedic referral
Rigid deformity — the hindfoot doesn't correct	Fixed collapse, beyond conservative care	Orthopaedic referral
Rapidly progressive deformity	Structural failure	Urgent orthopaedic referral
Sudden pop, then a flattening foot	Tendon rupture	Orthopaedic referral
Morning stiffness >30 min (In), other joints, systemic features	Inflammatory arthropathy	GP referral — do not load it
Hot, red, swollen ± fever, or a diabetic foot	Infection	🚑 See the infection page
Diabetes or neuropathy with a warm, swollen, collapsing midfoot	Charcot foot — diagnosis was delayed in 53.2% of cases in a systematic review (Korst et al. 2022) [20]	Urgent GP or high-risk foot service referral
Persistent pain despite well-dosed care	Reconsider the diagnosis	Reassess, then image
Athlete with persisting medial malleolar pain and a clear X-ray	Medial malleolar stress fracture — plain films missed every case in one series and MRI showed them all (Lempainen et al. 2012) [21]	Early MRI referral

The rule: flexible and painful is yours. Rigid, absent heel raise, or progressing fast is not.

Cross-links: Plantar fasciopathy · Medial ankle sprain · Infection / osteomyelitis / ulcer

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The 5-minute lesson is for members

Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.

Guideline anchor

No guideline exists for tibialis posterior tendinopathy, in Australia or anywhere.

Anchored for terminology and staging to the international consensus on progressive collapsing foot deformity (Myerson et al. 2020, PMID 32856474), and for treatment to the systematic review of exercise (Ross et al. 2018, PMID 30271611) and the orthotic systematic review (Gómez-Jurado et al. 2021, PMID 33040609).

PubMed Source

The PCFD consensus is a nomenclature and classification document written by foot and ankle surgeons. It is not a physiotherapy guideline and it does not tell you how to load a tendon. It is anchored here because the LANGUAGE has changed and students meet the new terms in reports, not because it directs conservative care.

Members

The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 19

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

2020Myerson et al. (2020). Classification and Nomenclature: Progressive Collapsing Foot Deformity. Foot & ankle international, 41(10), 1271-1276. https://doi.org/10.1177/1071100720950722
2024Pasapula et al. (2024). Review of Classification Systems for Adult Acquired Flatfoot Deformity/Progressive Collapsing Foot Deformity and the Novel Development of the Triple Classification Delinking Instability/Deformity/Reactivity and Foot Type. Journal of clinical medicine, 13(4). https://doi.org/10.3390/jcm13040942
2004Kohls-Gatzoulis et al. (2004). Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot. BMJ (Clinical research ed.), 329(7478), 1328-33. https://doi.org/10.1136/bmj.329.7478.1328
2006Alvarez et al. (2006). Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot & ankle international, 27(1), 2-8. https://doi.org/10.1177/107110070602700102
2009Kulig et al. (2009). Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Physical therapy, 89(1), 26-37. https://doi.org/10.2522/ptj.20070242
2009Neville et al. (2009). Effects of the AirLift PTTD brace on foot kinematics in subjects with stage II posterior tibial tendon dysfunction. The Journal of orthopaedic and sports physical therapy, 39(3), 201-9. https://doi.org/10.2519/jospt.2009.2908
2009Houck et al. (2009). Ankle and foot kinematics associated with stage II PTTD during stance. Foot & ankle international, 30(6), 530-9. https://doi.org/10.3113/FAI.2009.0530
2012Bek et al. (2012). Home-based general versus center-based selective rehabilitation in patients with posterior tibial tendon dysfunction. Acta orthopaedica et traumatologica turcica, 46(4), 286-92. https://doi.org/10.3944/aott.2012.2488
2015Bubra et al. (2015). Posterior tibial tendon dysfunction: an overlooked cause of foot deformity. Journal of family medicine and primary care, 4(1), 26-9. https://doi.org/10.4103/2249-4863.152245
2017Ling & Lui (2017). Posterior Tibial Tendon Dysfunction: An Overview. The open orthopaedics journal, 11, 714-723. https://doi.org/10.2174/1874325001711010714
2018Ross et al. (2018). Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines. BMJ open sport & exercise medicine, 4(1), e000430. https://doi.org/10.1136/bmjsem-2018-000430
2020Wang et al. (2020). Gait alterations in posterior tibial tendonitis: A systematic review and meta-analysis. Gait & posture, 76, 28-38. https://doi.org/10.1016/j.gaitpost.2019.11.002
2020Richie (2020). Biomechanics and Orthotic Treatment of the Adult Acquired Flatfoot. Clinics in podiatric medicine and surgery, 37(1), 71-89. https://doi.org/10.1016/j.cpm.2019.08.007
2021Gómez-Jurado et al. (2021). Orthotic treatment for stage I and II posterior tibial tendon dysfunction (flat foot): A systematic review. Clinical rehabilitation, 35(2), 159-168. https://doi.org/10.1177/0269215520960121
2021Ross et al. (2021). Clinical Tests of Tibialis Posterior Tendinopathy: Are They Reliable, and How Well Are They Reflected in Structural Changes on Imaging?. The Journal of orthopaedic and sports physical therapy, 51(5), 253-260. https://doi.org/10.2519/jospt.2021.9707
2019Henry et al. (2019). Adult-Acquired Flatfoot Deformity. Foot & ankle orthopaedics, 4(1), 2473011418820847. https://doi.org/10.1177/2473011418820847
2022Rhim et al. (2022). Characteristics and Future Direction of Tibialis Posterior Tendinopathy Research: A Scoping Review. Medicina (Kaunas, Lithuania), 58(12). https://doi.org/10.3390/medicina58121858
2023Polichetti et al. (2023). Adult Acquired Flatfoot Deformity: A Narrative Review about Imaging Findings. Diagnostics (Basel, Switzerland), 13(2). https://doi.org/10.3390/diagnostics13020225
2024Rehman et al. (2024). Diagnostic efficacy of posterior tibialis tendon dysfunction: a systematic review of literature. European radiology, 34(5), 3513-3523. https://doi.org/10.1007/s00330-023-10364-1

Mapped to this pattern

FPI-6
Foot Posture Index
static foot posture · 6 items · 4 min

Generic measures that also apply

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