Tibialis Posterior Tendinopathy Pain in Runners
The tibialis posterior muscle is one of the major players when we talk about the stability of the ankle joint complex. It plays a vital role in supporting the posterior tibial tendon, which helps stabilise the ankle and medial arch during running, walking, and jumping.
Unfortunately, due to overuse or biomechanical issues, this area is prone to injuries like tibialis posterior tendonitis, particularly in runners. These conditions often lead to ankle pain and can contribute to a broader running injury pattern if left untreated.
Recognizing Tibialis Posterior Dysfunction
Pain down the inside of the shin or behind the ankle bone can be indicative of posterior tibial tendon dysfunction. This often involves the posterior tibialis muscle and may present as an aching feeling at rest or a sharp, burning pain during walking, running, or jumping.
These symptoms frequently point to a posterior tibialis injury. Whilst it may feel better with rest in the short term, if you notice that the shin pain is still present or even worsening with activity, then it’s time to pay attention to the area. This type of dysfunction may also be linked with posterior tibial tendonitis or even posterior tibial tendinopathy, both of which require careful assessment and tailored rehab.
Understanding the Tibialis Posterior Muscle
If you’re suffering from the above symptoms, there’s a good chance your tibialis posterior muscle is dysfunctional and needs some work. First of all, let’s understand what this muscle actually does. The tibialis posterior is the deepest and most central muscle in the posterior lower leg.
It connects directly with the posterior tibial tendon, originating from the back of the tibia and fibula bones up near the knee joint, travelling down the leg and behind the ankle joint on the inside of the leg before finally attaching on the plantar surface of the foot just in front of your heel bone.
The tibialis posterior’s function is to plantar flex and invert the foot. Through its action on the ankle, it also helps the more powerful muscles elevate the heel off the ground when the foot is planted, making it a key player in running and jumping. When this tendon becomes inflamed, it may contribute to tibial tendonitis, which can result in both heel pain and foot pain, especially during load-bearing activity.
Other functions of the tibialis posterior include resisting foot eversion and supporting the medial longitudinal arch. This helps distribute body weight through the foot when it impacts or is planted firmly on the ground, for example, during the heel strike phase of gait in walking or running. Dysfunction in this region may also present as posterior tibialis tendon irritation, which shares overlapping symptoms with conditions like tarsal tunnel syndrome or posterior tibial tendinitis.
Possible Injuries and Strains
Given the role of the tibialis posterior, it’s easy to see how, if the whole lower leg and foot complex is either weakened or not functioning optimally, the muscle and tendon can endure more stress than it is designed to handle, leading to muscular strain, tendonitis, or tendinopathy.
Quite often, we see runners and walkers presenting with tibialis posterior tendon pain. Symptoms associated with tibialis posterior tendinopathy may include:
Pain and swelling anywhere from the inner side of the ankle and foot up to the inner side of the calf or shin bone.
Pain may be exacerbated by activity, standing on your tiptoes, or walking up and down stairs.
In some cases, there may be a limp or visible flattening of the arch of the foot during walking or running.
In more severe cases, especially when there's underlying instability or a history of ankle fracture, there may be an increased risk of tendon injury or longer-term dysfunction. While rest may bring temporary pain relief, it’s essential to properly assess and treat the condition.
Now, you may feel this is the cause of your pain, but it’s often best to gather a firm diagnosis to ensure you’re addressing the right issue and not wasting time on the wrong exercises. Fortunately, these tests are easy to do at home and can quickly confirm if this is indeed your injury.
In more complex or chronic cases, a physical therapist may incorporate progressive physical therapy strategies to restore function and prevent further overload on the posterior tibial tendon. Along with evaluating the location and type of pain, there’s a basic manual muscle test to assess for weakness or discomfort when isolating the tibialis posterior muscle as best we can.
Secondarily, you can do a simple calf raise — starting with double leg and then assessing single leg — to see if functionally there is any pain or weakness that may present from the tibialis posterior. This is especially relevant in identifying related issues like ankle pain, shin splints, or even strain near the achilles tendon.
In this test, as we get right up to the top of the calf raise at end range of motion, we want to see the foot or heel bone invert slightly toward the midline. This movement demonstrates the strength and activation of the tibialis posterior muscle. For those returning from injury, exercises like these are often included in physical therapy protocols to support the tendon and prevent further strain after issues such as ankle sprain or ankle surgery.
Finally, here’s a test we like to do to assess the endurance of the tibialis posterior. This is a valuable tool in both rehab and sports medicine because fatigue often needs to be present to replicate some of the symptoms seen in overuse or tendon injury cases. At home, you can mimic the muscle test from earlier or perform it side lying, as shown in the video, to make it easier on the tester.
An alternative we use in the clinic is to apply a strong resistance band in the side-lying position — a method you can replicate if you have access to one. During the test, we want to see at least a 20–30 second hold without any change in foot position. This helps test both the endurance and fatigue resistance of the tibialis posterior muscle and may even bring out underlying issues like achilles tendinopathy in some individuals.
If after all this you think you may have some tibialis posterior weakness or dysfunction, the good news is there are some really simple exercises and mobility techniques you can do at home to start building strength and restoring function. At Elite Health and Performance, we begin by de-loading the tissue with myofascial release, as shown in the video — a great starting point for both mobility and pain relief that you can perform on your own.
We then recommend starting off with isometric holds for a few days before progressing to concentric reps, especially important in the early stages of a tendon injury, or consulting your therapist to guide you if you’re unsure.
Watch video here - Tibialis posterior ball raise
Watch video here - Tibialis posterior band raise
If you’re still suffering from issues, it may be best to have a therapist assess your injury. Quite often, in the acute phase, methods such as tissue release and dry needling can help alleviate pain and tension, including secondary symptoms like neck pain that may arise from compensatory movement.
These approaches can then be followed by a personalised strengthening program designed by a physical therapist, tailored to your case and goals — whether you're dealing with hip pain, shoulder pain, or chronic dysfunction of the posterior tibial tendon.