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How to Self-Treat Posterior Tibialis Pain

FallenArchesThe most common cause of pain along the inside (medial) portion of your ankle when running may also be associated with the most common reason for adult acquired flatfoot.

It’s likely something most of us haven’t ever heard of before. Posterior tibial tendon dysfunction (PTTD), also known as posterior tibial tendon syndrome or tibialis posterior syndrome, can develop into a tibialis posterior tendon insufficiency which causes a fallen arch.

How to Self-Treat Posterior Tibialis Pain

The posterior tibialis muscle is a particularly important muscle in runners as it is used in plantar flexing the ankle (pointing the ankle/toes downward) and inverting the ankle (rolling it inward). More importantly, its role is to support the arch of the foot. Injury to this muscle is common in runners as well as those who play sports, such as basketball, involving high foot impact. It can be associated with a fall or can generally develop overtime depending on your risk factors and the strain your foot has taken.

posterior tibialis

Typically, PTTD begins as an overuse injury. It is almost always progressive in nature. It begins with pain in the ankle, and then progresses to a more serious condition, such as a falling of the arch. When left untreated, this can cause adult acquired flatfoot. A fallen arch is also a common cause of plantar fasciitis.

Common risk factors for posterior tibial tendon dysfunction (PTTD) include:

  • Gender. It is more common in women.
  • Those who are 40 years or older.
  • Obesity.
  • Hypertension (high blood pressure).
  • Diabetes.
  • Flat feet, which cause overpronation while running.
  • Poorly fitting or worn out shoes.
  • Weak ankle muscles (particularly, the posterior tibialis or the foot intrinsic muscles that help to support the arch of the foot).
  • Weakness in the hip, pelvic, and/or core muscles can lead to faulty gait mechanics.
  • A change in running surfaces or environments. This is most evident when transitioning from a softer running surface, such as dirt, to a concrete running track or running downhill. This causes overuse or overtraining of the tendon.
  • Training overload. Performing too high of training intensities and volumes. This overuse or overtraining of the tendon causes inflammation, swelling, and pain.

Symptoms of PTTD:

  • Pain is typically located along the length of the tendon (which is located on the inside of the foot and ankle near the bump known as the medial malleolus). Pain may also occur in the foot where the tendon attaches to the navicular bone near the arch of the foot.
  • The area around the tendon is usually red, warm, and swollen due to an active inflammatory process.
  • Pain located along the tendon is worse with activity. The higher the impact, the worse the pain.

As the condition worsens, the arch will begin to flatten. The ankle and foot begins to roll in as the toes move outward with each step.

Once the arch has fallen, pain is more commonly felt on the outside of the ankle (as the posterior tibialis tendon has usually ruptured at this point). In this stage, arthritis typically begins to set in and develop in the ankle. The calcaneus (heel bone) usually shifts outward at this point.

A common indicator of an advanced condition is known as the “too many toes” sign. When looking at the heel from behind, the third, second, and sometimes, the big toe are visible. Use a mirror to view your affected foot or enlist your spouse or friend’s help. How many toes are visible from behind? Typically, you should see only the pinky and/or second toe.

In addition, perform the following test. While standing, balance on your affected foot. Can you stand on your tip toes? In the case of PTTD, one will struggle to move on to his/her tip toes if it’s even possible.

Initial Treatment for PTTD:

This condition typically begins as an overuse syndrome with an active inflammatory cycle occurring. The initial course of treatment includes RICE, which stands for Rest, Ice, Compression, and Elevation.

  • Rest. In this case, rest would indicate tapering down from your regular exercise activity and discontinuing running (for the short term).
  • Ice. Apply ice to the painful area. The rule for icing is to apply ice no more than twenty minutes per hour. Do not place the ice directly against the skin, especially if you are using a gel pack style. A bag of frozen peas can be ideal. Individuals with poor circulation or impaired sensation should take particular care when icing.
  • Compression helps to prevent and decrease swelling. Swelling can cause increased pain and slow the healing response, so limit it as much as possible. A compression sleeve/stocking can help to limit the amount of swelling and promote blood flow back out of the lower leg. This insures better nutrient exchange, waste removal, and limits the swelling. I particularly recommend wearing a pair during your rehabilitation phase and when tapering back into full activity. Although there are many different styles of compression sleeves/stockings available, always be sure to choose a pair that is at least knee high. I have had luck using the Vitalsox graduated compression socks.
  • Elevation. Depending on your pain level and the amount of swelling present, this step may be more or less beneficial.

How to Self-Treat Posterior Tibialis Pain:

Self-mobilize the tissue. Be sure to mobilize the tissue in and around the shinbone (tibia). You could also use a tennis or lacrosse ball to aggressively work out the tissue along the shin (as demonstrated in Posterior Tibialis Tendon Dysfunction Exercises.pdf). Take care not to be too aggressive when mobilizing the posterior tibialis tendon initially or you may make the pain worse. Instead, initially focus on any other mobility and myofascial restrictions in the lower legs. Utilize a foam roller to address any lower leg tightness or restrictions. I tend to use the foam roller for the larger parts of the leg including the thigh, back of the leg, calves, and buttock muscles. Please refer to Lower Extremity Mobilizations using a Foam Roll.pdf.

Mobility Band Mid Foot Variation

Mobility bands, such as the Rogue Fitness VooDoo X Bands or EDGE Mobility Bands, are a novel way to self-mobilize the tissue of the calf, foot, and ankle. The use of mobility bands affects blood flow to the area and speeds up healing. Mobility bands also help reset some of the receptor cells in the muscle tissue that cause excessive muscle tightness.

Application of the band starts at mid foot, and then wraps directly over the ankle. You will then pump your ankle back and forth for as much motion as possible in each direction (as demonstrated in Posterior Tibialis Tendon Dysfunction Exercises.pdf). Typically, the mobility band is in place for one to two minutes. If you experience numbness or tingling, please discontinue the treatment. (If you suffer from any form of blood clotting disorder or are on blood thinning medications, I would advise against utilizing mobility bands for any type of deep compression.)

Strengthen your foot and ankle complex. Weakness in the foot and ankle muscles is a major risk factor in developing PTTD. I recommend initiating a complete ankle and foot strengthening protocol (as demonstrated in Posterior Tibialis Tendon Dysfunction Exercises.pdf).

Balancing on One Foot
Improve your balance. Poor balance is often associated with muscle weakness in the foot and ankle as well as the knee and hip musculature. Weakness and balance deficits can lead to poor foot mechanics, which can lead to excessive strain on the posterior tibialis tendon. Practice balancing on one foot.

If you change running surfaces, progress slowly. If you typically run on softer surfaces, such as dirt or a running track, progress carefully and slowly to running on a harder surface (like concrete). Over all, softer running surfaces are better for your body. If your job requires that you stand on a hard surface, adding a foam pad or rubber mat can decrease the strain on your foot and arch.

Avoid training overload. Don’t progress your training volume and/or intensity levels too quickly. PTTD is most commonly diagnosed as an overuse injury. Proper training is very important to avoid overloading your body. Improper progression of training volume and/or intensity can easily lead an overuse injury like PTTD, Achilles tendinitis or other lower extremity injuries.

Add an orthotic. Additional foot control is often needed to normalize gait mechanics. Many running stores sell an over-the-counter orthotic such as Superfeet Blue Premium Insoles. The blue tends to fit most feet, but a variety of options are available for customization. In my experience, these insoles can last 1,000 to 1,500 miles easily.

If you continue to experience pain related to your foot or footwear, then you may need to consult with a physical therapist that specializes in feet and orthotics. A custom orthotic may be necessary to correctly support your foot and insure proper foot mechanics. Seek assistance from a professional who is a runner and has experience with treating other runners.

Immobilization. Sometimes you may need to wear a walking boot in order to immobilize the foot and ankle complex to allow the tendon to heel. In very severe cases, you may need to completely avoid all weight bearing activities. Please seek instruction from your medical physician. If the condition worsens, it’s pertinent to intervene prior to tendon failure.

Ask for help. If you’re still experiencing pain after implementing these self-treatment strategies, then it may be time to seek additional help. Other medical conditions can mimic or be associated with PTTD. Your medical physician or physical therapist can help to determine if your pain is associated with a stress fracture, plantar fasciitis, shin splints or another condition. Your physician could also prescribe a stronger anti-inflammatory medication if necessary. The American Physical Therapy Association offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical physician’s referral (although it may be a good idea to seek your physician’s opinion as well).

RETURN TO RUNNING

Don’t forget that I have an in-depth rehabilitation guide for Posterior Tibial Tendon Dysfunction inside The Resilient Runner -the breakthrough injury program I developed in partnership with Marathon Training Academy.

As you return to running and your normal training activities, insure the following:

  • Your involved leg is as mobile and flexible as the other.
  • Your involved foot and ankle is as mobile and flexible as the other.
  • Your involved foot and ankle complex is as strong as the other leg.
  • Your ability to balance is equal in both legs.
  • You can jog, run, sprint, and jump without pain.

If you are not progressing after 3-4 weeks of implementing these treatment options, speak to your medical professional. Do not take this condition lightly. Be sure to properly address it so you don’t lose too much time with your training. As you taper back into your running program, follow these guidelines:

  • Although you will need to progress and train on uneven ground and hills, initially start with level terrain only.
  • Initially limit your running distance. I recommend starting with a distance approximately 50-75% of your pre-injury distance.
  • Initially start with a slower pace. Don’t immediately progress back into very intense running activities, such as interval or hill training, until you have worked back up to your previous running distances and paces without pain.

PTTD most commonly starts out as an over use injury. Although more common in runners and those who are involved in high impact sports, this condition can affect anyone. If the condition is left untreated, the end result is usually a falling of the arch which causes adult acquired flatfoot. When this condition is caught early, it can be self-treated. Once the arch has fallen, surgery would most likely be indicated. For additional information on common running injuries and how to self-treat, please visit www.thePhysicalTherapyAdvisor.com.

210 Responses to How to Self-Treat Posterior Tibialis Pain

  1. Susan March 29, 2016 at 4:52 pm #

    Ben,

    Can you please tell me what type of ‘tape’ or material that is around your ankle/foot in the photos 1 & 2? Is it the athletic kinesiology tape?

    Thank you.

  2. Ben March 30, 2016 at 6:35 am #

    Hi Susan,

    In photos 1 and 2 I am wearing a mobility/compression band around my ankle. Two popular brand names are EDGE Mobility Bands or VooDoo Floss bands by Rogue fitness. The material is basically a thick rubber band designed to apply short intermittent compression while you perform 1-2 exercises or stretches. It would never be worn more than 1-2 minutes at a time. Let me know if you have any other questions. Thanks!

    • mandy April 6, 2018 at 9:20 am #

      Hi Ben, my name is Mandy I am running the Boston Marathon in a week and a half and been having issues with posterior tibial tendonitis for quite some time now… I would love to write you more about it just checking to see if you would actually write back on here?

      • BenShatto April 6, 2018 at 10:49 am #

        Hi Mandy! Yes, I try my best to respond to each comment. Have you already read through the post and comments that may be similar to your situation?

        • Sarah April 9, 2018 at 9:01 am #

          Hi Ben – I’m a 3:18 marathoner and I am also running Boston in one week. I have been having pain in what I think it my posterior tibial tendon for the past two weeks. I’ve taken a break from running, been on the elliptical and icing/heating the injury to try and heal it. I haven’t tried running since last week (hurt a lot when I tried) but I feel small twinges in my ankle when I am on the elliptical. Do you think it is a good idea to still run the marathon? I know I could probably make it through the whole thing if pain is the only issue but I am worried about collapsing my arch and needing surgery (something I 100% want to avoid).

          This injury is driving me nuts and any advice would be so helpful!
          Thank you very much!!

          • Sarah April 9, 2018 at 9:03 am #

            One last thing – any recommendations for a brace I can wear during the marathon to try and minimize damage? I am already planning on wearing compression socks and KT tape if I attempt the race. Thanks!!

    • Shannen April 17, 2019 at 1:03 pm #

      Hey, I hope you will see this!!

      I have just experienced extreme pain in this areas where It is very painful to walk. And I almost can’t walk! What do you suggest. I am not a runner but have been trying to run more at the gym and it just came out of no where.

      • Ben Shatto April 17, 2019 at 9:13 pm #

        Shannen. First I would suggest you rest, ice, compress and elevate. If it is hurting that bad your body needs to rest. In extreme cases you may need to mobilize the lower lower leg for a week or two. If you have just started running and it came on this fast the most likely cause is in appropriate footwear and progressing your running faster than your body was able to handle. Once the pain is gone work through the suggested exercises and progress your running at 1/2 the intensity and duration you were doing when this occurred.

  3. JT October 3, 2016 at 8:07 pm #

    Hi Ben!

    Thanks for your article. I’ve been having this pain for years – I rest for a long time, then begin to run again when the pain secedes. Eventually it comes back – not only is it annoying and painful, it is also discouraging as I love to run – but this prevents me from accomplishing it.

    I understand the exercises I need to perform, and how to take care of it so that I can get back on the trail – but I can’t seem to find the appropriate shoes/support. Is there anything you recommend? Should I wear any sort of brace when I run as well?

    Thanks!

    JT

  4. Andy October 16, 2016 at 1:14 pm #

    I am training for the New York marathon, which is in 3 weeks. I recently (last two weeks) started to develop what seems to be PTT pain around mile 10. I stopped the prior week when the pain developed but this weekend did a 20+ mile run as a final long run before the race. I did experience the pain starting around mile 10 but it came and went and I was able to partially control it by focusing on clean strides and making sure I was running balanced without favoring or disfavoring the foot. When I am not running, I have no pain, no swelling, etc. and I can balance on the tip of my toes without any difficulty or pain. I will be tapering down for the marathon at this point. My question is whether this is an early warning sign meaning very minor injury that signals the potential for more significant injury, or is this perhaps some for of cramping that is occurring during my runs given that I am entirely symptom free when not running.

  5. Ben October 16, 2016 at 8:24 pm #

    JT and Andy….Great questions. Posterior tibialis pain is one of the most common pains in the foot. Andy…..yes the fact that you are getting pain is a warning signal that the tendon and/or the muscle is taking on more strain that it can handle. Pain is the first sign. Since you are on your taper you will likely be able to string this last marathon along but you need to figure out what is leading to the pain. Its usually a biomechanical issue. Meaning either something is off with your running form or you have a muscle imbalance somewhere up kinetic chain (leg, hip ect). Definitely address this now before the pain worsens.

    JT….just like Andy you need to figure out where in either your running form or kinetic chain are the imbalances leading to the PTT pain. Shoes can be helpful but you definitely need to find the cause. I would suggest a one time evaluation with a PT that specializes in running and running gait. Then get on a good home exercise program. As far as shoes and orthotics go…..the posterior tibialis tendon helps support the arch of the foot. So typically a person will need a shoe or orthotic that provides a better arch support. I’m a big fan of finding one that also provides good heel control that also supports the arch. The one I personally use is the blue colored Super feet.

    Let me know if you have more questions. Good Luck!

    • Andy November 13, 2016 at 2:00 pm #

      Thanks, just to close the loop on this, during my taper I used a strong arch support in my shoes (when I was running but also in my work shoes) and it seems the combination of the support and the taper provided needed rest and protection for my ankle and the tendons. Made it through the marathon with no issues, and now a week later I’m past all the normal post-race aches and feel 100% healthy. I didn’t mention in my first post that I’m 51 and have been running since I was 13, ran two marathons in my twenties without any problems, so I really do believe whatever was developing was from the stress on my older body from so much training leading up to the race as opposed to a fundamental issue with my form. I’ve learned to listen to my body and know the difference between the normal aches and the one’s that might signal an injury, so I will keep tuned to ankle as I continue running (though I think I’ve done my last marathon, maybe).

      • Ben November 13, 2016 at 9:33 pm #

        Andy….glad you were able to complete your goal. That is fantastic! I think as long as you listen to your body there is nothing to stop you from running for another 30 years. Good luck on the journey and glad you have kept the marathon door open 🙂

        • Kristen April 17, 2017 at 4:32 pm #

          Hi, just after some advice please! I am running the London marathon on Sunday and as of last Tuesday whilst running my inside of ankle was hurting and then progressively got worse. I rested it as it hurt to walk and then five days later as in yesterday I went for my 10 mile taper run! After a mile I could fee it niggling again and yep straight after it hurts again. I’ve decided not to run at all now so I’ll have a full week rest but I’m really worried that ( after all my research) that if this is his condition I’ll end up wending an operation!!
          It’s never hurt until Tuesday and it’s the exact place so I know it is this! I iced it tonight and did 3x calf stretch and used a roller! It felt better almost immediately! So what do you recommend? I’m so anxious now? Only a few days to go!

          • Ben Shatto May 12, 2017 at 6:09 am #

            I hope the marathon went well ! How did you do?

      • Zac January 22, 2017 at 2:15 pm #

        Did you end up going with the blue superfeet?

  6. sandy October 28, 2016 at 10:48 am #

    Hi,
    I have had this injury for 12 months now, started whilst recovering from insertional achilles tendon i.e. heel raises. Had a boot on for 3 months, I swim 30-45 mins once or twice a week as cannot cycle for longer than 20 mins. progressed from a resistant band to doing 3x 30 both feet on floor, twisting foot right to use the tendon whilst lowering. I just started single heel raises 3x 15 increasing by one every day and have to rest every other day as it’s flared up next morning. Therefore went to both feet on floor with 4kg weight as thought it was less stress than single leg. achilles and tibialis flared up, rested for 4 days and pain gone again. managed to swim 45 mins and 20 mins walking no pain after. What recovery would you recommend.

  7. Ben November 13, 2016 at 9:46 pm #

    Hi Sandy….I’m sorry this has been bothering you for so long. Have you had a medical professional look at the area? After such a long time you may consider it. Something else I have done in cases that are so chronic is avoid the higher reps and focus on low reps high resistance with good form. Not twisting or anything. An example would be…..warm up the area with swimming and a couple of body weight sets of 5-10 reps. Then do 3-5 sets of 5 reps focusing on eccentric only (lowering phase). The goal would be to over the next several months increase the resistance to as much as possible. It is not uncommon to get near body weight meaning your body weight plus that amount as your resistance. The key is low reps high weight 2 times a week. Of course you have to slowly progress to that don’t jump right in. If as you progress and taper up the weight the pain continues to bother you for up to 4 days post exercise then you need to seek a medial opinion to be sure you are not missing something. IF you have not been doing any eccentric only training start with that first before adding any resistance. In general the calves, Achilles ect should be some of the strongest muscles in the body. A common mistake runners make is to focus only on high reps. When instead strength should be the goal. The endurance portion of our training occurs with running. The strength portion should be just that. Strength only. Keep us posted and good luck.

    • sandy November 17, 2016 at 4:59 pm #

      Firstly thank you Ben for taking the time to give advise.
      I didnt get notification of your message, so just seen comment sorry..

      I will take your approach.

      Yes I am seeing a podiatrist and physio at the same appointment, unfortunately only 3 monthly.
      Therefore lack guidance when flares up etc.
      My worry was always what pain is acceptable the day after as taught with initial Achilles injury rest if stiff or pain next day.
      My theory will aso be to lose weight as a compliment to adding weight in tandom, does that make sense I.e. Try to loseweight at same rate of increasing weights steadily!!!
      I have on a positive been doing 20mins cross trainer as feet stay in groove and 20 min rowing machine same stationary foot. Helped my fitness / swimming & zero pain in foot as result.
      Cycling 15 mins also pain free, so encouraging.

      I will take your approach. Thanks

      • Sandy March 13, 2017 at 4:41 pm #

        Ben,
        Thank you for your advice. I followed it and as such have started to slowly increase running to a point I have done a 5k. My question is that there is a mild discomfort for a day or two after every run. If I massage the area it is not tender to the touch. What is a healthy discomfort i.e. strengthening tendon and what is a sign I should back off.

        • Ben Shatto May 12, 2017 at 6:12 am #

          Hi Sandy, Great question, but hard to answer. Only you will be able to fully answer that question. But if the area is not tender to touch and not affecting your mobility and ability to run then it is probably okay. IF you are having high pain, painful to touch, altered walking or running mechanics then that is a sign you need to back off. In the mean time if it is “sore” then continue to be very proactive with your treatment protocol.
          Hope that helps.

          • Sandy June 2, 2017 at 2:02 am #

            Ben, Your a star!!!. Thank you very much for your advice. I am back running and the pain appears to be deminishing. As I push the distance, I get mild aching for the next morning and recovers after rest day. That then sets the precidence as no pain until I go further once a week. I am now up to 10k, so Half Marathon goal is 3 months, all being well.

            • Sandy June 2, 2017 at 2:04 am #

              Ben, Your a star!!!. Thank you very much for your advice. I am back running and the pain appears to be diminishing. As I push the distance, I get mild aching for the next morning and recovers after rest day. That then sets the precedence as no pain until I go further once a week. I am now up to 10k, so Half Marathon goal is 3 months, all being well.

            • Ben Shatto June 2, 2017 at 8:30 pm #

              Sandy….That is fantastic news! Keep working on rehab until you are 100 % pain free. Good Luck on the upcoming half marathon !

  8. Michelle November 16, 2016 at 11:20 am #

    Hi Ben,
    My 14 yo daughter plays soccer on a premiere level and has developed posterior tibial tendinitis; we have seen an orthopedist and she was in a boot for a couple of weeks and was told to wear an ankle brace anytime that she plays. Do you suggest putting inserts in her cleats? Will they fit? I’m about to pull my hair out over this injury; just when we think she is better, BAM, it reappears.

    • Ben December 18, 2016 at 9:27 pm #

      Hi Michelle,

      Yes this injury can be very frustrating. The answer to your question is a bit tricky. I would say yes…..I would try adding an orthotic into her cleats. I would get a semi rigid one that is full length. I have found that it helps 50-75% of the time and personally I found it helpful back when I played soccer and had a similar issue. She may or may not be able to wear the ankle brace comfortably with the orthotics. It depends on the side of her shoe. Also be sure she is very diligent in working on the other aspects of the program especially lower leg strengthening. Good luck!

  9. Kendra December 2, 2016 at 9:30 am #

    Hello Ben,

    I have posterior tibia tendonitis or dysfunction in my left foot right now. Have begun seeing Physio and getting IMS and orthotics. Will be beginning rehab over the next few days.

    I have been started swimming and do some minimal cycling at lower resistance so far. I have been advised only weight bearing activity. I do weights upper body and so far squats and deadlifts – no lunges. I am wondering if the weights are ok. I have no pain when doing them but I am bearing my own weight. Please advise.

    • Ben December 18, 2016 at 9:32 pm #

      Hi Kendra,

      I hope your rehabilitation is going well. I find that weight training is fine during rehabilitation of this injury. The exercises to avoid temporarily tend to be the repetitive ones like running. I actually feel that doing exercises such as squats and deadlifts are a critical component to the rehabilitation process. If you have been advised otherwise please discuss it with your medical professional and see what the thought process is on your recovery protocol. Your medical professional may have another reason to limit some exercises initially. Good Luck!

  10. Angela December 27, 2016 at 8:43 am #

    Hello Dr Ben I have PTTD and I am diabetic . I go back soon for a MRI. He seem to THINK I have a torn tendon but I’m not trying to do any surgery because I’m overweight hypertension n diabetic. I want to keep my limbs. I trust God that there is no torn tendon. I want to request an aircast brace anything but surgery. He said he has done surgery on people with diabetes.

  11. Ben January 9, 2017 at 9:25 pm #

    Hi Angela,

    You will have to keep us posted on the outcome. I agree with you that people with diabetes can have a more difficult time healing. Any discussion on surgery should include a thorough consideration of a person’s health status and the risk vs reward benefit. If it turns out the tendon is partially torn then there is a chance that physical therapy may be of benefit. If the tendon is completely torn and surgery is not an option you may consider a consult from a certified prosthetist/orthotist to design you a custom brace to support your foot and ankle. A properly fitted brace can be an extremely successful alternative. Good Luck!

  12. Baard January 17, 2017 at 6:32 am #

    Hi Ben,

    Greetings from Norway and thank you for a great article. I’ve been moderately active for almost my entire life, and started to run and train for a HM in June 2016. Words like progressive training and recovery training were unfortunately not something I’ve heard of until I of course started to feel increasing pain in the inside of my right foot / ankle. I ran through my HM, achieving my goal, with pain killers and moderate pain coming and going throughout the 21 km track.

    I’ve seen a doctor and a PT for advise, and they concur that it’s most likely some form of PTTD (perhaps without the D). The trouble is that they could only diagnose this from what I told them, as any isometric(eversion, inversion with resistance etc) tests doesn’t give me any pain or discomfort. I can do single foot calf raises without any pain, and I can run short distances without feeling anything. After a two-three km’s of running I can start to feel like a pinch under the ankle bone on the inside of my right ankle, and this usually goes away after a km or so, but then it comes back and with more pain after additional km’s. I can a bit stiff in the affected area when stretching out my calfs after a run, but except the day after my HM, I’ve never felt any pain or discomfort outside of running.

    I do have an overpronation of my right foot, but I don’t know if this came before or after the PTTD, as I’ve played soccer for a number of years and had my share of ankle sprains.

    Does this sound like PTTD to you at an early stage? At this point in my recovery I feel I’m starting to become paranoid, always feeling and sensing if I have any pain or just anything out side of an ordinary running sensation. I have become better, and I’ve done a fair share of physical therapy, but even with easing back into running (only a few km’s a couple of times a week), I can’t help but feel like I’ve stagnated my recovery the last couple of months, and that I’ve hit a “max” km’s I can run before I start to feel any discomfort.

    Do you have any advise for my future recovery?

  13. Ben January 17, 2017 at 10:06 pm #

    Hi Baard,

    Great question and interesting scenario. I am not entirely sure if what you are describing is actually PTTD though weakness in this area could be contributing to your symptoms. You mentioned flat feet and over pronation I wonder if some of your symptoms are in relation to improper foot position. As the muscle fatigues you could be placing additional stress on other joints within the foot complex including the Navicular bone. This could explain the pain that occurs only after several km of running. You mentioned that you are a soccer player. Running in sports like soccer requires a different running pattern than in long distance running. There may also be a correlation in that regard. Typically in soccer the distances are short sprints on a grass field vs long duration on likely harder surfaces. So don’t give up you can increase the amount of km ran. But I highly recommend you be analyzed for a motion control shoe to prevent over pronation and/or orthotics to control over pronation. In addition have someone analyze your running form. Likely a few changes will be necessary (like a higher cadence and shorter stride length) and between the changes in running form and motion control for your feet you should be good to go. Of course keep with the cross training for good measure. Good Luck!

  14. Dustin Lind January 26, 2017 at 11:39 pm #

    Hi I’m a 16 year old competive runner who has ambitions of running at a division 1 level. I’ve had PTT pains in my left foot for about 4 years, started when I planted my foot awkardly in basketball. I’m positive that I developed this due to overuse and having already relative flat feet before with minimal support. I was kind of ignorant when I was recovering from the injury and maybe tried to play through the pain when I wasn’t suppose to. Anyway I’ve gotten much stronger and rarely have pains but sometimes as competive runner I have to wear minimal support during training and can have some soreness afterwards. I didn’t realize until about a month ago that this condition is actually progressive and your foot can get permanently flatter. I’m paranoid now that because I tried to play through pain with sports like lacrosse, soccer, and running that I’ve made my flat feet extremely worse. I’m beginning to wear my custom orthotics in all my shoes 24/7 because I’m not sure how long it takes for my feet to become more flat. So my questions for you are is how bad do you think I made my feet after my injury, also is there a way where aggressive strengthening and supportive shoes can improve my arch and make me more stable while I run? As you probably know extreme flat feet can be difficult for a quick turn over while you run.

  15. Krista Acke February 21, 2017 at 12:24 pm #

    Hi! My daughter is 17 and is in a preprofessional ballet program. She was dancing a minimum of 20 hours per week and about 10 of those hours was on pointe. Her ankle began bothering her in late August 2016. She started PT and it seemed to be getting better. However, she was casted in The Nutcracker as a soloist and decided to go ahead and perform the part.
    In December 2016 during a rehearsal she said when she pushed off of her bad foot she instantly felt something that she never felt before and began crying (which she has quite a high pain tolerance and has never cried from pain before this). She did all 3 performances and now is in a lot of pain that seems to come and go. She is still doing PT, but still has swelling and gets a sensation that feels like someone is stabbing her in her ankle. She attends dance class, but does not dance.
    We recently went to an orthopedic doctor who is attempting to get her a referral for a MRI, but at this point she is quite frustrated. Her PT did order her orthotics which she wears all the time, she ices her ankle several times a day and really is at a loss.
    Any thoughts or ideas would be greatly appreciated.
    Thank you in advance!
    Krista

  16. Ben Shatto February 21, 2017 at 9:41 pm #

    Hi Krista. I’m sorry to hear about your daughter. That can be so frustrating to have pain which limits your ability to progress in your chosen activities. Based off your description it is difficult to know for sure what may be causing her symptoms. If she has not had an x-ray or bone scan that may be helpful to help rule out a stress fracture. This can happen at her age and with this type of activity. Sometimes the fractures will not heal and form a non-union or pseudo joint that can lead to lingering pain. Depending on your daughters size, nutrition levels and hormone levels this can be more or less likely. It is also possible she sustained a ligament tear of one of the smaller ligaments that hold the carple bones. Though sometimes difficult to detect an MRI is probably a good choice. You definitely need to follow up with an orthopaedic specialist and I would highly recommend you find someone who works with dancers as that is definitely a unique class of athlete. Good Luck!

  17. Stacy March 1, 2017 at 11:55 am #

    I’ll throw my experience in the ring for everyone, as well. I’ve been running for 7 years…45YO, three completed marathons, four marathon training seasons…my 1st marathon was cancelled in 2013…stupid Dallas and its ice!

    I’ve always been flatfooted and I pronate, and for me the best shoes are flat, neutrals. My first pair of running shoes (motion control) gave me a pelvic stress fracture, then stability shoes with orthotics (per my ortho doc post-PSF) gave me chronic hip and lower back pain for a good couple of years. Only after I ditched the stability shoes and the orthotics did I finally begin to run pain and injury-free. I ran in the Brooks Pure Flows until the end of 2015 (after my 2nd marathon) when their “updates” made my feet hurt. I started running in the Nike FlyKnit Lunar 3 at the end of 2015 – can’t remember why TBH, but I didn’t have any problems training for and running two half marathons in 2016 before Chicago training started in June.

    About 12 weeks into training, I started having pain in my left ankle area when I did my bent-knee calf stretches and also “tightness” in my arch. Thinking it was just tightness (super hot summer + speedwork), I didn’t think much of it and it didn’t really impact my training much. Honestly, I didn’t realize I was injured until about mile 18 of Chicago (early October) when I had to start walking – now, I usually start walking later in my marathons, but this was due to a different kind of pain. I managed to finish (and PR, to boot…go figure) by walking/sprinting but was flat-out unable to walk by the time I met up with my husband after the finish. We had to Uber the short walk back to the hotel because of the pain. I knew something was wrong, but we had also registered for Honolulu and were planning on running it “for fun” (no time goals or anything) so I wanted to make sure I was ready for that.

    A week after Chicago I saw my PCP and he diagnosed me with PTT but also said running shouldn’t be a problem. He recommended Airrosti and I went to that twice…the first time, the pain absolutely DISAPPEARED. It was amazing. Then I ran the next day and it came right back. The second appointment provided no relief at all, so I quit going. I got a referral to my long-time PT and she put me on a regimen of strengthening exercises (balancing on my foot, which hurt my arch even more) and taping (didn’t help) and icing. She also told me to continue running, which I did…got back up to 12 miles before I decided Honolulu wasn’t going to happen and just stopped running. This is early December. Walking at this point is more painful than running…probably because when I run I don’t really pronate. My gait has me neutral-to-supinating.

    We go to Hawaii anyway (hey, everything was paid for) and I have trouble just doing normal tourist walking. We get back and I take the next three weeks off…no walking, nothing. It’s Christmastime, so I gain about five pounds. I’m a pretty active person so this was driving me crazy. With not much progress after total rest, I finally see a podiatrist who immediately recommends orthotics (and I have to explain that orthotics cause problems and solve none for me) and 2400 mg of ibuprofen a day for two weeks. Well, that worked wonders…while I was taking it. When I went off, within two days the pain was back. I’m still seeing my PT and at this point she’s added in ultrasound and deep massage, which is excruciatingly painful and not in a good way. Interestingly, I’m able to stand on my tiptoes without any problems, but I still can’t plantar flex my foot (inversion) without pain.

    My PT said this isn’t quacking like a duck and recommends I go get an MRI. I had to practically beg my podiatrist for an MRI, which I had on Feb 9. The results were “Advanced tibialis posterior tendinopathy, with interstitial longitudinal partial-thickness tearing/strain, greatest inframalleolar, extending to the navicular. Additional focal high signal intensity partial-thickness tearing at the navicular attachment. Moderate tenosynovitis.” My podiatrist tells me “three of ten doctors will tell you that you need surgery, but I don’t think we’re there”. He then tells me I need to go into a brace, which I ended up not getting because I felt more unstable in it than out of it. I did pick up a pair of Superfeet black, but after two weeks those started hurting my feet…as orthotics tend to eventually do with me. My podiatrist also recommend MLS laser therapy and I had my fifth session today with absolutely no improvement. I can tell you, that after I did my post-run yoga routine yesterday my pain level increased substantially and I’m wondering if the lower-leg stretching is part of the problem.

    So, I’m coming up on five months and I do believe I’m getting better, but at the same time I don’t think I’m making any additional progress. I feel like I’ve been stuck for the better part of a month and am wondering if I should find a new podiatrist (I liked him at first, but now am not very trusting), track down a sports medicine ortho doc, or just…wait. I thought my pelvic stress fracture (and being on crutches – no bearing weight whatsoever) for three months was bad, but that was nothing like this. To make matters worse, my husband and I are going to Europe in 2 1/2 weeks for 10 days…I plan on just sucking down the ibuprofen if I have to so I don’t ruin our dream trip. lol

    Thoughts? Sorry for the novel.

    • Stacy March 1, 2017 at 11:57 am #

      Oh, I also stopped going to PT at the beginning of February…we weren’t getting anywhere IMO.

      • Nick March 13, 2017 at 3:27 pm #

        I tore my Posterier it’s been 15 months. The brace helps sooo much and I consistently wear it. I’m not opting in for the surgery, just proper footwear, insoles, bracing, and resting.

        I really want to complete a marathon but we’ll see how things go. I think time will help you and technology/science is always getting better for options.

        • Camille October 25, 2017 at 10:58 am #

          Nick,
          I have a longitudinal splitting in my posterior tibialis tendon and I really would like to hear from someone who recovered without surgery. I’ve been told to get a customer orthotic by one doctor and the other PT only.

          If you or anyone feels like your program has helped you recover I would LOVE to hear from you. I do believe losing weight would help – has that helped you?
          Thank you,
          Camille

          • Camille October 25, 2017 at 11:00 am #

            Nick and Ben,
            I have a longitudinal splitting in my posterior tibialis tendon and I really would like to hear from someone who recovered without surgery. I’ve been told to get a customer orthotic by one doctor and the other PT only.

            If you or anyone feels like your program has helped you recover I would LOVE to hear from you. I do believe losing weight would help – has that helped you?
            Thank you,
            Camille

            • Ben Shatto October 25, 2017 at 8:31 pm #

              Hi Camille,

              A longitudinal tear is a little bit different than a standard horizontal tear. My advice would be to get the orthotic and to definitely see a PT. You will want to work on slowly and progressively strengthening the muscle and addressing any other biomechanical issues that may have lead to this. Weight would definitely be one of the issues to address. Your body mass will have a direct affect on how the foot functions and how much work it must perform. Keep us posted on your recovery.

      • Jay D March 29, 2017 at 4:37 pm #

        Posterior tibial tendonopathy is a long process and can take months. Im on my 8th month with minimal progress, nut still progressing. Absolutely no running or power walking. I know its hard, coz im a runner too and having runners-envy everytime I see a runner passing by where I work. Try eccentric stretches and strengthen the tendons. Have you tried getting a cortisone shot? It can temporarily help with the pain, but again those tendons take a long time to heal

        • Ben Shatto April 4, 2017 at 9:03 pm #

          Jay good advise on the eccentric strengthening. I would caution people on the use of cortisone as it can weaken the area causing more potential issues. As PRP injections progress you may look into that as an option.

          Ben

    • Ben Shatto April 4, 2017 at 9:01 pm #

      HI Stacey, Wow what an ordeal. Unfortunately this advice won’t help in time for your trip but you may want to consider prolotherapy. The practitioner basically injects an irritant where the partial ligament tear is located. This will cause additional scarring and hopefully more stability in the area which will help the pain and help to avoid surgery. The tibialis posterior tendinopathy may also be amenable to PRP injections. If that is not an option then you will really need to focus on strengthening the posterior tib tendon and the focus needs to be on eccentric muscle training. It will be slow and deliberate, and will take time and dedication. IT can be done on your own but will need to be very regularly. If you get the PRP injection then the rehab is similar with a lot eccentric muscle training. Keep us posted!

      Ben

      • Stacy May 7, 2017 at 1:33 pm #

        Hello! I actually made it through our Europe trip better than I thought I would…minimal pain (London cobblestone streets didn’t help, ha ha) and we were walking 6-8 miles a day. When we got back I was experiencing minimal pain overall; so much so that I decided to go out for a run – my first run since the end of November. Three uneventful miles, hooray! Took everything slow and easy but by week four the pain was creeping back in. My PT gave me a recommendation for a foot/ankle orthopedic guy and I’m seeing him tomorrow morning.

        I know this can be a slog…I’m going on nearly nine months since it started creeping up. I’m grateful I’ve only gained five pounds, lol…and at least I can walk the dogs now and am not totally hating my life, so I *am* making progress…just not sure at this point what I’m still dealing with.

        The good news is the pain is finally at a low enough level where I can actually DO the recommended exercises…that was my biggest issue before – everything I did to “help” just aggravated the injury more.

        Thanks for all the recommendations! My podiatrist did recommend a cortisone injection back in January and I said NO WAY to that. Not letting any needles near my foot! 🙂

        • Ben Shatto May 12, 2017 at 6:28 am #

          Stacy, Glad to hear you are improving. Keep us posted! Thanks!

  18. Dan April 12, 2017 at 2:24 pm #

    Hi,

    Ive been suffering with PTT since october. I got an OTC orthotics, which seems too hard, and I think it has developed a Plantaar Fasciitis. I recently got custom ones, but that seems to be the same problem.

    I am unable to walk 500 meters due to the PF, but running short distances seems fine (1k jogs with rest in-between).

    Cycling is out of the question, as that further worsenes the PF, both in normal and clipless racing shoes.

    I am single, and have been running/cycling long distances for years, making a great circle of friends, but due to this injury, I am now physically and socially isolated, not being able to go out and meet my friends.

    I fear the only reason it has taken so long is that I have to do something in the weekends, and not being able to walk, sports is the only alternative, which is a vicious circle.

    Thoughts?

    BR Dan

    • Ben Shatto April 15, 2017 at 8:52 am #

      Hi Dan,

      Recovering from injury can be so difficult. And as you eluded its not just the physical portion but the social and psychological components as well. Finding the right orthotics can be difficult. On average I do prefer a full length semi rigid orthotic. Something with a little cushion on top can be helpful. You may have to find an orthotist or physical therapist that makes orthotics to find something with more cushion. In my experience podiatrists tend to make a more rigid version.

      As far as the plantar fasciitis goes you definitely need to work through all the risk factors that may predispose you to both PF and PTT. There really is no reason that both conditions cannot be resolved with a full return to all activities. The biggest issue will be the amount of time and effort that you may need to put into your recovery. You cannot just haphazardly approach the rehab process. Go all in.

      When a person starts to see multiple injuries it is time to take a step back and look at the entire functional chain and see what may have been missed that is resulting in these issues. Find a good PT that is a specialist in running and sports med take a wide view before narrowing down on each injury. But definitely don’t give up. These conditions can get you down but should not derail you completely. Here is a link to my PF article. Hope that helps. Good Luck! Keep us posted on how your recovery goes.

      http://marathontrainingacademy.com/plantar-fasciitis

      Ben

      • Dan October 14, 2017 at 12:36 pm #

        Hi, thanks for the comment.

        I have been feeling better with formthotics, and am able to walk 5 km even without them.
        I do however, feel a swollen area underneath the foot, like extra fad padding, just in front of the heel. Multiple scans shows its not plantaar fasciitis.

        This makes me unable to run, since it swells up, and furthermore, it becomes painful when I cycle for more than a few miles, like it stings. Its only on the left foot.

        Can it be that the PTT inflames when I run or bike, causing this, or do you have any other suggestions?

        I have been trying for months to limit activity, but it does not go away.

        • Ben Shatto October 14, 2017 at 8:25 pm #

          Hi Dan,

          Your symptoms are very interesting. It is possible for the tendon to swell near its insertion area which is on the bottom of the foot more towards the inside. I would suggest a second opinion. I have heard descriptions like this before and the diagnoses have ranged from bone spurs, to cysts to extra bones called seismoid bones. I would seek out an orthopaedic foot specialist for a second option. Since it continues to bother you it will be worth finding out exactly the issue so you can tailor the treatment appropriately. Good luck home your running pain free again soon. Please keep us posted, what you find out may be helpful for someone else. Thanks for sharing. Ben

          • Dan October 16, 2017 at 10:40 am #

            Thanks, but you’re probably my 8th opinion, getting desperate here 🙂 – I bad bone scan and MRI which shows nothing, as well as ultra sound.

            • Ben Shatto October 16, 2017 at 8:42 pm #

              Hi Dan……okay now I see what you mean. I am glad you have gotten those scans but unfortunately that does make your symptoms even more difficult to diagnose. I would have expected any PTTD symptoms to show up on an MRI. And a bone scan would have shown any potential for a stress fracture. When there is not a clear cut diagnosis it definitely makes treatment more difficult but not impossible. When I have clients like this that do not fit a standard mold and standard diagnosistic tools do not give clear cut information I will take a big step back and start looking up and down the kinetic chain. Meaning we need to look up at the hip and down towards the toes identifying any and all biomechanical abnormalities and then working on correcting them. This is not an ideal strategy and definitely not easy. There has to be a cause to the pain and usually it is something above or below the site of injury that leads to an imbalance and pain at the injury site. So……..I am sorry I can’t be more specific but looks at mobility of the foot and hip as well as strength of the foot and hip and compare side to side. Try to get each side symmetrical with the other side. There will always be a difference, maybe subtle but there. Find that and correct it. In cases like this I use the rule of thumb….if it is too tight then loosen it, if it is too loose then strengthening it. I really hope this helps. There will likely not be a specific technique that fixes this but a series of things that leads to resolution. Don’t give up!

  19. Angie April 22, 2017 at 9:16 pm #

    Hi

    This is the second time I have experienced PTT. I successfully went through rehab and have had no pain until I switched shoes. I have found that I have to wear a very flexible shoe (Nike Free) or I have flares. I have one leg that has an irregular gait, caused by hip issues. My question is, can strengthening and exercises correct this? I cycle long distances with no problem, it just seems to be running that causes me issues. I am 45, female and in pretty good shape.

    Thanks!

    • Ben Shatto May 12, 2017 at 6:15 am #

      Hi Angie,

      Yes I do think this is a fixable problem. You need to really concentrate on the hip as much as the foot issues. Finding the right shoe is a good start and having the wrong shoe will often lead to pain and dysfunction. My advise is to work on your foot and ankle strength and mobility as well as the hip issue which is likely also a strength imbalance issue. But definitely keep with it. It is fixable. Good Luck!

  20. Jane April 26, 2017 at 2:26 am #

    Hi Ben,

    Thanks for this. I currently have mild PTT from what I think is over training and not helped by a change in trainers. Whilst running is obviously a no go or a while, is swimming ok? I can’t really afford to lose my cardio fitness at the moment so am trying to find ways around it. thanks v much

    • Ben Shatto May 12, 2017 at 6:18 am #

      Hi Jane,

      Swimming and aqua jogging are great options! Aqua jogging has been found to be an excellent method to maintain your VO2 max. So you can definitely maintain your fitness which you work through your recovery. Make sure you are really working towards addressing the issues that lead to PTT including looking at your hip strength to insure there is no imbalance there which is very common. Good Luck!

  21. Kate May 2, 2017 at 11:59 am #

    Hi Ben,

    I have been training since January for a 50 mile trail run (my first ultra). About three weeks ago I developed excruciating pain in my ankle and my PT diagnosed me with PTT. I am already flat-footed and never wore orthotics. My race is this Saturday and I don’t know what to do. I have been going to PT, riding the bike, trail-walking and doing the elliptical for the past three weeks. I can “feel” the injury but the pain is minimal. However, I have not tried running in the past 3 weeks. It has been recommended to me that I just go on Saturday and “go for it.” My other thought was to go out for a 5 miler on Thursday and see how my ankle feels. After researching PTT further, I am afraid to go for this run on Saturday as it seems it could make it worse (requiring surgery, etc…). I welcome your thoughts. Of course with all my training I would rather “go for it” but am hesitant to do this one ultra and risk permanent damage.

    • Ben Shatto May 12, 2017 at 6:21 am #

      Hi Kate, I like your idea of testing it first. Especially since this is a long event and a trail event. It is always important to insure safety when doing these events and risking injury is rarely worth it. Test it out and see how it feels. If you have to DNS don’t feel to bad. Better to get the issue fixed and live to run another day then to be out for a prolonged recovery. Let us know how it goes.

  22. Amanda May 6, 2017 at 10:13 am #

    Hi Ben,

    I was diagnosed with posterior tibial tendonitis in May 2016. This happened after I had been working out by running, walking and going to zumba classes 5 days a week for almost 2 years. I lost 40 pounds and felt great. Then this happened and ever since I can’t walk without pain for more than 20 minutes at a time, nevermind running or zumba classes. I have been seeing a podiatirst since this happened and I feel I’m getting nowhere. He put me in a walking boot for 6 weeks and then on crutches for 3 weeks. After that, a brace for 2 months and then custom orthotics which I’ve now been wearing all day every day for 8 months. I’ve also been in and out of physical therapy for the past 9 months. I have tried several types of supportive shoes like Asics Gel-Nimbus and GT1000, and most recently the Saucony Redeemer which is supposed to be one of the best. After a year with this injury, I feel very minimal relief. I’ve had 2 xrays but never an MRI – my podiatrist says it’s not necessary. I really feel like there could be a tear or something and I’m worried that he’s not taking my concerns seriously. Do you think a year with this condition is normal? How long can it take to fully recover?

  23. Ben Shatto May 12, 2017 at 6:25 am #

    HI Amanda,

    From the sounds of your story it sounds like you have been very proactive and aggressive with trying to get this fixed. At this point I agree with you that you should get an MRI. I also think you should find a new health care provider. I would find an orthopaedic doctor (not a podiatrist) that specializes in feet. Also try to find one that is a runner or likes to stay fit. I think they will be able to understand your situation better. Taking a year with a lot of aggressive treatment and still having pain is not normal. Get that second opinion and MRI. Good luck !

  24. Aidan May 13, 2017 at 11:31 am #

    I injured my PTT playing basketball 4 days ago and am worried about my arch collapsing. There is only a little pain on the medial side of my ankle as I am a couple days out of the injury and I am looking forward to getting back to playing. How long do you recommend staying away from intense physical activity? How am I to recognize the severity of my injury without risking further injuring myself? (I can balance and complete a calf raise to maximum contraction)

  25. Ben Shatto May 13, 2017 at 5:12 pm #

    Hi Aidan,

    Sorry to hear about your injury. Having a traumatic injury is definitely different than an overuse tendonitis. The question is how severe is the injury. If it is a grade I tear then you can mostly let pain be your guide. I would go easy for a couple of weeks then ease back into jumping sports. You may consider having someone tape it or wear a more supportive orthotic for the arch. If it is a grade II then I would wait 6 weeks or so before easing into more impact based sports. If it is grade III then you need to speak to your orthopaedic surgeon. Now of course these are just general guidelines from my experience, each case is individual. The only way to know for sure how severe the injury is would likely be MRI. Otherwise you have to use your best judgement and go off of pain and how the foot feels. Does it feel stable? Does your arch collapse more than before? When attempting to jump on one foot do you get pain? If you are unsure then I would suggest taking more time off and/or having a sports medicine professional look at the injury. I hope that helps. Good Luck.

  26. Mike B May 20, 2017 at 8:59 am #

    Mine split and half goes over the nob on my ankle and the other half under (where it should be). I dont know how long i have had this but i have run through it and compete in a lot of 5k’s. I went to the doctor because my ankle swelled several weeks ago on the top. Never suspected this and he said he has only seen three cases like this in 30 years.

    The pain is gone and the swelling is down. I can stand on my toes both sides no problem. I do have a problem balancing on my left foot (which is where the tear is). I can run without too much pain and the doc said that i have compensated for the aliment.

    As everyone here does – I love to run. Any suggestions ? Can I run if the pain is gone ? Obviously the two halves are not going to mend back together.

    Any advice would be appreciated

    • Ben Shatto May 21, 2017 at 8:40 pm #

      Mike….I have to say I have not heard of the tendon splitting that way either. You are right that the tendon cannot repair itself without surgical intervention. Though there is likley scar tissue that has formed that can help support the foot and navicular bone. I would be curious to hear what your physician said about the injury and continuing to run. My initial thought would be that running is still something you can do but you will have to be very proactive about how you take care of your feet. First you need to work hard on keeping the ankle and foot strong including symmetrical balance. You may also consider a custom orthotic to help support the foot and torn tendon. Pain can be a good guide initially, particularly with part of the tendon intact. If the tendon tears completely there is likely to be some initial pain and then no pain as there is nothing left to generate pain. This is where you can run into issues because if it tears completely then the next onset of pain will likely be from other structures that are taking too much wear and tear to compensate. So I would speak to your MD about options and in the mean time work on really strengthening the area and adding some external support during running. Keep us posted…..and…..Good Luck!

    • mikeb May 27, 2017 at 10:02 am #

      thanks so much….I assume that once it goes I am done. I know i might need a tendon transfer at some point in the future….When that happens am I done running ? I am working on strengthening the areas by doing one foot balancing etc…..

      • Ben Shatto May 27, 2017 at 8:27 pm #

        Mike, That is a hard question to know the answer to. It really depends on how the surgery goes, your body and how you recover. And of course how motivated you are. I have learned never put limits on people. But do you your best to keep the area strong and healthy, and support the area as needed. Its always best to try and avoid surgery whenever possible. Good luck!

        • Mo November 11, 2017 at 1:09 pm #

          Hello, I had an MRI a month ago on my left foot and the foot doctor said I have a partial tear in my posterior Tibial Tendon. When they did the MRI 3 years ago they said I had some micro tears, but it was relatively benign pain that would only flare when I did treadmill or play basketball
          They have recommended 8 weeks in a walking boot compression sleeve, and then 4-6 weeks of physical therapy. I’ve already done 4 weeks in the CAM Walker Boot and have stayed away from any sporting activity til it heals.

          Is this the right treatment? Can the immobilization and physical therapy fix this problem? Any other tips? I am largely trying to avoid any type of surgery and am OK with not doing strenuous physical activity.

          • Mo November 11, 2017 at 1:12 pm #

            I also wanted to mention that I did have flat feet and was wearing orthotics in my shoes to strengthen the arch.

            • BenShatto November 11, 2017 at 5:11 pm #

              These are all good questions. Standard practice is immobilization followed by physical therapy. Whether it works or not is highly individual. Here are a few points for consideration. After immobilization, the foot and ankle complex can become stiff. Although the immobilization gives the tendon time to rest and repair, it can exasperate problems that led to the injury. Your PT needs to make sure your ankle and foot and in particular, the forefoot and big toe regain full mobility. Otherwise, you risk injury.

              Another point to consider is that the muscle tendon unit of the posterior tibialis is going to be weak. This means you must perform a graded exercise program in order to strengthen this area or you risk re-injury. This could take 8-12 weeks of progressive overload training and eccentric training for full recovery.

              Finally, we need to remember that orthotics do not strengthen the arch. They only work as a means to support it and hopefully take strain away from the posterior tibialis tendon. Therefore, for complete recovery you need to also work on strengthening the arch of the foot. I would continue in the orthotic as a preventative measure, but you will have to be diligent in maintaining arch, foot, and ankle strength indefinitely. Hope this helps!

              • Mo November 18, 2017 at 1:15 pm #

                Very solid & detailed response. My podiatrist has recommended 4-6 weeks of physical therapy, twice a week. I am not sure the types of exercises/stretches they will have me do, but I will follow them precisely and incorporate what you just mentioned.
                Further, she recommended only wearing lace up dress shoes and not slip on (which I would typically wear).
                I also had a second opinion from an orthopedic surgeon, and he said the boot is not needed and to begin physical therapy immediately. He said 99% of the time surgery is not required.
                From looking at my toes, they have started to point outward a bit. I am guessing I have PTTD, which caused the partial tendon tear.

                • BenShatto November 18, 2017 at 9:09 pm #

                  Hi Mo,

                  Sounds like you are on track now. I like the recommendation to avoid slip on shoes for now. I will be curious to see how your PT progresses your rehab. Please be sure to share your experiences. We all appreciate it. Take care and get well soon.

                  • Mo December 20, 2017 at 4:55 pm #

                    After 7 weeks in the boot, I have now begun Physical Therapy. I go twice a week for an hour.
                    I have only gone to 4 PT sessions, but this is what I am currently doing.

                    Work with an elastic band. Stretching and flexing of the calf. Making J type circles with my foot to strength the Posterior Tibial.
                    Balancing for 30 seconds on the bad leg (I can only do about 10 seconds bc my leg is weak).
                    Calf raises and 10min of icing. She is also massaging the Posterior Tibial area.

                    Further, I found that wearing kinesiology tape along the Tibial Tendon seems to help. I am also wearing a PTTD aircast, which for now gives me a boost in my arch.

                    I’ve noticed that walking for more than 15mins gets my leg tired but at least I’m not in the boot! Any other recommendations?

                    • BenShatto December 20, 2017 at 8:17 pm #

                      Mo it sounds like you are off to a good start. She is right to progress you slowly after so long in a boot as to not flare things back up too much. As you progress in your strength program be sure to work on eccentric calf strength. Also be sure she checks the mobility of your forefoot as stiffness there will impact arch and posterior tib function. And you may want to ask her about doing exercises for the foot intrinsic muscles such as using the toes to pick up a towel or marbles as well as arch raises. Keep us posted as the rehab progresses. Good Luck!

  27. Benjamin Velic May 20, 2017 at 6:07 pm #

    Hello I’m a basketball player and it made me feel relieved when I found out about this forum because apparently some people have the sam problem as I do.My post tib has been hurting for almost a year I’ve got it from a stressed step while playong basketball.Im only 17 years old and basketball is my passion. I think one thing that also contributed to this injury is that I genetically have flat feet.I went to the doctor and tried some anti inflammatory gels and sports gels and ibuprofen and some relief pills and creams, but nothing seems to really help.Any solutions?

    • Ben Shatto May 21, 2017 at 8:33 pm #

      Hi Benjamin, At age 17 a year is a long time to suffer with this issue. Very often during the late teen years of development growth spurts happen and it is very common to find muscle strength and range of motion imbalances as either the bones or muscles/tendons ect fail to keep up with one another as you grow. Though flat feet can be an issue for a person so often that is not the whole issue. There are many people with genetically flat feet that have never suffered any pain from them. Me included. I would highly recommend that you find someone that can evaluate your lower body looking for imbalances in strength and mobility. Starting from the hips and working your way down. Having weakness in the hips can cause the femur to role inwards which can affect the knee and or cause the feet to pronate ( which causes the flat feet). Don’t rely on gels or medications that is just a band aid to the problem. You need to find out mechanically what is causing the excessive strain on the tendon. Good Luck!

  28. KV May 23, 2017 at 12:36 pm #

    Hello,

    I seemed to have developed this condition very suddenly. The pain, though initially along the inner side of the foot has now spread to the bottom of the calf as well. It has been 5 days of non-stop pain and the only pain-free time is sleep. The podiatrist diagnosed it as posterior tibial tendonitis and gave me a shot on the side of the foot and naproxen and recommended regular icing.

    My question has to do with the prognosis, something I failed to ask the doc – do patients make a complete recovery and return to weight-lifting activity like squats? Also, how does one go about making the right choice of orthotic support? Thanks

    • Ben Shatto May 23, 2017 at 8:33 pm #

      KV, an acute sudden case of PTT is usually due to a fall or some other traumatic injury. Otherwise it tends to be more of an overuse injury found in higher impact sports such as soccer, basketball and running. Your pain sounds quite intense and so I would suspect a partial tear of the tendon. Because of the severity of pain and the fact you had an injection I would be very cautious initially as the tendon may be weak and you could be at risk of a complete rupture. If the pain does not subside you may need to be in a walking boot to immobilize the area for a while. As far a a prognosis goes. For most people with the right treatment a full recovery is possible. And yes a full return to squats should also be possible, you just have to taper up the load and I suggest a slower progression as it is common for the muscles of the lower extremity to progress faster than the injured area so I would recommend a slower linear progression on the loads once the pain and symptoms have subsided. As far as an orthotic goes I would recommend a full length semi rigid orthotic that has a moderate amount of arch support but that also helps control the heel. You may consider a custom made one if not I typically recommend the super feet brand and find the size and one that fits the best. I find that the blue color works best for most people. Be sure to call the podatrist and follow up with any questions you may have.

      • Eric May 30, 2017 at 8:42 pm #

        Hi Ben- I developed posterior tibial tendon pain in my right foot years and years ago. I ran 4 marathons and then this developed so I had to stop running. The pain eventually went away but I don’t think I rehabbed it properly last time. It just flared up again and I’m curious, should you wait until you’re 100% pain-free before starting rehab on the posterior tibial tendon? Both achilles tendons got sore recently from hiking too much. I want to do the eccentric loading for both feet seeing they can strengthen the posterior tibial tendon and achilles but I really have no idea how long I need to rest for. It seems like even cross training will aggravate it. Is a month with nothing sufficient to wait or should it be 2-3 months of no activity then rehab? It seems like I never really gave it enough time to rest last time as I was running a lot. Just wondering if you’re supposed to be rehabbing through pain. Thanks for your time and reply!!

        • Ben Shatto May 30, 2017 at 9:39 pm #

          Hi Eric. Great question! So the short answer is no. You do not need to wait until you are 100% pain free before you start rehabbing. Now of course common sense should always be the first rule. If you are experiencing severe pain then you should not continue with any exercise activity. I do warn my clients that it is not unusual to experience a mild to moderate amount of discomfort during certain exercises or activities. However, pain should not increase to a severe about above the baseline amount of pain and should not linger for hours and hours. So as long as the pain levels do not linger or go higher than a mild to moderate discomfort then you can slowly proceed with your rehab. Remember rehabbing from these types of injuries does not typically go fast. The key is a slow progression of load with a heavy focus on eccentric training while insuring full ankle and foot mobility. Hope that helps!

  29. James Kenny June 14, 2017 at 5:29 am #

    I got PTT about 5 weeks ago after a 10 km race on a Monday, easy day on Tue, easy paced 8 mile cliff runon a Wed followed by 7 miles easy paced run on grass on Thurday.Rested for a week but resumed running ,two easy 5 mile runs and it returned.Visited sports surgery clinic, doctor took x ray nothing wrong with bones.Have rested since for 2 weeks.Went back running this week with elasticated ankle support did 6 miles felt ok, however yesterday I spent an hour cutting the lawn followed by an 8 mile run followed by 1 hour of cutting my neighbours lawn. I am back worse than ever.While my injured foot is flat fotted.I have ben running since 1982 used orthotics for a short while but then got rid of them.I have had very few injuries in the intervening years. I train on trail paths all the time in a wood near me. I run road , cross country and 1 marathon each October.The last year I missed doing a marathon was in 2001 .As I am turning 60 in Sept.I was hoping to break 3 hours for marathon to win age category.My marathon is 20 weeks away but I usually do a gradual 4 week build up before starting a 16 week training prog.Should I take a complete rest again.I am slow to get orthotics as I have managed well for 30 years without them. My friend suggests a cortisone injection but I am not interested.My weight is 154 lbs but it drops during my marathon training. Not sure if I should get an mri or just rest with patience?

  30. Ben Shatto June 14, 2017 at 8:42 pm #

    Wow…..James…..well there is a lot going on there. My initial question is what is different about running now vs the last many years. You are obviously a seasoned runner and you were not doing any mileage that would be out of the ordinary for you. So you need to investigate what has spurred this on. Different shoes? A specific incident during the run? A change in your health or something different else where in the legs and hips. Yes rest would be advisable as well as working through the exercises suggested in the post. But really try to dive deep as to the possible root cause of the injury. Otherwise the issue is likely to return. Good Luck!

  31. Lacey June 22, 2017 at 8:40 am #

    I had PTT in my right ankle last year. I went to physical therapy and rested it and it cleared right up. Around January I started feeling arch pain in my left foot. The pan hasn’t gone away, I usually just deal with it. I did go see a podiatrist and he diagnosed me with accessory navicular syndrome. I have extremely flat feet and fallen arches. I went ahead and got custom orthotics and I do love them. I am currently training for a 50 mile trail race in September. Will do these exercises and using the orthotics help clear this up?

  32. Ben Shatto June 22, 2017 at 9:27 pm #

    Awesome! 50 miles is quite a feat. Obviously you have to build up to a distance like that and so as part of the build up you will know if your feet can handle the distance. Because you have a history of PTT and fallen arches with very flat feet it will be important to be very diligent in making sure your ankle strength is very good. I would also encourage you to work on the strength of the foot and the foot intrinsic muscles. For a good resource be sure to read my posts on plantarfascitis. You will also want to make sure to work on your calf strength. Something a little outside the box is to work on hip external rotator strength and glut medius strength. If you have weak glut med then the femur tends to roll in more during stance phase (when your on one foot) this can also worsen the over pronation of your foot (or the tendency for the foot to go even more flat). There are a lot of posts that discuss how to strengthen the hips. So to answer your question…..I would hope with a diligence on your recovery exercises you can run the 50 miles by September. Let us know how it all comes out.

  33. Andy June 27, 2017 at 1:19 pm #

    Hi Ben,

    I was training for a marathon and in mid Feb i got a pretty bad Soleus strain. I went to see my PT for treatment and made a full recovery. I went out for my first proper tempo run after the injury in late April and all seemed well until a couple of hours later when I became aware of a soreness on the other leg. Having had PTT a couple of years ago I immediately recognised the symptoms and went back to my PT. he agreed and gave me some massage etc. After a couple of weeks and couple of sessions with him he suggested I should be okay to return to light running and gradually build up from there. I get no pain day to day but when I run anything more than a couple of miles the whole tendon gets really tight and a bit sore. With a bit of icing it settles down quite quickly but it certainly doesn’t feel ‘right’. I’ve been a bit reluctant to do too many calf raises or stretches for fear of aggravating the tendon but I’m wondering if I should just get on with it? The excersises don’t cause pain but sometime afterwards I get quite stiff, and ‘pinches’ a bit when I do a gastroc stretch is that a sign of it strengthening and a normal part of the recovery or a sign I need more rest? I don’t want to risk making it worse but I also don’t want to not get better because I’m not doing the work.

    What do you think?
    Andy

    • Ben Shatto June 29, 2017 at 8:37 pm #

      Andy, great questions. If you don’t think it “feels right” then likely it isn’t. In cases like this I would typically advise the client to start slow but work through a progression of stretching and strengthening exercises for the ankle and foot complex. Foot mobility may also be a factor that needs to be address. A bigger concern is why did it develop with such low volume as you progressed back from your other injury. You need to see a PT that specializes in running issues and have them analyze your gait and check your hip strength and mobility. There is likely another issue that is being missed that has lead to both the calf and PTT injuries. But since the issue is from April I do not think more rest will be the solution. A progressive linear approach to strengthening the ankles/foot would likely be advised but more importantly discovering the root cause of the injury. Hope that helps. Good Luck!

  34. Chris July 10, 2017 at 4:58 pm #

    My injury started with pain in my left Achilles, this got worse over maybe 4 weeks and was sore to touch,

    After a doctors visit she recommend 6 weeks of anti inflammatory,after another 3 weeks with the pain i asked for a referral to a orthopedic specialist, she ordered first ultra sound, x-ray and then MRI.

    The findings were:

    a small retrocalcaneal bursa effusion with mild oedema in kager’s fat pad

    moderate fluid seen around the tibialis posterior tendon and the extensor digititorum longus tendon consistant with mild tenosynovitis

    all tendons are intact

    I have all my bloods checked for gout etc and all are fine.

    I was placed in a moon boot, and then taken out from a physio, I have been having acupuncture and deep tissue massage for the past 2 weeks with some relief for a while, and I am now in the gym, pool, swim and stretch.

    This is now my 4th month and the mornings are terrible, so much pain, I am what you would class as fit, healthy never a smoker and active.

    I am so down with this as I can’t do anything in my life that I enjoy, dog walks, golf taking my 3 month old baby out for a walk.

    I have had custom orthotics made as they say I have high arches? My left calf muscle is wasting away and I can’t stand on my toes on my left leg.

    I have not really been given any answers and I will try anything to get this fixed, can or will I return to full fitness as Its effecting my mental health now

    Please help

    Chris ( 34 year old male )

  35. Ben Shatto July 10, 2017 at 8:40 pm #

    Hi Chris, I’m sorry you are in such a bad spot. Pain like that can be very difficult on a person. It sounds like you have gone through a lot of conservative treatment. At this point if you were my client I would return to the ortho MD for another evaluation and a possible steroid injection. It is possible that the swelling in the tendon and sheath is causing too much pain for the physical therapy to be effective. Once you have the injection you may need to return to the walking boot for a week or two then very slowly taper out of the boot with a very slow progression with a physical therapist that is familiar with the condition and works with clients with foot issues. Since you have “high arches” it is not uncommon for the foot to have poor mobility within the mid and forefoot as well as the great toe. The joint mobility of the foot needs to be assessed and a very slow but graded foot and ankle strengthening program should be initiated. I hope that helps. Good Luck!

  36. Lori Hewig July 17, 2017 at 1:57 pm #

    Hi Chris:

    I just wanted to say thank you for this post on PTT. I’ve had a chronic but mild case in my right foot for almost 3 years. I’ve learned to manage it by cutting way down on running mileage, not running on consecutive days, switching to stability shoes and doing exercises to strengthen my glutes and hips. Still, some mornings were pretty uncomfortable and I had to walk around on my tip toes until the tendon warmed up and stretched out.

    Anyway, for the past 10 days I’ve followed your foot/ankle strengthening exercises and have noticed a huge improvement! I added a 5 second isometric hold on the inversion/eversion exercises as it was challenging to get enough ROM for a 5 second eccentric release. Thank you for the focus on the eccentric moves. I really think that was the turning point for me. Balance is way improved, and I’ve noticed that my right hip/glute no longer tightens after a run. I could easily do lots of single leg calf raises before but now it turns out that weak calves weren’t the issue.

    I am very grateful for your sharing your expertise and program for free.

    Best,
    Lori

  37. Lori Hewig July 17, 2017 at 1:59 pm #

    Sorry, I meant to address to Ben!

  38. Ben Shatto July 17, 2017 at 5:30 pm #

    Lori….thank you so much for the kinds words. It is sometimes difficult to tease out the root cause of an issue, but it is critical for long term maintenance and hopefully for a full recovery. Adding the hold was a great idea. As your strength improves just switch to a thicker band. The side benefit of the hip strengthening work is that it can help prevent other lower leg issues from occurring in the first place.

    I am happy I could help! Keep spreading the word on running and if people need help we are hear for that too 🙂 Best of luck! Ben

  39. Jayne July 25, 2017 at 5:16 am #

    Hi Ben, I’ve really enjoyed reading your article & comments.

    I was diagnosed with PTT in May 2017 after increasing from zero to HM distance in 5 months, a trial of unstable shoes, and running uphill on a camber for 13km. I thought that because I was handling it in terms of cardio I’d be fine.

    I’ve had an MRI to confirm diagnosis, and I’ve been on complete “impact” rest since May. I’ve got custom made orthotics (awesome) and I’m doing balance & strength exercises for my ankles & hips.

    My doc has suggested I can commence a walk/run program in another 5 weeks (after 12 or 13 weeks rest in total).

    My question is – when I am told to gradually build up with walk/run and gradually build kms, how gradual is this? I know it will depend on my recovery & how my ankle handles it. But on “average” (whatever that is) how long should I expect it might take me to rebuild to HM distance? Eg 3 months, 6 months, never?

    Thanks!

  40. Ben Shatto July 25, 2017 at 7:00 am #

    HI Jayne. I am glad you are working on your balance and strength exercises. This will be key to a successful return to running. As you eluded in your question how fast a person can taper back up their running distance can vary significantly. One must keep in mind that your cardio vascular system can improve rapidly but the musculoskeletal system will take longer. And depending on your personal health status this can be highly variable. We need to keep in mind that there was a significant injury. Lets look at different injury as an example. So….for example in the case of a professional athlete that injures an ACL. Even with the best treatment and rehab in the world it is at best a 9-12 months recovery process. So I use that to remind people that injury can take a long time to recover from. And you do not want to progress too quickly and suffer a set back. To answer your question I would recommend 6-9 months, but if it takes longer then that is okay. You need to be true to your body. So yes returning to half marathon running distances is definitely possible, but please progress slowly. You may consider working with your physical therapist or a running coach to insure a proper return to running program. In general I am a fan of the walk/run program and I would be sure to not run on back to back days. In fact you may want to consider at least a two day rest after each running session. And be sure to continue with the strengthening protocol. Hope that helps and good luck! And don’t give up! You get to start running soon 🙂

  41. Jayne July 25, 2017 at 7:47 pm #

    Thanks heaps Ben. I really appreciate your response.

  42. Ali August 10, 2017 at 9:23 pm #

    Hello
    How long does it take for this kind of injury to heal.

  43. Ben Shatto August 10, 2017 at 9:28 pm #

    Hi Ali. Thanks for the question. I’m sorry I cannot give you a straight forward answer. The rate of healing time will vary wildly from individual to individual and depends on the severity of the injury and the length of time a person has had the injury. In cases of a mild to moderate injury I tell people it may be 4-6 weeks, but I have clients recover in 2 and others take 12 or longer particularly if surgery is involved. Best I can say is anticipate 4-6 weeks and let the symptoms guide your treatment are return to activity.

  44. Nancy August 20, 2017 at 6:44 pm #

    Hello Ben,
    I haven’t read all of the posts, so I hope I am not repeating any questions already asked and answered. I started with plantar fasciitis a year ago, doctor recommended anti-inflammatory, ice, stretching and rolling the plantar fascia and (oops) stair stretches (dropping the heel from a stair), which then led to a problem at the insertion site of my achilles. Ouch. (I would have done things differently had I known!!) Fast forward eight months (rest, failed the boot, trying to stretch the calves but that usually aggravated the achilles, confusion, physical therapy, acupuncture, chiropractor, massage) and a podiatrist recommended the boot again but this time with a heel lift. I stopped after 4 weeks in the boot because I felt the achilles had improved and I was worried that the boot was causing some imbalance in my hip. Moving on, the last 6 weeks (4 weeks out of the boot) I have been able to stretch my calves 4 to 5 times a day (standing wall stretch) 3 holds of 20 to 30 seconds each and that has helped a lot and no longer bothers the achilles yay. (Forgot to say that MRI in June showed insertional achilles tendonitis and plantar fasciitis, but we kind of knew that.) So why am I on this thread? For the longest time I couldn’t walk barefoot or in a flattish shoe. I had to wear shoes with a small heel. That seems to have bothered my posterior tibial tendon and I get inflammation in the area on the inside of my foot and inch or so below the ankle bone and running 3 inches or so towards the big tow. I am now in shoes that don’t have a lift, but I can’t seem to get rid of the posterior tibial discomfort. I have a pretty high arch and I finally found a podiatrist in my healthcare system who agreed to fit me for an orthotic, which I hope will help. Do you have any other recommendations? I am stretching the calves (standing wall 3 sets of 20 to 30 seconds ) 4 to 5 times a day, I stand on one foot for 30 seconds (look up, close eyes if possible),and I do the alphabet with my foot (these not quite every day). I am not running. I limit my walking. Bicycling seems to aggravate. Swimming seems to aggravate so I mostly swim using the pull buoy. I can do about 15 minutes on a stair machine. Thanks for any suggestions!

  45. Ben Shatto August 21, 2017 at 3:08 pm #

    Hi Nancy, I’m so sorry to hear about all of the struggles. I am hopeful that the orthotic can help allow you to increase your weight bearing activity. I know you said you tried physical therapy but as you probably know there is a lot of variability among most medical professionals and physical therapists are no exception. I would seek out a physical therapist that has additional certification in manual therapy. In cases as you described often we find forefoot and great toe lack of mobility significantly contributing to the issues found elsewhere in the foot. People with high arches often have very rigid feet anyway and until you can be sure the rest of the forefoot and mid foot are moving properly I think you run the risk of one of many different foot issues occurring. a good manual based physical therapist can help you with this, but it takes special training. Along with insuring proper mobility I also recommend you work on foot intrinsic muscle strengthening by doing the toe grabs and calf strengthening focusing on the eccentric motion primarily. This means your on the tip toes and the heel is dropping down (going up onto the tip toes is concentric, the opposite). Working up to high reps and high load. I hope that helps! Good Luck!

  46. Hannah September 18, 2017 at 8:25 am #

    Hi Ben,

    Thanks for this comprehensive write-up and for your responses to the thread! I’m having what I believe is PTT pain. I’m a seasoned runner and I’m on wk 8 of a 10 week half training plan for the Newport Half on 10/8. Training was going really well, and I was definitely on pace to PR at sub 1:40. I noticed a slight pain behind my ankle bone on the inside of my ankle area after my last hard session before taper. At this point that was almost a week ago. The day after the hard session I ran an easy 6 and felt the pain during and after the run, especially when going down stairs. I took the next day off completely. The next day I ran an easy 4 and felt the pain again – no better and no worse. I then took two whole days off, icing religiously and doing eccentric calf drops 3x per day. At the end of this two day period I felt big improvements when just walking around, and decided to try running again this morning. Unfortunately on my easy 4 I felt the nagging pain again.

    The pain has never been intense, nor has it caused me to change my gait in any way. I don’t notice it constantly during my runs, but I fear it’ll get worse if I keep pushing it. With the half just about 3 weeks away, what do you think my best course of action is?

    Thanks so much!
    Hannah

  47. Ben Shatto September 18, 2017 at 8:53 pm #

    Hi Hannah, I am sorry to hear about this pain. PTT can be a real nagging issue and as you are aware can become more serious if left untreated. This is where it becomes very tricky. Because you are 3 weeks out it will be a judgement call on your end if you choose to race or not. It maybe that you can race without issue or only pain as your consequence. But you could make the condition worse depending on how badly it is irritated. Since I cannot evaluate you, you would need to decide on your own or get a professional opinion. In many cases of PTT or other injuries 3 weeks can be enough time to heal some and still race. You may consider an orthotic and/or new shoes and finishing your taper with cross training or aqua jogging. Of course continue with the icing and eccentric heel raises. And of course be sure to break in the shoes some and trial the orthotic some insure it fits properly and does not aggravate the area or something else in your foot. Good Luck and keep us posted on how it all goes.

  48. Hannah September 19, 2017 at 7:27 pm #

    Thanks so much, Ben. Will do!

    • Hannah September 26, 2017 at 11:59 am #

      Also, Ben, as a follow up:

      I’ve been told by my PT that racing is alright, provided I re-evaluate my goals and run to finish rather than to PR. That being said, I raced a 5k this weekend on asphalt with surprisingly little pain (a 1 or 2 on a 10-pt scale). My hunch is that the noon gun time had something to do with the lack of discomfort since I was thoroughly warm from being up on my feet since 7am.

      I usually run in the morning, and my half starts at 730am, giving me much less time to warm up. What would you suggest in terms of a warm up routine for early runs and more importantly races?

      Thanks!
      H

      • Ben Shatto September 26, 2017 at 8:51 pm #

        Hi Hannah….thanks for the update. Sounds like you are on track and you are correct that a good warm up is critical to insure your body is ready to race. As part of my typical warm up for either a hard tempo run or longer run I will usually spend a few minutes at the house using a foam roller over my legs. I use it more to “wake” them up and get the blood flowing. Not too deep or too long in one spot. I also often do my thoracic spine which I feel helps my breathing and keeps upper back pain away. Then I will do a brisk warm up walk followed by a jog and then maybe a couple of quick sprints. Kind of my typical race warm up. In your case I would suggest getting a mobility band and use it around the foot. You wrap the band around the foot and ankle then do some ankle pumps and deep squats to get the ankle moving. That should be plenty of warm up. Something else you may consider is to run a very purposeful negative split meaning go out slower than usual and if you are feeling good and warmed up try running the 2nd half much faster. Hope that gives some food for thought on the warm up.

        Good luck and let us know how it goes on the race.

        Ben

        • Hannah October 11, 2017 at 7:41 am #

          Hi Ben,

          Good news – I made it through the half! Despite a challenging course and unfortunate weather conditions I actually managed to run a time I was happily surprised by. I fell about 1.5 mins shy of my PR, but considering the circumstances I’m proud of that. The post tib held up well throughout the race – just an ache (3-4 pain level) the whole 13.1. Immediately iced after and stayed on my feet. The next two days post-race I felt considerable soreness when walking and tenderness to the touch. Now, on the third day, I’m feeling improvement and little to no soreness when walking. What course of action do you recommend in order to get back out on the roads? Planning to take this entire week off save for yoga and stretching and cycling to/from work. I have a slew of rehab exercises from my PT that I’ll wait to resume until next week.

          Thank you again for your willingness to provide advice! It’s so helpful to have a credible advisor on an issue that can be expensive to treat.

          Best,
          Hannah

          • Ben October 11, 2017 at 8:54 pm #

            Hannah. Thanks for the update and nice work on the race. Sounds like you did really well in not the best of conditions. I think your plan above sounds great. I would probably not wait to start back on your PT exercises though. Start back with the easier ones then progress as you tolerate. I would take the week as planned then have your next run be next week and keep it light and easy, but always warm up first even for a light easy jog. If you don’t have any races coming up then keep the running on the easier side of things mainly to keep a base as you progress your rehab. As that progresses then pick a race date start a new training plan and have fun! But definitely take some time to keep a decent base and focus a lot on rehab so you can completely recover from the injury. Good Luck!

            • Hannah October 12, 2017 at 6:49 am #

              Awesome, will do. Is some discomfort during/after a run alright, or is that a sign I’m inhibiting my healing? I know that active recovery/rehab is generally good, so I’m assuming that some discomfort is alright. I’m just worried I’ll become one of those runners for whom pain will become chronic – any red flags aside from shooting pains/gait change that I should be looking for that would be signs to back off?

              Similarly, should I wait to increase distance or speed of my runs until I’m completely pain free?

              Thank you again!

              H

              • Ben Shatto October 12, 2017 at 8:41 pm #

                Hi Hannah, You are correct to be conservative with PTTD as it has a tendency to become chronic. I would say when discussing pain one should not feel more than a “minor” discomfort. That is slightly different for everyone, but since we are going into an off season taking more time to fully heal and recover is probably the prudent strategy so you can come out strong in 2018. So with that said I would advise not increasing run distances just try to maintain a base that doesn’t aggravate the condition while you worth through the rehab process. Once the pain is mostly gone you can slowly taper up the running. Be sure to avoid sharp/stabbing pains, or pain that lingers for long periods of time such as hours to days and any moderate or high levels of pain.

                Ben

                • Hannah October 16, 2017 at 7:48 am #

                  Great, this makes sense. Thanks so much!

  49. Reist September 27, 2017 at 7:48 pm #

    So this is the longest and most informative thread I have ever seen in a forum. Ben, it is unbelievable how cool you are to answer all of these questions…..one more!

    I have completed 17 marathons and a 50 miler. I have a right ankle that has all of the symptoms that everyone is talking about here. It has never been debilitating, more just annoying. This is how it affects me:

    1. When I first start running it is sore (not sharp) and as I warm up it fades. (Like Hannah, if I run in the evening, I have much less discomfort)
    2. The soreness comes and go, somedays it is not there and then I will head out for a run and it appears. (I blamed the weather!!)
    3. If I put KT tape on after a run, it relieves the discomfort

    I definitely pronate.
    I use green Superfeet
    Brooks Adrenaline / Asics Kayano shoes (Stability)
    I have high arches

    Let me know if there is more info you need.

    I really appreciate it.

    • Ben Shatto September 27, 2017 at 9:05 pm #

      Reist thank you for the kind words.

      What you are describing sounds like PTD or more specifically a tendonosis of the posterior tibialis tendon. Basically a mild chronic inflammation. Mostly annoying except over time the tendon can weaken and you could develop more issues. It’s interesting that you would pronate if you have high arches. Usually people with high arches would supinate. Pronating usually refers to your arches flattening out. If you are already incorporating the advise listed in the post then we need to think outside the box on why it maybe bothering you. The two places I would look first is at hip external rotation strength because weakness in this area will cause a person to roll there knee inward slightly which can lead to pronation. I would also look at the mobility of the big toe. Often times poor big toe mobility (specifically extension) will eventually lead to this issue as well as other foot/ankle issues. You can use a lacrosse ball to self mobilize the foot working at the arch and base of the big toe.

      Hope that helps!

  50. Reist September 28, 2017 at 11:04 am #

    Ben.

    Hilarious, the big toe on that foot has been broken several times over the years and is cranky about putting forth effort. Also I am a Clydesdale (6,3″ 210) and hip rotation and strength is something I need to work on .. so there you go.

    Thanks
    Reist

  51. Ben Shatto September 28, 2017 at 8:50 pm #

    Uncanny…..Well let us know how your progress goes and how it all turns out. Good Luck Reist!

  52. Lee October 27, 2017 at 6:11 am #

    I’m having a similar issue for the last 6 weeks or so. Male (52) running about 25-30Km a week. Current level: 5K (25:00min), 10K (52:00min). Shoe: neutral.

    Problem: A very light pain starts below/ around the Lateral malleolus (LEFT LEG ONLY), this normally disappears after 2-3 minutes BUT pain then “jumps” to the MEDIAL malleolus – the pain stays around there and increases slightly (possibly getting stronger during the push-off moment). At the same time there may be some radiating sensation of pain upwards behind the lower calf – roughly a third up (of the tibia) on the medial side . As the run progresses this pain can actually disappear completely. The next morning I can recreate the same pain around the medial malleolus (and up slightly) by hopping on the problematic leg. Normal walking will not be enough to elicit this pain. Also I cannot feel any pain when massaging the area (even vigorously) as it appears to be internal. No visible redness or swelling at all. Resting for few days clears it (almost) but I guess running brings it back. As the pain is low (even during running) I am always tempted to carry on. Any ideas?…
    I really want to deal with this. It seems (at my age) every time I improve my fitness something else in the body is becoming the weakest link and I need to get stronger in order to move on. Same thing happened with calf issues, then shin splits, now its this thing. Any help will be greatly appreciated. Thanks in advance.

    • Ben Shatto October 27, 2017 at 8:24 pm #

      Lee…..As far as the present symptoms go, they do sound like PTTD. But the more interesting and concerning issue is that you mentioned multiple injuries with shin splints, calf pains and now likely PTTD. At 52 there is no reason to think you cannot run pain free. So my concern is that there are a few biomechanical imbalances that are causing this breakdown in different areas of the calf and lower leg. Usually places to start are calf tightness, hip weakness and maybe running form issues. I would not just push through the pain you have now as PTTD can become chronic and difficult to eliminate. So I would recommend tapering down the running a bit and really work on identifying why these pains are occurring. Start with the exercise suggestions in this post. You may also read my post on Shin splints and incorporate that information as well. Hope that helps. Happy Running.

      • Lee October 29, 2017 at 11:33 am #

        Hi Ben,

        I guess my training is somewhat over-ambitious and impatient (frankly stupid). My runs (average: 10K each) tend to be ALL in the 85% of max HR (as the average HR for the duration of the run) which is probably higher intensity than what I should be doing on a regular basis. I do not possess a long history of continuous running and during 2017 I have been running only since May, so I believe I’m pushing myself “too hard too soon”.

        I run mainly on an undulating (moderately difficult) dirt trail where the footing is unfortunately less than good which makes it even more challenging on the lower legs.

        I have also been experimenting with various shoes, in the hope of reducing the heel drop to 4mm and even zero. It all takes time to fine-tune and learn where my body finds it’s ‘sweet spot’.

        Looking at my Garmin data would probably be enough to confirm that right now I have not achieved a good steady state of proper training, or base-training. I probably need to learn how to run slower and gentler and alternate the routes and effort-level each time I go out. I guess that running – at – or close, to your current limits is not that simple business, and despite the fact that I know better, once I’m on the trail I tend to forget what I know 🙂

        I totally agree with you that a conservative approach to the current pain IS the way forward.

        My previous injuries (calf tears – both legs, and some shin splints) are not from this year and could be in themselves a testimony to my ‘aggressive’ style of training.

        Unlike in the past, I now know that I must be more careful.

        I will certainly check at the exercises here, some I’m already doing, and the shin splints post.

        Thank you!

  53. Ben Shatto October 29, 2017 at 8:14 pm #

    Lee….sounds like you have already delved into deep introspection. Since you like to push yourself, you may find that following a pre-made training plan can help you advance your running and give you permission to push and permission to run easy depending on the day. Some find that following the plan allows them to “plan” their training runs more effectively. Angie here at MTA has some great plans. Just something to consider. Happy rehabbing!

  54. Kate November 1, 2017 at 9:01 am #

    Hi Ben! Thanks so much for all the information above. Can I add one more question to the mix?

    I’m a 29-year-old woman, a longtime recreational runner (20-40 miles/week for the last 12 years), and I’ve been training for my second marathon with no injury problems whatsoever, peaking at 50 miles/week with biweekly speed/tempo runs and lots of hills. The first week of taper I felt fine; I ran a 14-miler last Saturday (two weeks out from the marathon) with no issues, but then Sunday I felt some PTT pain in my left foot and stopped a mile into my recovery run. I took Monday off and then did an easy 5-miler yesterday; the pain got gradually worse, though never incapacitating, starting at around mile 3 (I would have stopped under normal circumstances, but was running point-to-point and had to meet someone…), and now this morning it’s stiff and sore; walking hurts. Will it kill my marathon goals to get some aggressive rest now?

    I’m guessing the best course of action is to ice and rest and see how it feels in a few days… do you have any other advice? Thank you SO much; this forum has been incredibly useful! I see several other people with taper flare-ups, and I’m wondering whether there’s something about decreasing mileage.

  55. BenShatto November 1, 2017 at 8:53 pm #

    Hi Kate,

    You ask some good questions but hard ones to answer. As far as PTTD developing because of the taper, that is unlikely. Most likely the condition was ready to occur and it coincidentally occurred during your taper. That being said it will be important to try and determine the root cause of the pain. Again go back to the most typical reasons for this to develop including issues with foot strike and footwear and of course hip strength as weakness in the rotators of the hip will cause foot strike issues and ultimately pain. If you plan on attempting to run the marathon in the next week or so definitely do not run until the day before the race. You have the mileage and training to meet the distance now you need your body to be recovered and ready. Trust your fitness and training plan. I would advise a short test run (warm up first) the day before. If the pain is still quite intense it maybe that the best course of action is to post pone the race. It really depends on how painful the area is. You have to be the judge and know your body to understand when to push through discomfort and when to be wise and not push into an injury. Either way try to determine why this occurred and in the mean time aggressively work on icing, mobilizing and any other trick or technique you need to do to help prepare you. If you have a local running store near by you may check with them to see who the best PT in town is for a quick “tune up” prior to the race. Hope that helps!

    Ben

  56. Narges November 25, 2017 at 9:33 pm #

    Hello
    I have pttd for 2 years. I was runner. I can’t run now. Can u help me?

    • BenShatto November 26, 2017 at 2:07 pm #

      Hi Narges, I would encourage you to read this article and the comments. It is loaded with great information. After that if you have a specific question I am happy to try and help. Be well !

  57. Dana January 17, 2018 at 10:56 am #

    I wish I had known about this article 6 months ago. My 15 year old daughter was diagnosed with PTT at the end of July. We took her to an orthopedic who specializes in feet and ankles. He put her in a boot, prescribed insoles, and required 6 weeks of PT before re-evaluating her. I was actually very pleased with him. I’m not sure she had the best PT though. The physical therapist never addressed her weak hips or massages her tight calves and tendon area. I have researched different massage techniques for PTT and that seems to help her. However, she can only seem to manage an easy run every other day. I’m addition, her knees are beginning to bother her and point inward even when her feet are pointing straight ahead. I feel like some of this would be addressed if we strengthen her hips. What is my best course of action now?

    • BenShatto January 17, 2018 at 8:32 pm #

      HI Dana,

      So sorry to hear about your daughter’s ordeal. It sounds like you are on the right track. If her knees are starting to roll in more and she is experiencing PTD pain and now knee pain then she definitely needs additional care. I would see out a different physical therapist and have her re-evaluated. The PT needs to start from the lumbar spine and then work down the kinetic chain to address her issues. At her age there is no reason for her not to be active and pain free. Don’t give up just find a better PT, and definitely start from the hips and work down. There will likely be several problem areas than need to be addressed, but the good news is that it is completely treatable and she should get full resolution. Good luck and keep us posted.

      Ben

  58. Maggie January 22, 2018 at 7:33 pm #

    Hi Ben,
    Thanks so much for all the info here. I was diagnosed with PTT recently, in the early stages of training for a spring marathon. I had been running about 50 miles a week before the injury. The doctor told me to take two weeks off running and then reevaluate. I’m now close to the end of that two weeks, have been diligent with physical therapy exercises, and have added Superfeet inserts, as recommended by the doctor. I no longer have pain, but I do have some discomfort when wearing running shoes, seemingly due to the pressure on the inside of my foot from the side of the shoe. Would you say that it is safe to try running again at this point, or would it be better to take additional time off? I don’t want to miss much more of my training, but at the same time really want to avoid this injury becoming chronic. Thanks for any advice you can offer!

    • BenShatto January 22, 2018 at 9:39 pm #

      Hi Maggie, Sounds like you have caught it in the early stages which is great. As you can see from the above posts it can be a difficult problem to get rid of when chronic. I would actually take another week off of training and keep with the PT exercises. I would also visit a local running store and try to find a running shoe that you can wear that does not put pressure over that area. There are dozens and dozens of different brands and styles see if you can find one that fits your unique needs. Your shoe needs to be comfortable and allow proper mechanics of the foot given your unique body shape and running stride. Good luck!

  59. Randy February 5, 2018 at 3:14 pm #

    Hello Ben,
    I’m going on 7 months with posterior tibial tendon pain that has been very sever. This developed from a forward fall on a step. It took a couple of months then the pain started and has gotten much worst over time. My 1st doctor had me fitted for insoles and prescribed Duexis 3 times a day. The meds took most of the pain away, but I don’t think I can stay on this due to side effects. The insoles had a high arch and actually increased my pain over a few days and I can’t wear them now. Went to another doctor. Was sent to PT for 18 weeks (I’m the one that suggested PT to the doctor.) I have 4 sessions left. Was sent to the New Balance store at 12 weeks for special insoles. I can manage wearing these insoles for a bit more time, but without the Duexis the pain hit a level 10 in a few hours. PT has tried lots of tools on me including ultra sound messages (works the best so far), grafting(?? with the metal bars), Multiple messages, cupping, taping, and several exercises. At the end of the day, only after working a desk job with limited walking, I still can’t stand up long enough to cook a meal at home that evening without extreme pain. I am on week 10 with a boot. Putting the new insole in the boot helps extend my time some on my feet. The new insoles have a high center that takes some pressure off the arch and in less painful. But if I have a falling arch, wouldn’t this be bad for it? I see my doctor again on Friday this week and will explain all this again to her. What else should I ask about? I’m a 53 year old male. I have high blood pressure and pre-diabetic… both treated with meds. I have had multiple gout attacks in this foot in past years. This is now treated with daily Allopurinol meds. What should I do from here? I have pretty much given up all the outdoor activities that I love and want desperately to return to something more normal soon. Also… MRI’s did not show a tear. Any advise is very much appreciated.

    • BenShatto February 5, 2018 at 9:50 pm #

      Randy I am so sorry to hear about all of this. There is a lot to your question and situation I will try to offer some opinions for you to check into. First I do agree that if the orthotics are too aggressive then they are likely to cause more pain and harm than good. I would suggest a semi rigid type but something with a fairly soft outside cushion. I would also suggest that the arch support be a little less than you might need and have a better heel cup to help control the position of your heel. You mentioned some of the manual techniques the PT did but were you doing any specific foot and ankle exercises and did the PT ever assess the mobility of the foot particularly the forefoot? Also was your hips and pelvis assessed to see if something up higher in the kinetic chain was also contributing. I realize it was a specific injury but with something going on this long it is likely there are other factors contributing.

      It sounds like you were in a boot a long time, so at this point I would look to try a steroid injection to help limit pain then slowly taper out of the boot while still doing PT. If you have gone for 18 weeks to the same PT then you need to find a different PT, find someone that has a good reputation in your area and has advanced certification in manual therapy or orthopaedics. Let me know what else your PT has been doing and I can try to offer some additional insight.

      Please let us know how it all turns out.

  60. Amin February 8, 2018 at 7:11 pm #

    Hello,

    I’m 16, and I have been experiencing a pain like this for quite some time. It is on the inside medial side of my ankle, and it seems to get worse the more I use it. But I am confused because for me it wasn’t an overuse injury, as a year ago I was playing soccer and rolled my ankle, the inside and outside of my ankle healed but this problem persisted for almost a month, on the inside of my ankle where the bone comes out. I missed a lot of time, and had to sit out but eventually it got better over time. But this year I have rolled my ankle in a similar fashion when getting kicked in soccer, and now 6 months later i’m back where I started (but it doesn’t feel as bad). Now when I run it gets progressive worse and worse, and I don’t know where to start! This injury has been very frustrating and I don’t know what to do.

    • BenShatto February 8, 2018 at 8:29 pm #

      Hi Amin,

      I’m sorry to hear about the ankle injuries. It maybe that there is an underlying ankle instability issue that is causing the posterior tibial tendon to be over worked during activity. Given the mechanism of injury there maybe something unstable in the ankle causing the overuse or the PTT itself was injured some how and is not fully recovering. Have you had someone assess the ankle? How was the rehab after the ankle sprain? If you are interested in a book that could help with rehab after ankle sprain you could try my book on the topic. Here is the link.

      https://www.amazon.com/gp/product/B075YC2716/ref=as_li_tl?ie=UTF8&tag=thephystherad-20&camp=1789&creative=9325&linkCode=as2&creativeASIN=B075YC2716&linkId=e44fabf3d550cfbb16d44d8e453f0422

      Keep us posted on how you are doing.

      • Amin February 19, 2018 at 5:11 pm #

        Hello,

        10 days later, the tendon is feeling better but it hasn’t gone away completely yet. I feel at this stage the Post Tibular tendon doesn’t hurt nearly as bad but simply does not want to go away. I’ve tried to come back and try running again, but anything more than a 2 mile runner just inflames the tendon further. I’ve been off it right now for another 4 days and i’m just going to sit it out for now, as there isn’t much I can do. Trying to strengthen it through exercises just hasn’t worked and icing hasn’t done much for me either. I took Aleve, once or twice and I haven’t taken it an a while even though I have felt that it made the tendon feel better. I would agree that I have an underlying ankle instability issue, because I have been very ankle injury prone recently.

        • BenShatto February 19, 2018 at 9:42 pm #

          Hi Amin, Given that information you really need to focus on the ankle stability or this condition is likely to continue to bother you. Exercise will not be a quick fix but a long term maintenance. Focus on calf and ankle inversion strength eccentrically where the muscle is lengthening during the motion and a lot of ankle stability drills.

  61. Jason February 12, 2018 at 11:48 am #

    Hi Ben,
    Really glad to have stumbled upon your site – lots of helpful info! I believe I have developed PTT after a recent HM training run. I have been running / cross training for about two years (and running exclusively for longer, but less intensively). Generally run about 15-20 miles per week with typically one 9-11 miler, mixed with biking and weight training. Problem arose after a 13-miler last weekend, which was at normal training pace, even a bit slower. When finished, I had a lot of soreness on the inner ankle area which I iced immediately. I took about five days off from leg workouts and then tried a light bike ride which went fine. The pain has subsided substantially over the past 8 days now, but it is still tender and particularly after doing calf raises or walking a lot. I am focused on stretching, weight workouts and some biking for now. I also recently started wearing a semi-rigid orthotic any time with my shoes.

    The HM is less than 4 weeks away, so I’m trying to figure out my best strategy to be able to run. Specifically how much and what kinds of exercise to reintroduce as the race approaches. What would you advise?

    Thanks so much!

    • BenShatto February 12, 2018 at 9:46 pm #

      Hi Jason,

      Does the new semi rigid orthotic correspond to the onset of symptoms. If you haven’t been wearing one then that could definitely cause an issue. If this is the case I would discontinue use until after your half. The most important thing in the next four weeks is to get the tendon to calm down. You know you can do the distance and so arriving on race day pain free is the key. Keep with the biking and cross training as well as the advice exercises in the post. To keep your cardiovascular fitness you can aqua jog or try an elliptical for a week or two. then progress into a couple of short 3 mile runs if pain free. If that all works then do one moderate run about 1 week out. If pain free then you are good to go. If not then it will be up to you to decide if you want to risk pushing it for the race. 4 weeks should be enough time if you can identify why it started and get the tenderness and inflammation out fast. Keep us posted!

  62. Jodie February 16, 2018 at 8:37 pm #

    Hi Ben,
    I am so glad to have stopped by this site.
    I’m a 15 year old girl. About a year ago, I started having pains around my arch because my feet started becoming flat. However, I got orthotics and it made the pain go away for about a few weeks. Later on, the pains came back everytime i played netball. I am a competiive netballer so I train and play at least 6 times a week. This means that I get pains quite often. Now recently, around 2 weeks ago, the tendon under my arch has started hurting much more severely. Would this be a case of PTT. I’m not to sure yet but I don’t know if I should get my feet looked at. In the mean time, is there any advice you can give me to help ease the pain? Or evn diagnose what it is?
    Thank you so much in advance!

    • BenShatto February 16, 2018 at 9:47 pm #

      Hi Jodi.

      I have a client right now that is similar in age and presentation and it is not PTD. Based off the initial description I am not sure you have PTT. You may have a case of plantarfasciitis. I will list a link to a post I wrote on this topic at the end. Given your age it is not uncommon to have issues further up the kinetic chain that affect how your feet are interacting with the ground. As odd as it may seem I would start a strengthening program for your hip and gluteus medius strengthening, an example of an exercise for this is side stepping with a band around your ankles or knees. Similar to what one may do for runners knee which I will also link to. The hip controls the internal roll of the femur which will affect how the feet strike the ground and can cause a relative flat foot. Hope that helps but follow the advice in the plantar fasciitis post and strengthen the hips. Let us know how you come out.

      http://marathontrainingacademy.com/plantar-fasciitis

      http://marathontrainingacademy.com/how-to-self-treat-runners-knee

  63. Elizabeth Brown February 23, 2018 at 6:26 pm #

    Hi Ben,

    I’m a 40 year old mom of 3 children. 4 months ago I fell on a staircase and dropped all my weight down onto my left foot, spraining my ankle. My health insurance plan has a 10,000 deductible, so I slapped an ace bandage on, thinking just like many people, it would heal up in a few weeks. I could walk on it, even if limping. In the mean time, the pain worsened over the next month, and I discovered that an accident insurance we have would cover the costs of treatment. So after xrays an orthopedic surgeon decided it was a combo injury of PF and PTT. He gave me a figure 8 brace, a shoe for nighttime, and told me to rest/ice for a month and go to physical therapy. My therapist turned out to be a pedontist as well and a real expert thankfully. He spent more time with me, and diagnosed a tarsal tunnel injury. Because I waited so long for treatment, he was concerned about the nerve, and clearly that was the source of my agony. He said in addition to the PTT, there was injury to the whole column, the artery, nerve, soft tissue etc. I was grateful he believed I wouldn’t need surgery though. He kept me in the brace, started exercises like nerve glides, and did ultrasound 2x per week. I had been in so much pain, my only relief was aleve and sleeping remedies. My life was extremely difficult wearing the brace, hardly being able to walk, and still trying to cook, take care of the house, and children (not even allowed to lift a grocery bag or laundry basket!!!) Finally, I was allowed to wean off of the brace. The ortho doc said I don’t need to see him and gave me a script for PT up until Aug. of 2018. Once I was out of the brace, I got fitted for orthotics for my sneakers. That helped with stabilizing my ankle and relieved some pain. I no longer have to sleep in the shoe either, the PF seemed to heal up quickly by the time I finished with the brace. Plus, I’ve been doing a lt of strengthening exercises to build up my foot/ankle. I’ve had a few setbacks, the first was about a week of agony, with injury to the calf, putting pressure on the vericose veins in my leg. It felt like fire in my leg. Ugh. Finally that went away, but after these few months, I had developed a limp. Then, I think from all the stress, exhaustion and lack of sleep, I came down with the flu! My kids brought it home to me. Anyway, I missed PT and was too weak to do my at home exercise program. Since I’m well from that, I felt my ankle getting stronger and pain finally reduced, so I was feeling encouraged. My therapist said my ankle is finally mobile and stable, but it’s not functional. So he increased my program to include a lot of strength and balance like one legged stands, squats, walking sideways, heel raises, and I was able to do them. He wanted me to go for short walks like 5-10 min. to try to develop a stride. Well, I’ve been doing all of that, including now exercises like bridges to strengthen my hip as well. Now I have a new problem. At my last PT visit, I showed where I had bruising and swelling above my ankle bone. It’s supposedly the upper end of the PTT but I think the insertion where the muscle in the side of the calf attaches? It’s a different spot than ever, but it hurts, the bruised spot, but also the area on the calf about the size of the palm of my hand. My therapist taped across my leg to reduce the contraction of the muscle. That only lasts two days. I’m supposed to go back to RICE!!! I’m so disappointed and frustrated. This is like the nightmare that never ends. I thought I was finally recovering, but this new pain is really nagging at me every step I take. My therapist recommend new sneakers to help, so I was fitted with the Brooks Ghost 10 which I love and have been wearing a few days now with the orthotics inserted. I am waiting for the insurance to approve a $300 pair of custom orthotics which my PT was saying should really help me. Honestly, I never had any foot problems or pain before this injury. I could run, wear flats or flip flops. I could lift heavy boxes. I have gained weight as a result of this. I’m dieting, but my only exercise now is my at home rehab program, up to like 16 exercises. I can’t believe how that fall has changed my life. It’s been 4 months since then. It feels like it’s never going to end. Do you have any advice for me? Thank you. I so appreciated this post.

  64. BenShatto February 23, 2018 at 9:56 pm #

    Elizabeth….I’m so sorry to hear about this ordeal. It really sounds like you are working hard to recover. I think the best advice I can offer at this time is to be more patient with yourself. Severe injuries like yours take a long time to heal and recover. Think about a professional athlete that tears his or her ACL. It is a year long recovery and many times they do not fully recover back to pre-injury levels. Severe injuries can take an extended time to heal. So though 4 months is a long time when looking at severe injury it is not. I know it sounds terrible to consider that 12 months could be the time period back to 100% but also take comfort in the fact that you are doing all you can do and this “nightmare” can/will end. You are correct to be concerned about body weight as that does have a major impact on feet/ankles and knees. So be patient, don’t give up and during this time don’t just focus on the foot/ankle focus on you and your body and making the changes you need to be healthy all around. Your body will thank you and you will recover. I look forward to hearing the rest of this story after you have healed. Good luck!

  65. Elizabeth Brown March 19, 2018 at 6:39 pm #

    Hi Ben,

    Thank you for responding to my story! I really appreciate your advice to be patient with myself, the healing process, and to stick with the program. I thought I’d update you with the recent developments. Thankfully, my PT is no longer having to do the ultrasound and massage, and I’ve advance to a full workout at home, replacing one of my therapy appointments, so I’m only going once a week. I also have custom orthotics being created right now and will soon be wearing them. I’ve had a lot of improvement since 5 months ago and am trying to focus on that and be grateful. I continue to have a lot of pain in many different areas of my body, in addition to the PTT. However, much of that is the muscle soreness related to the workouts, although my achilles and calf remain very tight and it’s annoying, even with all the stretching I do. I’ve finally been able to sleep, the nerve pain is gone, thank the Lord. I am also allowed to lift lightweight things again and am able to do a mini-squat which has made my life so much easier. I included some of the related ankle exercises from your website into my at-home workout. I thought the photos and explanation were helpful. I really appreciate you! Elizabeth

    • BenShatto March 19, 2018 at 8:54 pm #

      Elizabeth, Thank you so much for the update and the kind words. Injury’s are always tough to recover from and so often its the mental drain that is the hardest. Stay focused on the positive and making small daily improvements. You will continue to improve. Good Luck!

  66. Lindsey March 26, 2018 at 9:26 am #

    This is a really useful article. I had an injury after a HM 2 1/2 years ago. I was diagnosed with ptt, sinus tarsi syndrome and heel bursitis. I had a few steroid injections into the bursa and custom orthotics fitted. Ultrasound and x rays also show wear and tear of the ankle joint due to a break years ago. I was in constant pain for around 18 months and could barely walk without pain. Then when I was put on the waiting list for a consultant and I couldn’t see an end to the pain, it just stopped. I’ve gradually been increasing my running over the last 9 months or so and have had no pain at all. Until yesterday when I ran 11 miles. I’m due to do a HM in 2 weeks. I’m hoping that I have caught it early this time and am icing it and trying to rest. I can’t afford to go back to pain affecting my every day life but I really want to continue running if i can. I was hoping to be fit to train for a marathon but I think I will leave that as a dream. I’m guessing I should rest it for a while then start strengthing exercises for it. I was never really given any help towards rehabilitation before except for the orthotics. I didn’t really know what to believe before as I struggled to get answers

    • BenShatto March 26, 2018 at 8:51 pm #

      Hi Lindsey, PTT is a difficult condition to treat and for most it will take several months to fully recover from. The information in the article should help with the recovery. I have a more thorough write up in the Resilient Runner Program available through the site. The important thing is to keep up with the management of the condition and to progress very slowly with your marathon training. I don’t think you need to give up on the dream to run a marathon, you will just have to progress more slowly and be sure to eliminate as many risk factors for PTT as possible. For now hit the rehab hard then decide after a week if the HM is doable in 2 weeks. It may be. Good Luck!

      • Lindsey March 27, 2018 at 3:53 pm #

        Hi Ben, thanks so much for replying. I am definitely going to get going with the rehab exercises. Just done some and I’m going to try them throughout the day at work. My foam roller is coming out of the shed tomorrow where it’s been for quite a while! I also get some mild hip pain on that side, which I’m guessing could be linked so I should all focus on that. I really want to do the HM if I can but I know I need to focus on long term. I’ve been so enjoying getting back to running again especially as I have lost a lot of weight and feel the massive benefits in my strength and pace of running.

        • BenShatto March 28, 2018 at 8:36 pm #

          Lindsey, sounds like you have a good plan. Keep with it. Definitely explore more into why that hip is bothering you. It may be related back to the PTT. Good Luck!

          • Lindsey April 8, 2018 at 4:31 am #

            Hi thought I would reply to say I ran the HM yesterday and got a PB too by 5 mins! Am keeping up with the strengthing exercises for it

            • BenShatto April 8, 2018 at 12:42 pm #

              That is Fantastic News!!! Thanks for the update!!!

              • Lindsey July 10, 2018 at 12:39 pm #

                Hi Ben. I thought I would reply to say that I decided not to give up my marathon dream and I am signed up to my first one next April! I’ve started to feel slight tenderness over the tendon again and am currently icing it after a 5k run. I’ll continue with the strengthing exercises again. I know ice is recommended for pain and/or swelling but would heat be beneficial to aid recovery also?

                • Ben Shatto July 10, 2018 at 9:00 pm #

                  Hi Lindsey, Good question. If your looking at heat vs ice as a recovery aid I would probably recommend trying contrast baths, where you alternate heat then ice. If you want to use heat only, try soaking your feet in warm water with some Epson salts vs just using a hot pack. This way you get the benefit of the magnesium absorption as well. April is a good goal as it gives you plenty of time to slowly taper up your running. Good Luck!

  67. Monica March 29, 2018 at 1:09 pm #

    Hi Ben,

    I am 22 years old and developed Posterior Tibial Tendonitis near the end of January 2018. I performed HIIT exercises without sneakers and the impact injured my right ankle.

    One month ago, I began to perform strengthening exercises as per my doctor’s instructions. She told me to start with low reps and slowly increase. Within that month, I definitely feel my ankles stronger and increased to the full sets of 30 or so reps. I am now on week 4 of my recovery, and my ankle seems to have flared up again. I decided to try going without my ankle brace for a couple of days and the pain returned in that period.

    I feel discouraged. I want to begin exercising again but with the pain returning I am not sure what to do. I cannot afford to visit a physical therapist every week, and just want my ankle to heal. What do you think I should do? And do you think that I will have a full recovery?

    I also wanted to add that I have been eating an antinflammatory diet and take turmeric capsules everyday to keep the pain at a minimum. Thank you so much.

    • BenShatto March 29, 2018 at 8:47 pm #

      Hi Monica, this is a tough one. It depends on how badly the PTT was injured. But on average its a 2-3 month recovery. So there are always some bumps in the road. Just go back to wearing the brace, take it easy a few days then start back on the exercises just lower reps for a while. Are you doing the exercises in this post or different ones? And yes a full recovery is possible, just be patient and consistent. And get some good shoes 🙂 If you try barefoot it has to be a very slow prolonged progression. I usually have people take 3-6 months to go from shoes to no shoes to avoid injury.

  68. Marianne Pickrell April 1, 2018 at 9:07 am #

    I am diagnosed with PTT in my left foot. Previously I have had 2 cortisone injections to cure this. Having now flared up again my Foot and Ankle Consultant asked me to have another injection. The ultrasound scan shows a tear in the tendon. This week I will be having this injection but I ‘must’
    wear a full foot boot as it is feared that the tendon will rupture. Should a rupture occur its major
    surgery. If I follow instruction and rest the foot and ‘am lucky’ and it does not fully rupture, how long do you think it will take to heal and do you think it ‘actually’ will heal, I have my doubts.
    I am not a runner but have played golf for 35 years on a regular basis up to 3 times per week
    walking many miles over grass terrain.

    • BenShatto April 1, 2018 at 8:39 pm #

      Hi Marianne, You are correct to fear the “major” surgery as it is a long recovery. After the injection and wearing the boot I would anticipate at least a 3-4 month recovery. Whether or not you can fully heal is debatable. The hope is that the tendon will scar down and foot can gain a little stiffness to help stabilize that area. Once you are out of the boot you need to spend an extended time period slowing tapering up the strength of the foot and ankle and making sure that forefoot and great toe in particularly have good mobility. You will also want to look into a rigid or semi rigid custom orthotic to help support the arch. If you rehab well I would expect you to be back out on the golf course doing what you love. Good Luck!

  69. Elizabeth Brown April 6, 2018 at 11:22 am #

    Hi Ben,

    Thank you for the encouragement and kind words too. My PT also said something along the lines of the “psychology of injury” and having faith and keep focused on the positive, sticking with the program. I have a new issue I’m dealing with. I got the custom orthodics a week and 1/2 ago. I tried to follow the instructions of slowly increasing the wear. It’s a HUGE adjustment. It feels like I’m walking on sticks and stones. After the first few days, I’ve had the weirdest combination of symptoms. I’ve had a lot of unusual types of pain in bizarre places in my body. For instance, the worst has been the upper back pain, right below the base of my neck. It radiates out in all directions and has made my trapezius super tight. It’s honestly been excruciating. I also have sharp pains in the L5 area as soon as I put them in my shoe. It feels like I have a knife stabbing the center of my calf sometimes. I’ve had muscle cramps all over. My foot and ankle have been hurting, but I thought it was supposed to help that pain. I can’t wear them more than a few hours each day so far, and I’ve had some scary symptoms too like creepy crawly sensation up and down the leg with the PTT. Also one night I felt like my lower calf and ankle had a super hot sunburn. Is this a normal response to a custom orthodic? I have a good PT, but she doesn’t communicate well, doesn’t answer questions. I’ve been taking Aleve with tylenol and that only just barely cuts some of the pain. I had been taking the curcumin but ran out. I ordered more and bromelain too in case this was just inflamation from the sore muscles, but I never had sore muscles like that after workouts. This is making me exhausted and honestly debilitating. It’s hard not to get discouraged. I don’t want to wear the orthodic but it was $350 and I want to give it a sincere try. The packaging says it could take 3 weeks to adjust. Again, even if it supports the tarsal tunnel and PTT, at what cost to the rest of my body? I’ve had people compliment my walking and posture since I’ve been wearing them though. Like less of a limp, standing up straighter. What advice do you have for me? I see my therapist on Monday. Thanks so much, Ben! Elizabeth

    • BenShatto April 6, 2018 at 8:47 pm #

      Hi Elizabeth. Wow. Sounds like the orthotics have really altered your posture. I will try to answer your questions. The weird pains up the leg like a sun burn or creepy crawly pains is most likely from the nerve and from the tarsal tunnel. The pains throughout your body are likely due to the change in posture and asking your body to behave in a completely new way. Your body had obviously adjusted to the way you were moving with the injury and now changing that movement pattern has really stirred things up. It sounds like your entire system is quite sensitive to change. Some people’s bodies are just more sensitive than others. I would suggest keeping with the orthotics if you can, but you may have to taper up wearing them even more slowly. Changing your posture can be an uncomfortable proposition because it makes muscles work and move in ways they haven’t been. Try to progress forward in small baby steps. Don’t progress too fast. Your body is telling you that it needs more time to adjust. If you have access to a hot tub it may be just the trick to relaxing all of those muscles. Keep going, just take it slow.

  70. Ben Shatto April 9, 2018 at 5:29 pm #

    Hi Sarah,

    As you know these are difficult questions to answer. There is no way to know how injured the tendon is without imaging. If the tendon has been injured before and/or you have had this pain a long time then the risk of a tendon collapse is much higher than a new onset of tendonitis. At least in most cases. So I couldn’t say how high the risk is only that there is risk and your personal health status and body type would make a big difference on the amount of risk. I think you are doing the right thing to try and rest it prior to the race and just work on keeping a decent base with cross training. Since you are an experienced runner you know you can do the distance. The choice really comes down to how important is this particular race to you. You can always run the race and risk any potential negative outcomes. Or if you have other more important races later in the season skip this one. It is a hard choice. As far as a type of brace, no not specifically. I would be a bigger advocate of trying a foot orthotic that had had the appropriate arch support and heel support for your foot to avoid excessive strain on the arch and over pronation if that is an issue for you. So if you plan on racing you may consider that as an option though you wouldn’t have time to trial it much so you do run the risk of it causing its own issues. Kinda like racing in a brand new shoe. Not always the best strategy but in your case may be worth the risk. You could have someone with a back up pair of shoes available for you to switch them out if needed.

    Let us know what you decide and how it goes. That information may help someone else. Good Luck!

    • Sarah April 12, 2018 at 1:50 pm #

      Thank you so much for the response!! This is very very helpful and I will definitely let you know how it goes!

      (Sorry for the double-post, I didn’t see your response at the bottom of the thread!)

      • BenShatto April 12, 2018 at 5:45 pm #

        NO problem. Wish you all the best! I will be interested to hear if you decided to run it or not and if so how did it all turn out. Take care.

        • Sarah April 14, 2018 at 11:14 am #

          Hi again Ben – thank you for your advice and guidance. After a trial 3 miler yesterday, where I was limping pretty badly by mile 2, I’ve decided not to run Boston on Monday. It’s a pretty heart-breaking decision but I’d rather still be able to run for the rest of my life than run this one race (at least that’s what I’ll keep telling myself this weekend while I head to Boston to watch my dad run without me).

          Best of luck to everyone recovering from and healing their injuries – being sidelined is no fun at all.

          • BenShatto April 15, 2018 at 11:46 am #

            Hi Sarah, I’m sorry to hear you had to miss the race but if it was hurting that badly then you definitely made the right decision. This condition can get out of control very quickly and derail you for months and months. If you haven’t already you may want to be evaluated by a medical professional who treats this condition often and see exactly what you are dealing with. Is there a tear or just bad tendonitis. If you need guidance or input after your evaluations feel free to reach out.

  71. Sarah April 12, 2018 at 1:47 pm #

    Hi Ben – Thank you for your article! Quick question(s) … I’m a 3:18 marathoner and I am also running Boston on Monday. I have been having pain in what I think it my posterior tibial tendon for the past two weeks. I’ve taken a break from running, been on the elliptical and icing/heating the injury to try and heal it. I haven’t tried running since last week (hurt a lot when I tried) but I feel small twinges in my ankle when I am on the elliptical. Do you think it is a good idea to still run the marathon? I know I could probably make it through the whole thing if pain is the only issue but I am worried about collapsing my arch and needing surgery (something I 100% want to avoid).

    One last thing – any recommendations for a brace I can wear during the marathon to try and minimize damage? I am already planning on wearing compression socks and KT tape if I attempt the race. Thanks!!

    This injury is driving me nuts and any advice would be so helpful!
    Thank you very much!!

  72. Elizabeth Brown April 15, 2018 at 1:13 pm #

    Ben, I am still amazed at the wonderful, helpful and free advice you’ve offered here. I was encouraged by your last reply. I’ve seen my PT this week. She said my case is a “head scratcher”. Obviously not a normal response to an orthotic. I printed out a list of my symptoms for her, but you explained much better what is probably going on, so I’m not as alarmed. She agreed that I must have a sensitive system and to scale back the use of the orthotic. So I’m wearing it a few hours a day, and slowly the symptoms are subsiding. She checked my alignment and my stride, and she said my hips are level, the orthotic is helping my walk. My posture and the tendon/ankle are better, but the pain in my upper back, glutes, and lower back has been unbelievable. She gave me a bunch of neck and back stretches to do, I took the hot baths like you suggested, extra rest, and heating pad. She said I will acclimate over time. I’m feeling slightly better than a week ago, but still exhausted, not sleeping well because of the pain. I also have an appointment with a massage therapist to help with the knots in my muscles and pain. So I’m trying to resist throwing out these orthotics LOL. I guess I really didn’t understand what it meant for my whole body, to have a fallen arch in one foot. I continue to be shocked at how much one injury can change a life. Thank you again, Elizabeth

    • BenShatto April 16, 2018 at 8:43 pm #

      Hi Elizabeth, Injury is such a weird thing. It can/will affect each person different and how a person’s body responds can be so different. It sounds like you are slowly improving. Good idea to have a massage. Give it time and go easy with yourself. It is a process. Good Luck!

  73. Tanya May 8, 2018 at 8:15 pm #

    Hi Ben. Apologies if something similar to my issue has been asked of you before. I am a 46 year old female. I started running for health and fitness (not specifically to lose weight) last November. I began slowly and never overdid it (or so I thought) and built up to running a 15km race 17 days ago. I had no problems on the run and during my training I would have occasional twinges in ankles and knees, but it was nothing that lingered and I put it down to age. Since the run I’ve self diagnosed PTT as all the symptoms fit. It is very mild, most of the time I have no pain at all, but now and then I can feel mild soreness in my left ankle – anywhere from my shin to the arch of my foot. And now I’m feeling similar twinges in the right ankle. I have tried running twice since the 15k and both times have felt pain the next day – again, very mild, but it’s there. I feel it in the morning as well, but as soon as I start moving it’s fine. My question is where do I go from here? I don’t want the situation to get worse, and I want to get back to running as soon as I can without causing further injury. Are there other things I can do to maintain fitness without affecting the PTT – swimming or cycling, for example? Would massage or acupuncture or any other alternative medicine help? Should I be icing the ankle, even though I don’t actually feel pain (or extremely little pain) in day-to-day activities? Should I be strapping it to limit mobility? I haven’t been doing anything to encourage healing yet, other than just not running.

    Thank you for your advice.

    • Ben Shatto May 8, 2018 at 8:57 pm #

      Hi Tanya,

      It is good you are being so proactive upfront. I agree you do not want to let the pain get out of control or further injure the area. As far as fitness goes you could try an eliptical trainer or aqua jogging to keep the cardiovascular fitness. Massage and acupuncture can both be helpful in promoting healing and reducing inflammation. However, the key is to get at the reason why it is developing in the first place. Is it a shoe issue? A running form issue or a muscle imbalance? Or something else. This article gives you some basic strengthening exercises to start with, the resilient runner program has even more information. The other option is to see a physical therapist that works with runners and have an evaluation and then see if he or she can give you a home program. Best of luck!

  74. Eric May 11, 2018 at 1:17 pm #

    Ben et. al.

    Just wanted to stop by and say thanks. This thread is highly encouraging. I’m a 24 y/o grad student and I rely on running to keep balance in my life. Last spring, a series of ankle rolls in my left ankle kept me from training as much as I should have for my first 50k. Regardless, I raced a road 10k and a highly technical trail 50k the same week – to top it off, I took very little time to recover, upping my weekly mileage pretty much immediately. I certainly neglected some underlying weaknesses, and a few months later (after MANY more ankle rolls in both ankles) a pain in my right arch developed and slowly worsened until I could no longer run. I was diagnosed with PTT (lucky as hell I didn’t tear it as I was running 40-50 trail miles/week for 4 months before I saw a doctor). Long story short, I’ve been trying to rehab this thing for 6 months and have lost the ability to do just about all of the things I love to do. Sub-obtimal.

    Two weeks ago my podiatrist recommended a cortisone shot – which I was highly hesitant to agree to. I still can’t do anything but minimal walking and my PT exercises, but I actually feel like I’m making an improvement for the first time since the injury started. Good to see that other folks have successfully rehabbed this injury and returned to running. I day-dream about my first steps back on trail – good luck to all of you dealing with this incredibly frustrating injury!

    • Ben Shatto May 11, 2018 at 8:53 pm #

      Eric…..I’m so sorry you are enduring all of that, but thank you so much for the kind and encouraging words and for sharing your journey. There is definitely light at the end of the tunnel. Did the podiatrist every assess the ligaments of your foot? After so many rolled ankles you may have torn several of the ligaments which can cause some instability of the foot and could be associated with the PTTD. I would definitely have that assessed. Good Luck! And all the best in your recovery.

  75. Kishor jadhav May 15, 2018 at 8:21 pm #

    Hi Ben
    I am preaparing for recuirtment physical exam .last 8month before when i started running everything is fine but after 2 month in my right leg near posteroior tibial bone and joining muscle there is pain.doctor consult after mri its stress fracture.i take rest for 6 month .
    Then last few days before when i started running pain come back on both legs near posteror tibial bone.sound in my ankle and also calf muscle very tight.
    Sir please guide me what shall i do .next month is my joining to physical training programme

    • Ben Shatto May 15, 2018 at 9:04 pm #

      Hi Kishor, It sounds like there is something going on with your running that is putting too much stress on your foot and lower leg. It maybe an issue with your running form or footwear. I would follow the advice in his article and also try getting a different shoe with more arch support. Also be sure you are very slowly tapering up the amount of running you are performing. Look for a good beginner 5k program as a place to start and I wouldn’t run more than 2-3 times a week for now. If the pain continues you will need to have the area re-checked to determine if there is additional injury then get advice on how to prevent it. Good Luck!

  76. Becky Ashley June 9, 2018 at 9:15 am #

    Ben,

    Do you recommend doing the Posterior Tibialis Tendon Dysfunction Exercises daily? These are all very similar to the exercises I did at PT when I had this issue in my right ankle about 4 years ago. I am now having the same issue with my left ankle. When I did PT, I only went three days a week.

    Thanks!
    Becky

  77. Ben Shatto June 10, 2018 at 8:50 pm #

    Hi Becky, good question. I typically have people perform the exercises 3-5 times a week.

    • Butch Searle-Spratt June 17, 2018 at 2:06 pm #

      I am doing the exercises 5 times a week. After 4 weeks i can now lift the heel of my left foot off the floor one inch! It is not pain free yet, but I am doing it. According to some sources that is not supposed to happen but my left foot was NOT listening. 4 weeks ago I could not lift the heel one millimeter, let alone an inch.These exercises work but one must maintain a drive to see it through to the end, which could take months and months.

      I am also using laser therapy and massage. All together it is working.

      The end result will be worth it all in the end. Stay focused folks.

  78. Butch Searle-Spratt June 12, 2018 at 6:36 pm #

    Hi Ben,

    I am a 69 year old male and a longtime runner. I was recently diagnosed with PTTD in my left foot. I do NOT have the “too many toes” or a permanent flat foot. I do, however, fail the heel rise test, as I am unable to perform it on the left foot. The navicular bone seems to be very prominent on my left foot and somewhat dropped as compared to my right foot.

    I have been doing the exercises as you have outlined for almost 4 weeks now and it appears that the navicular bone is starting to regress a very little and the arch seems to be getting better, albeit very slightly. Is this even possible to reverse the dropping of the navicular or am I just wishful thinking here. I am also utilizing an AFO for further support. Thank you for any input you have the time to furnish.

  79. Ben Shatto June 12, 2018 at 8:45 pm #

    Hi Butch, Yes it is possible to gain enough strength to help support the navicular and improve the arch. However, engaging in higher impact exercises may be an ongoing issue if the bone is already starting to rotate downward. This would indicate to me you have a tear in the tendon or it is very over stretched. If you plan on continuing running you may have to limit the distances some and rely on a rigid orthotic for added support. Definitely keep with the exercises on a regular basis. Good Luck!

    • Butch Searle-Spratt June 13, 2018 at 1:21 pm #

      Hi Ben, thank you so much for that prompt reply. I should have been more clear. My long distance running days are over as per the advice of my podiatrist. These days it is more like medium distance walking interspersed with short running regimens usually 1/4 to 1/2 mile each. I do have custom made orthotics but it has been an ordeal with them as that dropped navicular bone tends to become irritated from the rigid orthotic causing discomfort.

      I am encouraged by your response that there is hope for me through an exercise regimen to somewhat reverse the navicular drop maybe to the point where it is not so irritating to me on my orthotic. I have not yet experienced any deformity of the foot other then the navicular and would like to keep it that way.

      One more question, after starting these exercises, I also seem to have noticed there is less discomfort in the Sinus Tarsi area. It was never that severe to begin with, but seems to be getting less. Is this another awesome side effect of doing these exercises? Thank you so much for this site and your willingness to assist us in our afflictions.

      Butch

      • Ben Shatto June 13, 2018 at 8:43 pm #

        Hi Butch, Sounds like you are well versed in your anatomy. Yes, as the muscular integrity of the foot increases while maintaining good foot mobility you will see improvements in many common foot/ankle related issues from plantar fasciitis to sinus tarsi syndrome and of course PTTD. As far as the orthotic goes. Sometimes having a rubber or felt type coating over the harder plastic can help with discomfort from the orthotic. See if your podiatrist can add something to pad the area a little if it continues to be an issue. Sorry the long distance running has decreased but glad to hear you can keep doing some running and activity. Take care!

  80. Butch Searle-Spratt June 14, 2018 at 8:12 am #

    Hi Ben. Once I was diagnosed with Stage 2 PTTD I made a concerted effort to learn everything I could about the condition in a effort to better treat it and halt any further progression.

    The hard part was in trying to discern the facts from the fiction. Your site has supplied me with many of the facts and for that I am quite appreciative and grateful. I will keep on keeping on with the exercises as at week 4 I am really starting to see the benefits.

    My Podiatrist explained to me the tendon is not torn but used the analogy of a rubber band that is over stretched and lost some of its elasticity. That makes sense to me. She also explained to me how at Stage 2 the pain can migrate from the inside of the ankle to the Sinus Tarsi as some of the foot mechanics have changed. I seem to be reversing that process somewhat so I am hopeful.

    Have a great day and thanx once more.

    Butch

    • Ben Shatto June 14, 2018 at 8:57 pm #

      Thank you Butch, and I hope others that read this post will be encouraged to continue with the exercises and realize relief is possible. All the best!

  81. Henry July 3, 2018 at 1:37 am #

    Hi Ben,

    I believe I am suffering from PTTD. I have had it before and where I was advised to do some resistance band exercises and heel raises. It was never that painful however I often fell into the trick of it feeling perfectly fine until I ran which then took it back to square one. It eventually recovered after months of no running.

    Years later I believe it is back. I do not want to stop running for as long as last time. Again not sore at all unless I try to run again at which point I stop as soon as I feel it coming on. It might be sore the day after the run but soon feels completely better again (deceivingly).

    This time I’m trying to use a heat pack twice a day which I’m hoping will promote blood flow and healing. Do you have any suggestions to accelerate healing with hot and/or cold packs?

    Thanks in advance,
    Henry

    • Ben Shatto July 3, 2018 at 9:02 pm #

      Hi Henry,

      You can definitely use heat and cold and do a contrast or alternating of both. I typically advise a 15-20 minutes on/off approach. And yes this will bring more blood flow to the area which should bring in more nutrients and theoretically help it heal faster. But you need to get at the root cause of why it is starting in the first place. Is it a muscle imbalance, a poorly fitting shoe, an issue with your running style. I would encourage you to look deeper to insure a long term recovery. Good Luck!

  82. Simone July 13, 2018 at 4:10 am #

    hello BEN, I am an Italian boy (ROMA) of 40 years, in the preparation of the marathon in March, during the first long of 30km I finished with a nuisance around the inner malleolus of the left ankle. The next day, after 3 km I felt pain in the same area. From standing still and walking I did not feel pain, only after 4-5 km began the discomfort on the posterior tibialis.
    I did hyperthermia for two weeks, I started to run gradually and I could even race for the next two months, without any bother.
    Shortly ago during a light run I had again the same discomfort at the tibialis rear … 🙁 I thought I had solved and instead of pain again.
    I immediately stopped for a few days.
    The strange thing is that running in the mountains, even races from 10 km of climbs and difficult descents, I have no problem, but as soon as I do 4-5 km of the plains I feel the annoyance again until I have to stop …
    Magnetic resonance imaging and ultrasound did not see any posterior tibial injuries, but a strange thing that came out is SOLEO ACCESSORIO, which the doctor said could bother the posterior tibial tendon after a few km of run …
    what do you suggest me?

    Sorry for my english, I’m helping with google 🙂

    • Ben Shatto July 13, 2018 at 9:06 pm #

      Hi Simone, This is an interesting diagnosis. In english this is an accessory soleus muscle and is found in 3-10% of the population and usually males. The most common issue is pain with prolonged exercise particularly running sports. This is likely something you will have to manage by finding the best footwear and appropriate terrain for you. I can only surmise that the heel running placed different stress points on the muscle and that is why it did not bother you, or if the surface was softer vs harder such as a bark terrain vs concrete. If you were my client I would have you work on a preventative program to keep your feet, ankles and hips strong and monitor the running surfaces and types of foot wear that work best for you. If the pain gets too severe surgery to remove the extra muscle can be performed and is mostly successful. I hope this helps you out some. Good Luck!

      • Simone July 16, 2018 at 2:11 am #

        hi Ben and thank you for your precious answer, running in the mountains, downhill and uphill could help me to strengthen my ankles, my hips? Or do you think it is still the case to stop for at least 2 weeks and try again slowly to run? At rest or in MTB I have no discomfort …

        • Ben Shatto July 16, 2018 at 8:58 pm #

          Hi Simone, running pain free is always good but to strengthen the ankles and hips you need to do targeted exercises like the ones I have mentioned in the blog post or in other posts on how to strengthen the hips. When you return to running be sure to slowly taper up the distance. No more than a 10% increase in distance per week.

          • Simone July 17, 2018 at 12:37 am #

            I will follow your precious advice, thank you very much

  83. Cheryl July 23, 2018 at 12:45 am #

    Ben,

    First let me say what a wonderful site you have here with a wealth of information! Also, you sound to be have compassion for others in offering your advice!

    I’ve been suffering from bilateral PTTD (late stage 1 or early 2) for about 15 months. I had a lengthy illness in which I was stuck in bed (4 months) and once healed, had quite a bit of muscle atrophy from disuse. (Still do)

    I’m in my early 50’s and thin. After this illness, I wanted to slowly get back into shape and began taking walks (about a quarter mile) in the evenings. On the second evening, I came home with hip and ankle pain in which I never experienced prior. I did a lot of calf/hip stretching and felt fine the next day.

    Within a week, my left ankle began to hurt with mild swelling (oddly enough, in the peroneal area) and I went to see an Ortho. He suggested perhaps a sprain and sent me home with an ankle sleeve/brace. As the days passed, my ankle became more painful and I experienced some spasming in the peroneal muscles. Within 2 weeks, the right foot began to mirror the left, pain-wise. It’s been a vague pain in my feet/ankles and cramping travels into my calves.

    To make a long story short, I saw several podiatrists, foot and ankle surgeons, rheumatologists, neurosurgeons, orthopedic surgeons, neurologists,vascular, neuromuscular neuro’s and the list goes on. I had a plethora of blood work, MRI’d from head to toe, all sorts of x-rays, nerve biopsies, EMG’s, MRI’s of both foot/ankles as well as ultrasounds of both feet and ankles. I’m sure that I’ve missed some testing but all testing was normal. (Cost a fortune!)

    I’ve been working with a podiatrist that specializes in biomechanics. I’m on my 2nd pair of custom orthotics that he’s made. He said that my MRI’s and ultrasounds look fine with no tears, etc. however has said that my navicular bones have dropped a bit. He guessed me to be Stage 1 (late) or possibly early Stage 2. I’ve had several adjustments on the orthotics and my feet are just having a hard time getting used to them. He feels that atrophy is hindering me.

    Regardless, it’s been very difficult to strengthen from the waist down. I have participated in aqua therapy which was painful on my feet, as well as land therapy. I no longer participate in either. I currently see a Massotherapist weekly and a Chiropractor about once a month. The Massotherapist tells me that my calves/hips and back are tight and the Chiropractor tells me that I have tight hip flexors, psoas, as well as other tight areas.

    Until recently, I was told by every MD that I had seen (including certified foot and ankle physicians, podiatrists, etc.) to stay in bed with my feet up. As you can imagine, I have much more muscle atrophy/disuse than I did a year ago! (I’ve been on my feet minimally for the past year+)

    I do have flexible flatfeet which I never knew and never bothered me until this ordeal. My feet/ankles hurt daily and I can only do short walks outside for about 10 minutes a few times a day. The remainder of the day I have to rest. With my new orthotics, (I’ve been wearing them for 2 months with several adjustments thus far) some of the mild swelling has dissipated around the ankles and heels, my achilles no longer hurt so terribly and my sinus tarsi pain has decreased. When I’m in bed or wake up in the middle of the night from sleeping, I have no pain at all.

    Would you suggest trying the exercises above of trying physical therapy again? PTTD scares me and it’s been going on for a long time. I certainly don’t want 2 flatfoot reconstructions on my feet. My podiatrist is wondering if half of my problems that are causing my feet/ankles such grief are coming from the severe atrophy as well as the tight hip flexors, calves, etc.

    Since this began and progressed, (not sure if it’s atrophy, PTTD or both), I can no longer walk stairs, squat, sit on the floor as I can’t get back up. Standing in one place for more than 5 minutes hurts. I can no longer do many things that I once took for granted and it’s quite depressing. My feet don’t look like the pictures that you see online of those with PTTD, my arches aren’t like pancakes, although I do pronate and my ankles do, as well. (The orthotics have helped some of this)

    At this rate of walking about 30 minutes a day or less, it’s going to take me 30 years to build any muscle tone. My feet must always be flat, otherwise my feet/ankles hurt)

    As you can imagine, I’m desperate for some help. I’m not asking for medical advice per se, only asking if perhaps I should give physical therapy another try or the exercises you have above. I would also love to know if muscle atrophy from disuse for this period of time could cause a majority of the pain I’m in.

    I apologize for the length but appreciate you taking the time to read it over. You sound like an extremely compassionate physical therapist to help so many! Thank you for your time and any thoughts you may have.

    • Ben Shatto July 25, 2018 at 9:42 pm #

      Hi Cheryl,

      I’m sorry to hear about all the issues you have been having. In my opinion you will not be able to rest yourself out of all the aches and pains you have. So yes I would be in favor of staring physical therapy again for you. You need a therapist that can slowly guide you back into activity starting by targeting your weakest areas then progressing to overall fitness. Given your history of PTTD I would also be concerned about worsening it, so the exercise program will just have to be slow. The key is slow and steady. If you continue to have pain I would look into this new product. I’ve been hearing a lot of great results form it. Ask around in your area who is doing these types of treatments. Here is a link that briefly discusses the treatment. The product is called Amniofix, And it could be a good treatment option for many of your described issues. Best of Luck!! https://www.silvesterfootclinic.com/library/amniofix-injections-for-plantar-fasciitis.cfm

      • Cheryl July 30, 2018 at 9:52 pm #

        Thank you for your response, Ben. I appreciate you taking the time to offer your advice.
        I’m going to speak with my primary physician about a script for physical therapy, perhaps this time with “CRPS” as a diagnosis so that the physical therapist isn’t rough with me (this time) and takes it slower. I’ll also inquire about Amniofix and see what I can find out about it, thank you!
        It’s hard for me to fathom that all of these “specialists” have suggested bed rest for over a year and are continuing to do so. When in the hospital, they get you up and moving as soon as possible to avoid atrophy!
        I’m guessing if a physical therapist can help address all of the weakness (at a slow pace) and help me to strengthen my muscles, maybe my orthotics will begin to work as intended.

        Again, thank you for your advice and in taking the time in reading over my situation. I think it’s wonderful that you take the time to help others!

        Best,

        • Ben Shatto July 31, 2018 at 8:04 pm #

          Cheryl you are so welcome. I am also surprised by some of the advice that is offered to people. I believe the human body functions best when it is able to move and remain strong. This looks different for everyone depending on his or hers own medical and physical situation but everyone should strive to be their best self. Go slow but keep moving forward. Be well and best of luck!!!! Let us know how your recovery goes!!

  84. Adrian Maybanks July 30, 2018 at 2:35 pm #

    Ben

    I have PTTD and a recent mri shows a tear in the Left ankle Posterior tiblias tendon. I have been given an air brace by the orthopedic surgeon which has helped with the pain. I have grade 4/5 tiblias tendon weakness and significant degenerative tendonopathy. It was orginally suggested that I have a steriod injection, but the Consultant Radiologist said it was not a candidate as an injection will probably cause a rupture. I have been referred back to the ankle consultant. I am awaiting a total knee replacement and I landed on my ankle whilst waiting for the operation causing the PTTD and the knee op was canclled 🙁 . Is it possible to avoid any operation on my PTTD as the brace helps and deal with it by physio / air brace, to be honest my left knee is the real problem and would like to sort that, but not sure I can do the post knee op execises with PTTD. Any thoughts? Regards Adrian

    • Ben Shatto July 30, 2018 at 9:11 pm #

      Hi Andrian, So sorry about the injury. It was the right call to avoid the steroid injection because of the risk of complete tear. Yes you could most likely do all of the knee rehab exercises after your total knee even with the PTTD. Though I would see if you can get it feeling better before the surgery. My suggestion if possible would be to look into one of the newer forms of treatment like the amniofix injections or a platelet rich plasma injection to try and stimulate some healing in the tendon while working on the strength of the foot muscles and keeping good calf mobility. IN the meantime be sure to work on the exercises you will be doing post op knee replacement. It will help you prepare for surgery. Good luck!

      • Adrian July 31, 2018 at 1:39 am #

        Thank you Ben. Will look into your advice. Many Thanks Adrian

        • Ben Shatto July 31, 2018 at 8:00 pm #

          Best of Luck! Keep us posted on your recovery!

  85. Marsha November 22, 2018 at 6:53 pm #

    Hi Ben,

    I just completed the NYC Marathon and have PTT. I’m a neutral runner and have never had any PTT issues, but I didn’t train properly for the race. I think that it’s due to a one time overuse rather than chronic issue, so I think it’s just a question of letting heal rather than form correction. I’ve been doing strengthening exercises since then and it is slowly improving, but I am dying to go for a run. I haven’t ran at all in the last 3 weeks for fear of deforming my foot. It still hurts when I walk, but I was wondering if it was ok to return to short runs while it’s still healing, or if I should completely avoid it. It’s perfect running weather right now and I’m dying to get back out there!
    Thanks for your help. I’ve been doing loads of research on this and your column is the only one that has been helpful.

    • Ben Shatto November 23, 2018 at 11:22 am #

      Congrats on the NYC marathon, Marsha! Thank you for the input on my post. I don’t have a solid answer for you unfortunately. I agree it sounds like it was more of a one-time issue versus a chronic issue. However, one must always be aware of a one-time injury becoming chronic if not taken care of properly.

      If you want to attempt a run, it depends on the severity of the symptoms. I would suggest a very thorough warm up, then a short run to “test the area”. If you wear orthotics, be sure they are in the shoes in order to give the arch more support (which will take pressure off of the tendon).

      If the pain worsens after the run, you will know that the injury maybe a little worse than you thought and that you will have to be diligent in your rehabilitation. Always listen to your body and intuition. If you’re not entirely sure, don’t push it. See a medical professional in order to assess the area to insure there isn’t something more significant going on such as a tear versus tendinitis.

      Hope that helps!

      Ben

  86. William February 1, 2019 at 12:05 pm #

    Ben,

    I was diagnosed with posterior tibial tendinosis after doing too much too soon to train for a marathon. I’m a lifelong runner, but had taken some time off. The pain came on the day after a 12 miler, and I could barely walk. This was 12 weeks ago. Since then, through eccentric exercises, other physical therapy, rest, and cross training, the pain has almost completely subsided. About 1-2 times a day, it is very slightly tender, and I can make that go away with a quick massage. During my time off, I’ve also tried to address possible hip/glute weakness as I read this can be a cause.

    My question is, do I need to be 100% symptom free before returning to running? I am planning a very slow progression of running/walking, but I don’t want to cause any setbacks. Running is a huge part of my life, and the time away has been depressing, but I’d rather sit out longer than risk a setback or turn this into a permanent issue.

    Thanks for your help!!

    • Ben Shatto February 2, 2019 at 11:17 am #

      Hi William. Great question. No you do not have to be 100% symptom free. However, more importantly look at the symmetry of your legs. Is your hip, ankle and calf strength the same side to side? Is your balance the same side to side? If no then you need to address that. Otherwise I have people start back on an extremely slow progression. Typically half what they might call a “slow” progression. The key is to very slowly creep up the volume so your tissues have ample time to accommodate to the stress and load. Remember connective tissue takes a very long time to adapt unlike muscle or your cardiovascular system. During the taper continue the rehab and spot training. Hope that helps! There is also a very extensive write up on PTTD in the MTA Resilient Runner Program. All the Best!

      • William February 4, 2019 at 8:56 am #

        Ben,

        Thanks so much for the reply. I don’t believe I have any strength imbalances, but will certainly keep an eye on that. Great point about the cardio system. I think that’s what got me injured in the first place. My cardio system was in great shape, but my connective tissue apparently was not. Probably why I felt great on the run that ultimately injured me.

        Thanks again – this article and your continued responses to readers’ questions over a 3 year span has been a great resource. Excited to start my slow comeback this weekend.

        • Ben Shatto February 4, 2019 at 9:47 pm #

          William…..thanks for the kind words. All the best in your recovery.

  87. Julianna February 7, 2019 at 10:18 pm #

    Hello Ben,

    My doctor believes I have postural tibial tendonitis. It happened while I was stretching after an Orange Theory class. I felt my calf tense/seize up for about 30 seconds (the longest 30 seconds of my life..). I noticed some pain in my foot afterwards while walking, but didn’t think much of it and continued with my orange theory classes for another 4 weeks until stopping completely and beginning anti-inflammatory medication.

    Thus far, I have been to a physio appointment, a podiatrist, and have an ultrasound booked in the coming weeks. The podiatrist recommended I get custom orthotics and an ankle brace, and mentioned that this injury will not go away on its own – making them necessary for recovery. As I do not have benefits that cover these costs, I would love to know your opinion on this, and if there is a certain ankle brace that you would recommend? (the one he quoted me was $70). I do have my first half marathon booked for June, and am hoping for a quick recovery!

    Another thing I wanted to note is that since I started lifting weights 4-5 years ago, I have noticed an imbalance in my glute/legs. I notice that when I am doing exercises with my right leg, my hamstring tends to take the load rather than my glute. I am wondering if you have any insight on this. (This occurs on the opposite leg of the injury). I have been perplexed as to why this happens.

    This is such a wonderful forum. Thank you so much for your time and help!!

    • Ben Shatto February 8, 2019 at 10:09 pm #

      Hi Julianna…..Thanks for the compliment and the questions.

      I think the ultrasound is a good idea. It can help provide a diagnosis which can help guide treatment and recovery. As far as the podiatrist goes, I truly am not a fan of the type of orthotic most podiatrists make. They are very rigid and uncomfortable. Most people tend to not wear them so they end up a waste of time and money. Often times you can get an over the counter brand like Superfeet and it will do the trick just as good. I can’t comment specifically on the brace as I don’t know what type. But I would wait to buy anything until after the ultrasound. If the tear is significant you may have to go in a walking boot for a period of time. Lets hope its just a strain or a small tear. In that case you will have to focus on first toe mobility, calf and ankle strength and balance and finally address your glut issue. There are many exercises that can activate the glutes. YouTube is a great resource. Otherwise a properly performed back squat and dead lift as well as lunges are my favorite. In most cases if your glutes arn’t firing correctly then your likely not doing the exercise correctly. A common mistake is to make the exercise too hard. Your body will want to automatically use your stronger muscle groups to help compensate. Lighten the load and focus on technique then slowly progress the resistance. But always with perfect form. Go slow on the eccentric or lengthening phase. There are also a lot of great glut medius exercises noted on some of my MTA articles on knee pain. For a thorough write up the Resilient Runner program is the way to go. I hope that helps and gives you some insight onto next steps. Keep us posted! All the best!

      Ben

  88. Chris February 20, 2019 at 5:58 pm #

    Hi, thanks for the great article. I was hoping to get your opinion on some pain I’ve been having. Slight pain in inner ankle area that started almost 2 weeks ago. Initially it was present for the duration of full runs. After a few days, the pain was only present off and on throughtout runs. Then a few days later the pain was only present for the very initial part of the run then goes away completely. However, immediately after I stop I can feel it walking. All of the pain is completely tolerable but it’s in my head because I don’t want to cause further damage. It’s not sore to touch, no swelling, and I can push up to my toes without pain. Also at times the pain is in my arch instead of ankle. I honestly notice it more walking than running at this point.

    Addionally I already have custom orthotics I’ve had for 18 years and I added yoga to my training plan for the first time ever. Not sure if those tidbits are important but thought I’d throw them out there. Have my 2nd marathon in late April and am willing to run through slight pain to make this goal. But don’t want my foot to snap in half or something in the meantime haha.

    • Ben Shatto February 20, 2019 at 10:23 pm #

      Hi Chris, Sounds like you are being really proactive about this. Which is great. Not sure how old your orthotics or shoes but it maybe time for a new pair. Weird aches and pains can be a sign of worn out footwear. Also it does sound like you may have had the start of PTTD. I would treat it as such as make sure your foot, hip and pelvis mobility are all symmetrical and without issue. Just make sure you haven’t missed anything that is out of balance up the kinetic chain. Then keep going on the training plan. It sounds like it is all resolving. If the pain does not continue to resolve over the next 1-2 weeks then get more aggressive with the rehab and maybe incorporate a reduced training volume until your back on track. Hope that helps. Keep us posted!

      • Chris April 16, 2019 at 9:56 am #

        Well I don’t know what it is/was but I was able to train through and have pain maybe 5% of the time now. I suppose the yoga/icing are what got me through. I also wore compression socks 2 times a week including my long runs. Thanks for the info and the response to my comment.

        • Ben Shatto April 16, 2019 at 8:45 pm #

          Chris….sounds fantastic. Glad your on the mend. All the best!

  89. Joana Delgado Carreira April 13, 2019 at 4:04 pm #

    Dear Ben,
    First of all, I have read the entire thread and plenty of excellent advice here, thank you.
    My story is a long one…

    My name is Joana, I am 31 years old, 5’1” and 47 kgs.
    I was a ballerina from the age of 3 to 17, I have been running since 2013 and from 2014 I started running half-marathons, I have completed 6 and never had any serious injuries, until last year when I thought I would like to run my 1st marathon.
    I land on my forefoot (always have) and I have high arches, I have been assessed several times and I have always been classified as neutral.

    In early 2018 I followed a 16 weeks program for the London marathon and at the very end of one the last long runs (27kms, which I had never ran at the time) I had BILATERAL pains to my posterior tibial tendons, just over the navicular areas, worse when I stopped running and walked and so bad that walking was extremely painful for days. Waking up was the worse and the first few steps were terrible.

    I am a nurse practitioner and I have decent notions of anatomy, so I thought it could be PTT or plantar fasciitis (or both?).
    I had an ultrasound a few days later that showed minimal fluid/inflammation to both tendons, normal plantar fascia. This was March 2018.
    I was advised to defer from that marathon in order to exclude accessory navicular syndrome or something more complex and decided to rehab myself for 2019.
    By the time I had an x-ray and MRI in August and fully rested there was nothing abnormal, other that bilateral lower Achilles insertion (and as far as I know I have never had Achilles issues). No fluid to the tendon, no thickened plantar fascia.

    I started working with 2 physios, one of them believes that because of my high arches I must start pronating due to fatigue at the end of the long-runs and started me on exercises not dissimilar to yours. The other physio diagnosed me with weak glutes and tight calves (I know I have tight calves) so I also have been doing strengthening to these areas. Additional to that I had laser therapy, shockwave therapy and regular massages with multiple technology.

    I started running up to 5-6kms (which for years was my minimal distance) in September 2018 and since then was very “aware” of both my feet, of this occasional tightening sensation and always concerned that it would developed further. But it never did, and in January this year I have started another 16 weeks programme for the London marathon, ran only 2 to 3 times per week, very minimal speed training (because that really loaded my calves last year) and progress of no more than 10% per week on the long runs.
    I have progressed very well until my 28kms run, which was brilliant and restored my hopes for this race. My feet would feel slightly “tight” immediately at the end of the long-runs but no actual pain and the next mornings were totally back to normal.

    I did my last long-run before the marathon 2 weeks ago, 32kms, both feet felt tighter and slightly swollen in the navicular areas than previously but again no actual pain, just a niggle.
    The next morning, however, they felt painful and that is how I know this injury is back. I have only managed one 6kms run since and every morning my feet feel painful when I get out of bed. They get better during the day but the discomfort never totally resolves.
    I have tried taping, massages, Ibuprofen, NSAIDs gel, I am now only using the elliptical and the bike and not running until the marathon, which is in 15 days.

    What can I do?
    I am so distressed, so frustrated. I have so diligently done all the exercises for almost 1 year, spent so much money with physio, put so much effort into this training, not skipped one single strengthening session, only to end up again like last year.
    I am pretty sure I will still run the marathon as I am not in agony like in 2018 and it is my last change with my ballot place… but I know I will be in pain at the end and that is not how I wanted to remember my first marathon.
    I am sad and depressed for this past week, exercise is a big part of my life and I just feel like my body is broken, that will never be able to cope with that distance.

    I am so sorry for such a long story. I guess we are all looking for hope somewhere.
    Thank you.

    • Ben Shatto April 13, 2019 at 9:05 pm #

      Joana I am so sorry to hear about this struggle. It sounds like you were very diligent in keeping with a rehab protocol. Of course at only 15 days till the marathon the best advice I can give is to try and be as healthy and pain free as possible for the race. Aqua jogging can also be a great alternative and has the benefit of hydrostatic pressure which your feet will appreciate. Not being able to evaluate myself makes it difficult. There are 4 things that pop in my head immediately.

      1. Are you using any type of orthotic to help give more stability to the arch?
      2. Has anyone assessed your 1st metatarsal mobility and your forefoot mobility in general?
      3. Did any of the physio’s assess your hip external rotator strength, not just the glut medius?
      4. Have you had an actual video gait analysis to see if there is a small issue with your running form that eventually gets you as the miles add up?

      I wish you all the best and I admire your tenacity. Don’t give up. I’m sure you can figure this thing out. Sounds like you are already 1/2 way there as you don’t have the severity of pain you did last go around. Let us know how the London marathon turns out.

      Ben

  90. Joana Delgado Carreira April 14, 2019 at 5:29 am #

    OMG, thank you SO MUCH for your next day response Ben!
    I’ll try to answer your questions:

    1. I have always ran in neutral shoes, I have Brooks Glycerin, Nike Pegasus and Asics Nimbus and each one I have been assessed for at the shops.
    Last year, after this injury I was advised to get a pair with more support, so I’ve been running with Brooks Adrenaline GTS. But no, I’ve never had orthotics. I have a pair of Enertor comfort insoles for my work shoes (I am an emergency nurse practitioner so 10 hours shifts but these days definitely less on my feet than last year, when I was not a practitioner yet).
    This week I was advised by one of the physios to get the performance insoles from Enertor which I now have but haven’t had a chance to try them yet as I have not ran at all. They do feel very firm and definitely take space inside my shoe so I think it would be a terrible idea to run with them on race day but I may try them on short runs afterwards, in order to get used to them.

    2. No, that has not been formally assessed. I can tell you that my mobility on the 1st metatarsal/big toe is limited and whilst I don’t actually have hallux valgus I definitely have that tendency, the slight angulation is visible on x-ray.

    3. No, they assessed my overall glutes strength but nothing else. Moreover I was told I do have strong glutes, they were just difficult to activate and that has definitely improved for the past months. I have this whole activation routine with clams, donkey kicks, banded crab walks etc that I have performed before every single run.
    What kind of exercise would you recommend for the hip external rotator in particular?

    4. I have several gait analysis videos on the treadmill (and very happy to send them to you) done last year but they are all from very fresh runs and unfortunately I do not have a video of my fatigued form.

    Many thanks once again.
    Joana

    • Ben Shatto April 14, 2019 at 1:22 pm #

      HI Joana,

      Happy to help if I can.

      1. First of all definitely do not try new footwear this close to a race or on race day. That almost always ends in disaster. While in theory I like zero drop or neutral shoes our running experiences these days are not in a vacuum and the surface you run in and total volume of work load your feet do can be more than they can handle. It isn’t just the running on concrete surfaces but time spent walking on hard floors and concrete. None of which is a natural running surface. So having extra support in the shoe maybe necessary particularly as we push the distance. And there is no conclusive research that a more cushioned built up shoe is better than a zero drop. And in the cases of dysfunction one may need additional support. I often wear a neutral shoe for my short runs or speed work but may revert to a more built up shoe with an orthotic for longer runs. Just my preference. Your tissue may just need more support with high mileage on a firm hard surface.

      2. Poor 1 ray/MET mobility can be a risk factor for PTTD. So as much as you can work on this and of course keep with the calf mobility as tight calves are also a risk factor.

      3. Sounds like you have a great glut work out but the hip external rotators are more difficult and nuanced. I like the monster walk, star drill on a cushion and clam shells, maybe even seated hip external rotation. With clam shells people often use too much resistance so go light resistance and very slow – 5 sec up, 5 sec hold and 5 sec down for 10-20 reps. You should feel it deep behind the trochanter. In a standing position the key is to monitor where your femur position is and make sure your patella is in line with the 3rd or 4th toe to insure your engaging deep hip external rotation. This position must be held throughout the work out/exercise.

      4. For an issue that is more nuanced like yours seems to be I would seek out a running lab in your area and have then run a gait analysis after a longer run. You may find a running lab either in or near an Olympic training center, a very niche high level physio clinic or tied to a university. It will take effort on your part to get it all arranged but it maybe highly revealing.

      Ben

  91. Joana Delgado Carreira May 1, 2019 at 5:52 am #

    Dear Ben,

    I have made it. I ran the London marathon and it was such a bittersweet experience.

    My tendons were tight from the start, the pain steadily increased until km 10 and then was static until the end but it radiated up the medial leg, so probably the entire tendon, which I had never experienced before (it was always only my feet).

    My calves felt very loaded from 30km onwards and cramped up several times, so much that it felt like my feet were not working properly and I had to walk. My hamstrings also cramped a bit but not as bad as the calves… Having to walk definitely felt like defeat as I had never walked during training and because of that I finished in 5 hours.
    Now, I had ran my 28kms in 2hrs47min and my 32kms in 3hrs17min, both very comfortable paced runs and they felt so much better than race day. I had a goal somewhere between 4:15 and 4:30, which I thought was not irrationally ambitious and I was gutted when I saw 5 hours on that watch.

    I guess I am still digesting this whole experience. I feel frustrated because I am pretty sure that this would have been my experience in 2018, had I not deferred in order to rehab myself. So much work, so much money and effort and it really feels pointless now.

    I can see from some pictures later in the race that my pelvis is not aligned and my knees are turning inwards, I thought that would be interesting to you. Also, I am not lifting my knee nor bending my legs as much as I usually do. That is what I can objectively see from my very fatigued form.

    I have not decided if I will ever run another one. This was supposed to be my bucket list experience but I was supposed to enjoy it and give it my best.
    On one hand I want to try and rehab myself (but how?) and then slowly build up the distance again, maybe book a cheap, simple marathon that I can drop out last minute if needed and if this tendonitis does not hit me again then I would try to run the entire distance. I will definitely not run with this pain again, ever.
    On the other hand I just feel like quitting, like my body is telling me “marathons are not for you, your tendons are too weak, your body is not efficient for so much distance”.

    What are your thoughts on changing my foot strike? I have been told by 2 people that I could try that, the fact that I have a very high arch and land on my forefoot is likely putting more pressure on the tendon.
    I have never been a heel striker, I remember running like this since childhood and that maybe comes from ballet (I did ballet from the age of 3 until the age of 17) but I could try to heel strike… Other people have told me that if it is my natural gait then there must be a reason and changing it could bring further issues up in the kinetic chain.

    Thank you so much for your time. I am feeling quite lost right now.

    JoanaDC

    • Ben Shatto May 1, 2019 at 9:04 pm #

      Joana….It sounds like it was a tough experience but it should not be lost that you just ran 26.2 miles. That is no easy feat and most will never be able to say they did that. And to run with that much pain is also impressive and a testament to your internal strength. So well done! Changing a person’s running gait is also not an easy task and will take a lot of effort. There is also no guarantee it will produce the outcome you want. If your thinking of trying a new running gait you may want to consider trying to learn a running system like the Pose method or Chi running. IF you were seeing pictures of you running with terrible form it does likely signal that you have underlying weakness in the hips which definitely can affect your running. Running should not be about the marathon but the experience and for the love of running. Maybe for now your body is best suited for shorter distances like the 1/2 marathon until you can properly rehab, but that really doesn’t matter. What matters is your ability to enjoy running for as long as you want to. For now rest up, re-group and hang in there. You really did accomplish something amazing.

      Ben

  92. A. Elliot May 19, 2019 at 11:23 pm #

    Hi Ben,

    I’ve been trying to help my wife think through treatment plans for what is ostensibly PTTD (we live in the Bay Area).  She is 36, we have a 5 y/o and a 3 y/o, and she has been suffering from bilateral PTTD (we believe) for roughly 1.5 years (since Feb of 2018).  It began in Feb 2018 after she did an intense step/weight/cardio class without her normal insoles, wherein both feet were burning by the end.  The pain moved up the ankle and lingers in both the ankle and up the calf on the internal side (all the way up to the attachment point, to the point where there is bone sensitivity as well as calf tightness/pain).  She is generally healthy (no longer running), 5’4″, and 120 pounds.  

    The pain / sensitivity has progressively worsened despite conservative treatment (ice, anti-inflammatories, etc.) for months at a time.  She has seen orthos, the UCSF specialist in foot/ankle, received an MRI in Sept 2018 with no findings (they ordered a lower back MRI as well, which was clean), and had a follow up XR in Feb of 2019 with no findings. She did four months of PT, which seemingly exacerbated the problem. She also did a diagnostic numbing of the PTTD which resolved the pain for 4 hours, including up the calf.  She has been in a CAM boot for the past 5 weeks in her left foot, and it has had virtually on affect on the pain level (although the arch is slightly higher in this foot than the right).  Two weeks ago, we did a PRP of her right PTTD under ultrasound, and the doctor believed he saw a brief longitudinal separation as he injected, making us think she may have a longitudinal tear that didn’t show on other imaging when the tendon was under tension.

    Any ideas on where to go next…?  We’re at a total loss – despite treatment, the pain has progressed, and she is not getting any exercise at this point (bike, swimming, etc.).  She can barely walk for more than a few minutes before the pain worsens.  

    Thanks so much in advance for any thoughts you might have! Any thoughts/help would be amazing.

    • Ben Shatto May 20, 2019 at 9:08 pm #

      WOW…..that is an amazing story. I think after all the treatment she has had that the answer likely is that she has bilateral longitudinal tears. I have not heard of this before but it does fit the description and why imaging has not revealed an issue. You have already trialed so many different things with little success. I’m not sure I can offer too much other than you may need to consider working very closely with a surgeon who specializes in this area. Two thoughts come to mind. One would be a surgery to explore/repair any potential issue the other would be a trial of Stem cell injections followed by immobilization and then PT. The hope would be to stimulate a healing response and then a very targeted rehab protocol similar to a post surgical patient where we work towards strengthening the muscle and tendon. I would expect a very slow and long recovery possibly 4-6 months post procedure given the treatments she has already done and lack of success. Don’t give up. The body has an amazing ability to heal. You just need to find something to stimulate the healing response and then help the body slowly repair the injury. But the capacity of the body to heal from this is there. Best of luck!

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