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Inner Ankle Pain while Running: How to Fix Posterior Tibialis Tendinopathy in Marathoners

There is nothing more frustrating than being sabotaged on a long run with vague pains and twinges, traveling along the inside of your foot and ankle.


It's stabbing every time you push off your toes.


And it gets worse the moment you try to pick up the pace.


Once you get home, you start googling.


You're inundated with calf stretches you've already tried, the same old banded ankle exercises you've been doing as prehab (that obviously aren't working), and then WebMD decides you have a shin splints or worse...a stress fracture.



Welcome to the Running Fit Fam.

I'm Dr Whitt Fit, a runner of 15+ years and a practicing Doctor of Physical Therapy.

I know what it's like train hard and feel as if all your hard work has been ripped away by a random, strange twinge.


Let's demystify this inner ankle pain and find out: is it really posterior tib tendinopathy?

How do I know I have Posterior Tibialis Tendinopathy? Where is the pain located?

"The runner typically presents with medial foot and ankle pain and difficulty with tendon loading activities [63]."

Quick answer: You'll probably feel pain underneath and around your inner ankle bone. But don't be fooled: you could also end up with discomfort along the inside of your foot and almost near the bottom of your foot by your big toe.


You may experience tenderness if you press on a swollen area surrounding the tendon and notably have greater pain when you're walking briskly or running (in general, load bearing on the injured side.)


Can I do a test on myself to find out of it's my Post Tib?

I'm so glad you asked.


There are"4 clinical tests for (posterior tibilias tendinopathy):

  1. pain on tendon palpation (this means pressing on the tendon and eliciting pain)

  2. swelling around the tendon (looking at the ankle and noting swelling along the tendon)

  3. pain/weakness with tibialis posterior contraction

  4. and pain during or inability to perform a single-leg heel raise.


Let me give you the punch line right away:

"Of all tests, the single leg heel raise was the most reliable between clinicians and best related to imaging findings in individuals presenting with posterior tibialis tendinopathy, aligning with contemporary thinking of tendinopathy as a load-related clinical presentation."


WHAT THIS MEANS: if you do a single leg heel raise on the side that hurts and you can re-create the pain you felt on your run, you have most likely successfully ID'd your problem and pain as post tib tendinopathy.


Now, because I believe in accuracy and giving you the RIGHT tools to use, check out the exact "how-to" for this calf raise:


"The single leg heel raise test was performed barefoot, with light finger tip support from the examiner as required. Participants were asked to perform 1 single leg heel raise to maximum height in a controlled manner. Maximum height was judged by visual observation in comparison to the asymptomatic side, or to the plantar flex-ion range achieved in non–weight bearing when there were bilateral symptoms."


BUT HOW DO YOU KNOW: you may need to take a video of yourself from behind. All you would do record yourself performing a single leg calf raise on your good side vs. your painful side and then compare how high you calf raises were. If you find the injured side is both painful and it's calf raise was not as tall, you're probably struggling with post tib.



So how do I fix this NOW and prevent this pain from coming back?


Old School Thinking: "Post tib tendinopathy treatment is primarily non-operative with NSAIDs, immobilization, bracing, and foot orthoses for arch support Rehabilitation focuses on eccentric exercises to stretch the tight gastrocnemius and strengthen the tibialis posterior muscles"

This is from a more recent research paper. And it breaks my heart. We can do better.


New School Thinking: Really and truly: work on your foot "core" and ankle strength. More and more research is pointing to just how strong we need our feet and ankles to be as runners. And calf raises are nice and a great place to start, but we can't forget about the rest of the muscles in our lower legs and feet.


That being said, if you need rest, take it. If light stretching helps, then ok.

But your primary focus should be to add in load (think weight bearing exercises) as soon as possible, starting gently and then gradually making the exercises harder.


Because something I want you to notice with the quotes above: "tendinopathy as a load-related clinical presentation."


What this means for you: no more repeat icing, popping advil, resting and hoping this gets better and goes away.


Nope. We manage pain, respecting our bodies. But then, we get to work.

Are there certain running shoes I should use if I have Post Tib Problems?

Because every runner is so different, I don't dare attempt to recommend only one shoe from one brand.

So here's a comprehensive guide to which shoe may be the best for you:


What exercises should I do RIGHT NOW?

oh I got this one! let's hop right in ;)


image goes here


Posterior Tibialis Exercises for Long Distance Runners

Circuit:

2-3 sets each // LIGHT & medium weights


Single Leg Balance on Pool Noodle: High Knees

  • 2 versions (below): 2-3x to fatigue on injured side

Single Leg Calf Raises on Pool Noodle

  • 2 versions (below): 5-10 sec isometric hold; 2-3 sets of 12 reps.

Skater Lunges on Pool Noodle

  • 2 versions (below)

    • isometric: 2 sets of 8-12 reps

    • calf raise added: 3 sets of 8 -12 reps


How to Fix Inner Ankle Pain for Marathon Runners


Single Leg Balance on Pool Noodle: High Knees

  • I know it can seem like a lot: 2 versions for EACH EXERCISE? Trust me. You're gonna want them.

  • The first version to get you started has the first third of your foot smack dab on the middle of the pool, standing on one leg, performing high knees, which resemble the beginning of your running stride. This is to wake up your intrinsic foot muscles and work on your initial single leg balance.

  • PROGRESSION: this is where things get super-running-specific. I need you to stand on the EDGE of the pool noodle so that your entire big toe/most inner part of your foot is OFF the noodle entirely. To keep you stable and the rest of your foot muscles working, I need your big toe ON the floor. You're going to repeat the high knees here.

  • But be careful: this can get very spicy very fast. If you start to have foot pain or cramping, stop and go back to the other version.



Single Leg Calf Raises on Pool Noodle

  • Now hold up: don't jump right away into a calf raise. THIS IS DIFFERENT.

  • I want you to place the first third of both feet on the pool noodle and start your calf raise with both legs going up. At the tippy top, put all your weight onto the injured leg. If this is mildly painful or just hard/weaker than the other side: hold this position for 5-10 secs or until you start to drop the height of your calf raise, coming back down with 2 legs

  • PROGRESSION: once the isometric is easy or no longer painful. gradually work your way to single leg calf raises on the injured side, taking away help from the "good" leg: up with 2 legs, down with injured leg, making sure you heels doesn't wobble side to side

  • as simple as this seems, the pool noodle is unstable. That's deliberate. By putting you on an unstable surface, your feet and ankles have to work hard and get stronger to hold you upright. Don't believe me? Try these calf raises OFF the pool noodle. You'll notice a difference. ;)


Skater Lunges on Pool Noodle

  • this is probably one of my favorite incognito calf exercises.

  • Staying with the same set up, place the first third of your foot in the middle of the pool noodle. Let it be easy at first and just travel through the motion of a skater lunge/curtsey lunge, holding onto the wall for balance as needed.

  • THE SECRET: traveling through this motion actually requires you to engage your post tib muscle through ankle eversion and plantarflexion, which are the exact jobs of that particular muscle. We always want to make sure that an injured muscle can successfully complete it's job without pain.

  • PROGRESSION: same set up and the same motion. But now, at the top of the motion, add in a calf raise. Things just got spicier ;)


WRAPPING UP

Post Tib Tendinopathy is NOT a death sentence.

It does get better.

It does go away!


But it can be an annoying, nagging gremlin if you don't pay attention to it and get to work on it.

Probably the MOST IMPORTANT thing you need to walk away with is:

this blog post is just the beginning.

It's to get you started.


I hand picked these exercises to invite your post tib to the PT-party, to join in on the exercises in a way that finger's crossed won't irritate it too much.


But you need to know: you need more.

Because running isn't just standing on pool noodles.


It's high impact.

It requires single leg strength, from your hip to your literal toes.

You need single balance.

You need plyometrics to build that tendon strength.

and you need heavy load (aka strength training!)


But I want you to have the tools to get you started-especially easy accessible one that don't require you to spend 100's of monies on fancy things to step on.


If you like those toys and they make you feel better: use them!

If you love simple and cost effective pool noodles: we can be friends ;)


If you're looking for even more strength exercises specifically made for runners looking to fix or prevent future running injuries, check out my FREE strength guide for runners HERE.


Until next time running fit fam


Dare to Train Differently,

Marie Whitt, PT, DPT //@dr.whitt.fit


 

REFERENCES:


Clinical Tests of Tibialis Posterior Tendinopathy: Are They Reliable, and How Well Are They Reflected in Structural Changes on Imaging?: https://www.jospt.org/doi/epdf/10.2519/jospt.2021.9707


Current Concepts in the Evaluation, Management, and Prevention of Common Foot and Ankle Injuries in the Runner: https://link.springer.com/article/10.1007/s40141-024-00437-7


 
 
 
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