Physical therapy protocols for PTTD: A complete guide

If you’ve been diagnosed with posterior tibial tendon dysfunction (PTTD), your doctor or podiatrist has likely mentioned physical therapy as part of your treatment plan. But what exactly does PT for PTTD involve? How long does it take? And most importantly—what exercises will actually help?

This guide walks you through what to expect from physical therapy for PTTD, the key exercises that strengthen your posterior tibial tendon, and how to approach your rehab journey with confidence.

What is PTTD and why does it need physical therapy?

The posterior tibial tendon is one of the most important structures in your foot. It runs along the inside of your ankle and arch, supporting the medial longitudinal arch and helping your foot absorb shock when you walk, run, or stand.

When this tendon becomes overloaded or damaged—often from overuse, trauma, or anatomical factors—it can weaken, stretch, and eventually fail to support the arch properly. That’s when you start to see the hallmark signs of PTTD: pain along the inside of the ankle, swelling, and the progressive development of flatfoot.

Physical therapy addresses PTTD in two essential ways:

  1. Strengthening the posterior tibial tendon and surrounding muscles to restore support
  2. Correcting movement patterns that may be contributing to tendon overload

What to expect at your first PT appointment

Your initial evaluation will typically last 45-60 minutes. Here’s what happens:

Assessment

Your physical therapist will:

  • Evaluate your gait — How you walk reveals a lot about tendon function
  • Check range of motion — Both in your foot/ankle and related joints
  • Palpate for tenderness — Identifying exactly where pain originates
  • Assess foot posture — Looking for arch collapse or flattening
  • Review your symptoms — Understanding pain levels, swelling, and functional limitations

Goal Setting

Together, you’ll establish realistic goals:

  • Reduce pain and swelling
  • Restore full range of motion
  • Return to specific activities (walking, running, sports)
  • Prevent progression to later stages of PTTD

The stages of PTTD physical therapy

Your PT protocol will depend on which stage of PTTD you have:

Stage 1: tendonitis

In early PTTD, the tendon is inflamed but not yet structurally damaged. Treatment focuses on:

  • Reducing inflammation (ice, rest, NSAIDs)
  • Gentle strengthening
  • Activity modification

Stage 2: tendinosis

The tendon has developed degenerative changes. Rehab expands to include:

  • Progressive strengthening
  • Biomechanical correction
  • Custom orthotics integration

Stage 3: flexible flatfoot

The tendon has failed, and the foot has begun to collapse. Physical therapy becomes more intensive:

  • Detailed strengthening program
  • Gait retraining
  • Possible bracing or surgical consultation

Key exercises for PTTD rehabilitation

The following exercises form the foundation of most PTTD physical therapy protocols. Start with your PT’s guidance—these are general guidelines, not a replacement for professional care.

1. Toe Curls (Towel Scrunches)

Target muscles: Intrinsic foot muscles, flexor digitorum longus

How to do it:

  1. Sit with your foot flat on a towel on a smooth floor
  2. Curl your toes to drag the towel toward you
  3. Use only your toes—not your whole foot
  4. Repeat 10-15 times, 2-3 sets

Why it works: Strengthens the small muscles that support your arch independently of the posterior tibial tendon.

2. Heel Raises

Target muscles: Gastrocnemius, soleus, and tibialis posterior

How to do it:

  1. Stand holding a wall or chair for balance
  2. Rise up onto your toes slowly
  3. Hold at the top for 2-3 seconds
  4. Lower slowly
  5. Start with 10-15 repetitions, build to 3 sets

Progression: Once standard heel raises become easy, progress to single-leg heel raises for added challenge.

3. Tibialis Posterior Strengthening (Resisted Inversion)

Target muscles: Tibialis posterior (the star of the show)

How to do it:

  1. Sit with your leg extended, foot relaxed
  2. Loop a resistance band around your foot
  3. Anchor the band to the outside of your leg
  4. Turn your foot inward (inversion) against resistance
  5. Slowly return to start
  6. Perform 10-15 reps, 2-3 sets

Important: This exercise should cause mild fatigue in your inner ankle—not sharp pain.

4. Arch Lifts (Short Foot Exercise)

Target muscles: Tibialis posterior, flexor digitorum longus, abductor hallucis

How to do it:

  1. Sit or stand with your foot flat on the floor
  2. Press your big toe down while lifting your arch
  3. Imagine you’re trying to pick up a marble with the middle of your foot
  4. Hold for 5-10 seconds, release
  5. Repeat 10-15 times

Why it works: This is one of the most important exercises for PTTD because it directly trains the posterior tibial tendon to activate and support the arch.

5. Calf Stretches

Target muscles: Gastrocnemius, soleus

Why it matters: Tight calves contribute to overpronation, which stresses the posterior tibial tendon. Stretching them reduces compensatory strain.

How to do it:

  1. Stand facing a wall, arms’ length away
  2. Step one foot back, keeping it flat on the floor
  3. Bend your front knee while keeping your back heel down
  4. Feel the stretch in your back calf
  5. Hold 30 seconds, repeat 3 times per leg

How long does physical therapy take?

Recovery timelines vary significantly based on:

  • Stage of PTTD — Earlier stages heal faster
  • Consistency — Doing exercises regularly speeds results
  • Individual healing capacity — Age, overall health, and tissue quality matter
  • Activity demands — Returning to sports takes longer than returning to walking

General timelines:

  • Stage 1: 4-8 weeks of PT
  • Stage 2: 3-6 months of PT
  • Stage 3: 6+ months, often requires surgical consultation

Integrating PT with other treatments

Physical therapy doesn’t exist in isolation. Your PT should coordinate with:

Orthotics

Custom orthotics provide arch support that reduces posterior tibial tendon strain during activities. Many PTs work with podiatrists who prescribe orthotics alongside the exercise program.

Activity Modification

Your PT will help you identify activities that aggravate your tendon and develop alternatives. This might mean:

  • Swimming or cycling instead of running
  • Reducing standing time
  • Avoiding uneven surfaces

Bracing

For moderate-to-severe cases, an ankle brace or Arizona brace may be recommended during activity to provide external support while the tendon heals.

Warning signs to watch for

Progress isn’t always linear. Contact your PT or healthcare provider if you experience:

  • Increased swelling after exercises
  • Pain that worsens during or after exercise (mild muscle soreness is normal; sharp pain is not)
  • No improvement after 4-6 weeks of consistent PT
  • New symptoms such as numbness, tingling, or significant weakness

Conclusion

Physical therapy is the main part of non-surgical PTTD treatment. While the exercises may seem simple—they’re incredibly effective when performed consistently and correctly. The key is patience: tendon rehabilitation takes time, but the payoff is reduced pain, improved function, and potentially avoiding surgery.

If you’re starting your PTTD rehab journey, work with a qualified physical therapist who can tailor these protocols to your specific case. And remember: the exercises you do at home matter just as much as what you do in the clinic.

Sources

  • American Academy of Orthopaedic Surgeons: Posterior Tibial Tendon Dysfunction
  • Journal of Foot and Ankle Research: Rehabilitation protocols for PTTD
  • Physical Therapy for PTTD: Clinical guidelines and evidence-based practice