Tibialis Posterior Trigger Points

Introduction

The tibialis posterior is a deep calf muscle responsible for foot inversion, arch support, and ankle stability. When trigger points develop in this muscle, they can cause inner ankle pain, arch tightness, and foot instability, often mimicking posterior tibial tendinitis, plantar fasciitis, or tarsal tunnel syndrome.

Name and Area

  • Name: Tibialis Posterior

  • Area: Located in the deep posterior lower leg, running from the tibia and fibula to the navicular bone and medial foot arch.

Indications

Tibialis posterior trigger points may contribute to:

  • Pain Along the Inner Ankle and Arch (Mistaken for Posterior Tibial Tendinitis or Plantar Fasciitis)

  • Pain That Extends to the Bottom of the Foot and Big Toe (Can Mimic Nerve Compression or Flatfoot Pain)

  • Weakness in Foot Inversion (Difficulty Maintaining Arch Support and Balance)

  • Pain or Fatigue in the Arch and Ankle After Walking or Running

  • Instability in the Foot That Feels Like "Collapsing" (Common in Those with Flat Feet or Overpronation)

  • Pain That Worsens with Prolonged Standing, Walking on Uneven Surfaces, or Wearing Unsupportive Shoes

Pain from this muscle is often mistaken for posterior tibial tendinitis, plantar fasciitis, or nerve compression syndromes.

Muscle Action

  • Inverts the Foot: Moves the foot inward, helping with balance and ankle stability.

  • Plantarflexes the Ankle: Assists in pushing off the ground while walking or running.

  • Supports the Medial Arch: Plays a critical role in foot posture and weight distribution.

The tibialis posterior is crucial for foot mechanics, arch stability, and lower limb function.

Signs and Symptoms

Individuals with tibialis posterior trigger points often report:

  • Pain on the Inner Ankle and Arch That Feels Like a "Deep Ache" or "Tugging Sensation"

  • Pain or Weakness When Lifting the Arch (Can Resemble Flatfoot-Related Discomfort or Tendinitis)

  • Pain That Worsens with Prolonged Walking or Running, Especially on Uneven Surfaces

  • Cramping or Fatigue in the Arch and Inner Ankle After Long Periods of Standing

  • Pain or Stiffness That Worsens in the Morning or After Rest (Can Mimic Plantar Fasciitis Symptoms)

  • Instability in the Foot That Feels Like It’s "Rolling Inward" or "Collapsing"

Pain worsens with excessive walking, prolonged standing, or sudden high-impact activities.

Perpetuating Factors

Common causes of tibialis posterior trigger points include:

  • Overuse in Running, Sprinting, or Jumping Sports (Common in Runners, Hikers, and Dancers)

  • Flat Feet or Overpronation (Can Lead to Overuse of the Tibialis Posterior for Arch Support)

  • Wearing Unsupportive Shoes or High Heels (Increases Strain on the Arch and Inner Ankle Muscles)

  • Walking or Running on Uneven Terrain (Forces the Tibialis Posterior to Work Harder for Stability)

  • Tight Calf Muscles or Weak Foot Muscles (Can Lead to Overuse of the Tibialis Posterior for Balance and Support)

Trigger Point Referral Pattern

Trigger points in the tibialis posterior refer pain to:

  • The inner ankle and lower leg (Can Mimic Posterior Tibial Tendinitis or Medial Shin Splints)

  • The bottom of the foot and arch (Mistaken for Plantar Fasciitis or Heel Pain)

  • The inner calf and Achilles tendon (Can Resemble Soleus Dysfunction or Nerve Irritation)

Pain from this muscle is often confused with posterior tibial tendinitis, plantar fasciitis, or tarsal tunnel syndrome.

Differential Diagnosis

Tibialis posterior trigger points may be mistaken for:

  • Posterior Tibial Tendinitis (Pain and Swelling Along the Inner Ankle and Arch, Worsens with Walking and Running)

  • Plantar Fasciitis (Heel and Arch Pain, Worse in the Morning or After Prolonged Standing)

  • Tarsal Tunnel Syndrome (Burning or Tingling Pain in the Inner Ankle and Foot, Due to Nerve Compression)

  • Flatfoot-Related Pain (Arch and Ankle Discomfort, Common in Those with Fallen Arches or Excessive Pronation)

  • Soleus or Calf Dysfunction (Deep Calf and Achilles Pain, Can Contribute to Foot Fatigue and Instability)

A thorough lower leg, ankle, and foot examination is necessary to rule out these conditions.

Associated Trigger Points

Tibialis posterior trigger points often co-exist with:

  • Gastrocnemius (Calf and Achilles Pain, Affects Ankle Stability and Running Mechanics)

  • Soleus (Deep Calf and Achilles Pain, Common in Runners and Walkers)

  • Peroneus Longus and Brevis (Outer Foot and Ankle Pain, Can Affect Balance and Gait)

  • Quadratus Plantae (Arch and Heel Pain, Can Resemble Plantar Fasciitis or Foot Cramps)

Anatomy and Innervation

Muscle Origin Insertion Innervation
Tibialis Posterior Posterior tibia and fibula Navicular bone, medial cuneiform, and metatarsals Tibial nerve (L4–L5)

The tibialis posterior is innervated by the tibial nerve (L4–L5), which also controls foot inversion, ankle function, and arch support.

Patient Examination

A comprehensive examination should include:

  • Palpation: Identify tender nodules along the inner calf, ankle, and foot arch.

  • Resisted Foot Inversion Testing: Assess pain and weakness when turning the foot inward against resistance.

  • Gait Analysis: Look for foot instability, excessive pronation, or difficulty maintaining balance while walking.

  • Ankle and Foot Arch Strength Testing: Rule out ligament sprains, nerve compression, or muscular imbalances.

Corrective Actions

Dry Needling

  • Dry needling can release trigger points in the tibialis posterior, reducing inner ankle tightness and improving foot function.

Manual Therapy

  • Trigger Point Release: Apply deep sustained pressure to tight spots in the lower leg and foot arch.

  • Massage Therapy: Helps improve circulation and reduce muscle tension in the inner ankle and foot arch.

Stretching

  • Toe-Pointing Stretch: Sit with the legs extended and point the toes downward to stretch the tibialis posterior.

  • Inner Ankle Stretch Against a Wall: Helps reduce tension in the inner calf and foot arch muscles.

Strengthening Exercises

  • Toe Raises: Strengthens the tibialis posterior for better foot control and arch support.

  • Single-Leg Balance Drills: Improves proprioception and reduces foot instability.

  • Resistance Band Foot Inversion: Helps improve ankle mobility and foot strength.

Postural and Footwear Adjustments

  • Wear Shoes with Proper Arch Support (Prevents Overuse of the Tibialis Posterior and Reduces Shin and Foot Pain)

  • Use Custom Orthotics If Needed (Provides Better Foot Stability and Prevents Excessive Pronation)

  • Avoid Excessive Walking or Running on Hard Surfaces Without Proper Warm-Up

Conclusion

The tibialis posterior plays a crucial role in foot inversion, arch stability, and ankle function, but trigger points in this muscle can cause significant inner ankle, foot, and lower leg pain. By incorporating dry needling, manual therapy, stretching, and strengthening exercises, individuals can reduce pain, improve mobility, and prevent arch dysfunction.

➡️ Learn more about Trigger Points

➡️ Explore our Trigger Point Index

Sources:

  • Travell, J. G., & Simons, D. G. (1983). Myofascial Pain and Dysfunction: The Trigger Point Manual (2nd ed.). Williams & Wilkins.

  • Simons, D., & Travell, J. (1999). The Trigger Point Manual, Volume 2: The Lower Extremities. Williams & Wilkins.