Managing PTTD Flare-Ups: What to Do When Symptoms Return

You’ve been doing everything right. You’ve completed physical therapy, you’re wearing your orthotics, you’ve been careful about your activities. And then suddenly, out of nowhere, the pain comes back. Your ankle is swollen, tender, and making it hard to walk.

Welcome to the frustrating world of PTTD flare-ups.

A flare-up is a temporary worsening of symptoms in a condition that had previously been stable or improving. For many people with PTTD, flare-ups are a normal part of living with a chronic condition. The good news is that they’re usually manageable, and there are things you can do to minimize both their frequency and their severity.

What Causes PTTD Flare-Ups?

Understanding what triggers your flare-ups is key to managing them. While everyone’s triggers are different, some common culprits include:

Overdoing It

The most common cause of flare-ups is doing too much, too soon. Maybe you had a particularly active weekend, took a long walk you weren’t prepared for, or increased your exercise intensity too quickly. The posterior tibial tendon has limits, and exceeding them—even accidentally—can cause inflammation and pain to return.

Activity Changes

Any significant change in your activity level can trigger a flare-up:

  • Starting a new exercise or sport
  • Returning to exercise after a break
  • Increased standing or walking (vacations, travel, new job)
  • Walking on uneven terrain

Inappropriate Footwear

Going without supportive shoes—even for a day—can aggravate PTTD. Flats, sandals, or walking barefoot on hard surfaces can quickly cause problems for vulnerable feet.

Weight Changes

Gaining even a few pounds increases stress on your feet and ankles. For some people, holiday weight gain or changes in activity level can trigger flare-ups.

Weather and Temperature

Some people notice their PTTD symptoms worsen with cold weather or changes in barometric pressure. The reasons aren’t fully understood, but the effect is real for many.

Other Illness or Stress

When your body is fighting off an infection, dealing with other medical issues, or under significant stress, healing processes can be compromised—and that can manifest as a PTTD flare-up.

Incomplete Recovery

Sometimes a flare-up happens because you returned to full activity before your tendon was truly ready, even though you felt fine.

Recognizing a Flare-Up

How do you know if you’re having a PTTD flare-up versus something else? Look for these signs:

Pain Patterns

  • Pain that comes on suddenly or is more intense than usual
  • Pain returning after a period of feeling better
  • Pain with activities that previously didn’t bother you

Physical Changes

  • Visible swelling around the inner ankle or arch
  • Increased warmth in the affected area
  • Redness or tenderness to touch
  • Difficulty doing things you could recently do easily

Functional Changes

  • Limping or changed gait
  • Trouble standing on tiptoes (especially on the affected side)
  • Your foot feeling “unstable” or like it’s giving way

Immediate Management: What to Do When a Flare-Up Hits

When you feel a flare-up coming on—or realize you’re in the middle of one—here’s what to do:

Rest

This is the most important step. Reduce or eliminate activities that aggravate your symptoms. This doesn’t mean complete bed rest (that’s usually not helpful), but scale back significantly. If walking causes pain, limit it. If standing bothers you, sit when you can.

Ice

Apply ice to the painful area for 15-20 minutes several times a day. This helps reduce inflammation and pain. Always use a barrier (like a towel) between ice and skin.

Compression

If there’s swelling, gentle compression with an elastic bandage can help. Don’t wrap too tight—you don’t want to cut off circulation.

Elevation

When sitting or lying down, prop your foot up above heart level to help reduce swelling.

Over-the-Counter Pain Relievers

NSAIDs like ibuprofen or naproxen can help with pain and inflammation. However, use them carefully:

  • Follow package directions
  • Don’t use for more than 10-14 days consecutively
  • Take with food to protect your stomach
  • Check with your doctor if you’re on other medications

Stick to RICE… But Don’t Rely On It Forever

Rest, ice, compression, and elevation are the first-line response to flare-ups. They’re appropriate for short-term management (a few days to a week). However, if you’re using RICE regularly because flare-ups keep happening, it’s a sign something more fundamental needs to change.

When to See Your Doctor

Some flare-ups can be managed at home, but others need professional attention. Seek medical help if:

Red Flags

  • The pain is severe or getting worse despite rest
  • You can’t bear any weight on the foot
  • There’s significant swelling, redness, or warmth (could indicate infection or other issues)
  • You have a fever along with foot symptoms
  • The flare-up follows an injury or trauma

If It’s New or Different

  • This is your first flare-up
  • The pain is in a different location than usual
  • The pattern of symptoms is different from previous flare-ups

If Home Management Isn’t Working

  • You’ve tried RICE for a week and nothing’s improving
  • You’re needing pain medication frequently to get through the day

If You’re Having Frequent Flare-Ups

If you’re having more than 2-3 flare-ups in a few months, that’s a sign your current management plan isn’t working. It’s time to reassess with your doctor.

Long-Term Strategies: Reducing Flare-Up Frequency

The best approach to flare-ups is preventing them when possible. Here are strategies that can help:

Consistent Orthotic Use

Never skip your orthotics, especially during activities. They’re working to support your arch and reduce strain on your posterior tibial tendon.

Gradual Activity Progression

When increasing activity, do it slowly. The 10% rule is helpful: increase activity by no more than 10% per week in terms of duration or intensity.

Regular Strengthening

Continuing your physical therapy exercises—even after formal therapy ends—keeps the muscles that support your foot strong. Strong muscles mean less strain on your tendon.

Appropriate Footwear

Make supportive shoes a non-negotiable part of your life. This doesn’t mean you can never wear fashionable shoes, but be thoughtful about when and how often.

Listen to Your Body

Learn to recognize early warning signs. Often, there’s a window between “something’s not quite right” and “I’m in full flare-up mode” where you can intervene with rest before things spiral.

Manage Weight

If you’ve gained weight, even modest weight loss can reduce stress on your feet.

Address Other Health Conditions

If you have diabetes, arthritis, or other conditions that affect healing, managing them well reduces flare-up risk.

Stress Management

Chronic stress affects inflammation and healing. Find stress-reduction techniques that work for you—whatever helps you relax can indirectly help your PTTD.

Working with Your Healthcare Provider

If you’re having frequent flare-ups, talk to your doctor about:

  • Whether your current treatment plan needs adjustment
  • If there’s been progression of your PTTD
  • Potential use of supportive devices (different orthotics, braces, night splints)
  • Whether additional treatment is needed

Sometimes flare-ups indicate that the underlying condition has progressed, and treatment adjustments are necessary.

The Emotional Side of Flare-Ups

Flare-ups can be frustrating and discouraging. You might feel like you’ve taken steps backward or that you’ll never fully recover. These feelings are completely normal.

A few thoughts:

  • Flare-ups don’t mean failure. They’re a normal part of chronic conditions
  • Progress isn’t always linear. There will be ups and downs
  • You’re not starting from zero. Your body still has the strength and progress you’ve built
  • Temporary setbacks are temporary. Most flare-ups resolve with appropriate care

If flare-ups are significantly affecting your mental health, don’t hesitate to talk to someone. Living with chronic pain is hard, and support helps.

The Bottom Line

PTTD flare-ups are frustrating but usually manageable. Understanding your triggers, responding quickly when flare-ups occur, and working on prevention strategies can reduce both their frequency and severity. The key is paying attention to your body, not ignoring warning signs, and working with your healthcare team to find what works for you.

If you’re having frequent or severe flare-ups, don’t just accept them as normal—talk to your doctor. There may be adjustments to your treatment that can help.

Sources

  • American College of Foot and Ankle Surgeons: PTTD treatment guidelines
  • RICE protocol: Sports medicine research
  • Always consult with your healthcare provider for personalized medical advice