Introduction

Evidence-Based Physical Therapy (EBP) uses the best research evidence with clinical expertise and user’s preferences to produce the most appropriate and effective care. At week 44 in 2025, we had International Course in Spain, A Coruna, in the Faculty of Physiotherapy at University of Coruña about EBP. The program was opened with welcome words of the president of The European Network of Physiotherapy in Higher Education (ENPHE) and followed with the basis of EBP and teachers who highlighted the main challenges at different Physical Therapy fields. More than 30 physiotherapy students and 9 teachers from six universities (Savonia University of Applied Sciences, Finland, Universidade da Coruña, Spain, Charles University Czech Republic, CERRFF and École D´Assas, France, and Escola de Santa María de O Porto, Portugal), actively participated this week and shared experiential group dynamics and social activities. The students collaborated and wrote articles on a range of topics, including evidence-based neurology, respiratory and musculoskeletal disorders, geriatric and pediatric care, as well as sports injuries and related issues.

This student team (Picture 1) concentrated on a musculoskeletal topic, specifically posterior tibial tendon dysfunction (PTTD). In collaboration, our objective was to identify evidence-based practices and current limitations in the management of this condition. The project involved a systematic literature search and critical appraisal of recent studies, with particular emphasis on the role of physiotherapeutic interventions in musculoskeletal care. The outcome of this work was a blog-style article aimed at disseminating key findings and clinical recommendations. The article highlights the importance of active exercise and conservative, non-surgical strategies as central components of effective management for individuals affected by PTTD.

Background

Posterior Tibial Tendon Dysfunction is one of the most common causes of acquired flatfoot in adults (Houck et al.,2015). It leads to medial ankle pain, reduced muscle strength, and a collapse of the medial arch, resulting in functional limitations (Jeong et al., 2008). Conservative treatment is recommended for stages I–III and usually includes foot orthoses and therapeutic exercise (Kulig et al.,2009). The aim of this article is to evaluate whether combining resistance training with foot orthoses offers better improvements in pain, strength, and function than the traditional approach of stretching exercises with orthoses in adults with stage I–III PTTD.

Methods

We used the PICOS framework to formulate a structured research question: In adults with stage I–III Posterior Tibial Tendon Dysfunction, does a resistance training program combined with foot orthoses improve pain, function, and strength compared to foot orthoses combined with stretching exercises? We then defined the eligibility criteria. Inclusion criteria were: Adults (≥18 years) diagnosed with stage I–III PTTD, Intervention: resistance training (including Heavy Slow Resistance) combined with foot orthoses, Comparison: stretching exercises combined with foot orthoses, Outcomes: pain, function, and strength (measured via isometric testing or heel-raise test), Study design: Randomized Controlled Trials (RCTs) published after 2005. Exclusion criteria included: Surgical cases with less than 6 months post-operative recovery, Non-conservative treatments (e.g., laser therapy, injections), Unsupervised or non-HSR exercise programs, Other lower-limb pathologies, Non-RCTs, systematic reviews, or case reports. We searched the following databases: PubMed, PEDro, Google Scholar, Science Direct, and the Cochrane Library, using keywords such as “Posterior Tibial Tendon Dysfunction,” “Tibialis posterior tendinopathy,” “Heavy Slow Resistance,” “Stretching exercises,” “Foot Function Index,” and “Muscle strength.” We performed a structured literature review following PRISMA guidelines to assess the effectiveness of Heavy Slow Resistance training programs for PTTD. Each reviewer independently extracted data and assessed the articles they reviewed. Methodological quality was evaluated using the PEDro scale, with scores classified as high (≥8/10) or low (<8/10).

Results

A total of 367 studies were identified. After full screening, four randomized controlled trials met all eligibility criteria and were included in the review. The results of these four studies are presented below. Bek et al. (2012) compared a supervised (center-based) rehabilitation program with an unsupervised home-based program. Both groups improved in pain, Foot Function Index, and muscle strength, with no major differences between groups, except that the supervised group achieved significantly greater posterior tibial muscle strength (p < 0.05).

Jeong et al. (2008) evaluated a 6-week combined stretching with strengthening program versus standard conservative care. The exercise group demonstrated significant improvements in pain, ankle strength, and range of motion, highlighting the benefit of adding exercises in early-stage PTTD.

Houck et al. (2015) compared orthoses combined with stretching and strengthening to orthoses with stretching alone. Both groups improved significantly in pain and function after 12 weeks, with the strengthening group showing better short-term functional gains at 6 weeks. However, by week 12, the differences were no longer statistically significant.

Kulig et al. (2009) investigated orthoses with supervised resistance exercises versus orthoses alone. The intervention group showed significant improvements in pain, Foot Function Index and posterior tibial muscle strength, with eccentric resistance training yielding the greatest gains.

Conclusion

Across the four RCTs analyzed, both treatment approaches—orthoses with stretching and orthoses with strengthening—led to meaningful improvements in pain, foot function, and muscle strength in adults with stage I–III PTTD. While resistance training often produced slightly greater gains in strength (and sometimes in short-term function), the overall differences between interventions were small and not always maintained long-term. The current evidence supports the use of combined conservative programs (orthoses plus stretching or strengthening exercises) as effective management for early-stage PTTD. However, more high-quality research with larger sample sizes and longer follow-ups is needed to determine whether resistance training is definitively superior. During the international course week, we learned how to formulate research questions, search and assess studies, and present findings as a team.

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Authors:

Anas Khida, physiotherapy student, Charles University, Czech Republic.

Tereza Mezerová, physiotherapy student, Charles University, Czech Republic.

Pablo Otero, physiotherapy student, University of A Coruña, A Coruña, Spain.

Nicolas Metoi, physiotherapy student, École D´Assas, France.

Dagmar Pavlu, PT. Assoc. Prof. Charles University, Czech Republic.

Ivana Vláčilová, PhD., PT. Charles University, Czech Republic.

Marja Äijö, PT, PhD Principal Lecturer of gerontology and rehabilitation, Savonia, University of Applied Sciences, Kuopio, Finland.

Veronica Robles García, PhD. PT. OT. Associate Professor, University of A Coruña, A Coruña, Spain.

Zeltia Naia Entonado, PhD. PT. University of A Coruña, A Coruña, Spain.

María Vilanova Pereira, PhD., PT. University of A Coruña, A Coruña, Spain.

Adrien Pallot, PT, MSc, Lecturer at École D´Assas, France.

Aurel Bellaïche, PT, Lecturer at CEERRF, France.

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References:

Bek, N., Simsek, İ., Erel, S., Yakut, Y., & Uygur, F. (2012). Home-based general versus center-based selective rehabilitation in patients with posterior tibialtendon dysfunction. Acta orthopaedica et traumatologicaturcica, 46(4), 286-292. 10.3944/aott.2012.2488

Houck, J., Neville, C., Tome, J., & Flemister, A. (2015). Randomized Controlled Trial Comparing Orthosis Augmented by Either Stretching or Stretching and Strengthening for Stage II Tibialis Posterior Tendon Dysfunction. Foot & ankle international, 36(9), 1006–1016. https://doi.org/10.1177/1071100715579906

Jeong, T. H., Oh, J. K., Lee, H. J., Yang, Y. J., Nha, K. W., & Suh, J. S. (2008). The effect of the combined stretching and strengthening exercise on the clinical symptoms in posterior tibial tendon dysfunction patient. Journal of Korean Foot and Ankle Society, 47-54.

Kulig, K., Reischl, S. F., Pomrantz, A. B., Burnfield, J. M., Mais-Requejo, S., Thordarson, D. B., & Smith, R. W. (2009). Nonsurgical management of posterior tibialtendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Physical Therapy, 89(1), 26-37.