Early Signs of Posterior Tibial Tendon Dysfunction: What to Watch For

Posterior tibial tendon dysfunction (PTTD) is one of the most common causes of adult-onset flatfoot, but it doesn’t happen overnight. The condition typically develops gradually, with early warning signs that are easy to miss—if you know what to look for.

Recognizing these early signs can help you seek treatment before the condition progresses to more severe stages, when recovery becomes more challenging.

What Is Posterior Tibial Tendon Dysfunction?

Before we discuss early signs, let’s briefly review what PTTD is:

Posterior tibial tendon dysfunction occurs when the posterior tibial tendon becomes damaged, weakened, or inflamed, compromising its ability to support the arch of the foot. This can lead to:

  • Progressive flattening of the arch
  • Ankle pain
  • Difficulty walking
  • Chronic foot and leg fatigue

PTTD is classified into stages, with early detection in Stages 1-2 offering the best outcomes.

PTTD Stages

  • Stage 1: Tendon is inflamed but intact; arch remains
  • Stage 2: Tendon is damaged; arch begins to collapse
  • Stage 3: Severe tendon damage; significant flatfoot
  • Stage 4: Arthritis develops in the ankle joint

Early Warning Signs of PTTD

The earliest signs of PTTD are often subtle and can be mistaken for general foot fatigue or soreness. Here’s what to watch for:

1. Pain Along the Inner Ankle and Foot

The hallmark early symptom:

  • Pain behind the medial malleolus (that bony bump on the inside of your ankle)
  • Dull, aching pain that worsens with activity
  • Pain that improves with rest but returns with activity
  • May feel like “growing pains” or general fatigue

Why it happens: The damaged tendon struggles to handle the load of supporting your arch, causing pain with each step.

2. Swelling Along the Tendon

Early inflammatory response:

  • Mild to moderate swelling behind the inner ankle
  • May be more noticeable after activity
  • Can come and go in early stages
  • The area may feel “full” or tight

Note: Swelling may be minimal in the very early stages, especially if the condition is more degenerative than inflammatory.

3. Weakness When Pushing Off

Loss of tendon function:

  • Difficulty rising on your toes
  • Feeling weaker than usual when walking or running
  • A sense that your ankle “gives out” occasionally
  • Unexplained fatigue in your calf or foot during activity

Test yourself: Try standing on your toes. If one foot is significantly weaker than the other, this could indicate PTTD.

4. Morning Stiffness

Classic early sign:

  • Stiffness in the inner ankle after periods of rest
  • Pain with the first few steps in the morning
  • Improvement after walking for a few minutes (the “warm-up” effect)
  • May also occur after sitting for extended periods

This stiffness differs from general morning achiness—it tends to localize specifically behind the medial malleolus.

5. Changes in Foot Shape

Early arch changes:

  • Slight flattening of the arch (may be subtle at first)
  • One foot looking different from the other
  • The heel may start to roll outward slightly
  • Your shoe may wear differently on the inner edge

What to check: Look at your feet from behind. If you have early PTTD, you might notice your Achilles tendon angling inward rather than being straight.

6. Pain That Travels Up the Leg

Compensation patterns:

  • Pain along the inside of the shin
  • Pain in the knee or hip (from altered gait)
  • General leg fatigue, especially after standing or walking

This happens because your body compensates for the weakened tendon by changing how you walk, putting stress on other areas.

7. Difficulty With Certain Activities

Activity-related symptoms:

  • Pain when walking on uneven surfaces
  • Difficulty walking hills or stairs
  • Discomfort that makes you want to stop and rest
  • Reduced endurance during exercise

8. Feeling of Instability

Early instability:

  • A sensation that your ankle is “loose” or unstable
  • Occasional “giving way” sensations
  • Reluctance to walk or stand for long periods

What Causes These Early Signs?

Understanding why these signs appear can help you recognize them:

Overuse

The most common cause. Years of activities that stress the posterior tibial tendon (running, walking, standing) can gradually take their toll.

Biomechanical Factors

  • Flat feet or low arches
  • Overpronation (rolling inward when walking)
  • Leg length discrepancies

Risk Factors

  • Age (most common between 40-60)
  • Being female (higher risk)
  • Obesity or sudden weight gain
  • Diabetes
  • Previous foot or ankle injuries
  • High-impact sports or activities

How to Check for Early PTTD at Home

While you should see a professional for an accurate diagnosis, here are some simple self-checks:

The Single-Leg Heel Rise Test

  1. Stand behind a chair or near a wall for balance
  2. Lift your good foot off the ground
  3. Try to rise up on the toes of your affected foot
  4. If you can’t do this or it causes significant pain, it could indicate PTTD

The “Too Many Toes” Sign

  1. Have someone look at your feet from behind while you standing
  2. They should observe how many toes are visible from the back
  3. If more toes are visible on one side, it indicates the foot is rolling outward (common in PTTD)

Arch Observation

  1. Stand on your feet and look at your arches
  2. If one arch is lower than the other, or if you’ve noticed a recent change, it could indicate early PTTD

When to See a Doctor

Don’t wait until symptoms become severe. See a healthcare provider if you experience:

  • Persistent pain lasting more than 2-3 weeks
  • Pain that interferes with daily activities
  • Visible changes in your foot shape
  • Difficulty with activities you previously did easily
  • Any weakness or instability in your ankle

Early Treatment Is Key

The earlier PTTD is caught, the easier it is to treat:

Stage 1 Treatment (Usually Successful)

  • Rest and activity modification
  • Ice and anti-inflammatories
  • Physical therapy
  • Orthotics
  • Supportive footwear
  • Recovery: Often 4-8 weeks

Stage 2 Treatment

  • More intensive physical therapy
  • Custom orthotics
  • Bracing
  • Possibly injections
  • Recovery: Several months

Stages 3-4 Treatment

  • Often requires surgery
  • Longer recovery period
  • More invasive interventions

Prevention: Protecting Your Tendons

While not all cases can be prevented, you can reduce your risk:

  1. Wear supportive shoes

    • Avoid flats and unsupportive sandals
    • Replace worn shoes
    • Consider orthotics if you have flat feet

  2. Strengthen supporting muscles

    • Calf raises
    • Toe exercises
    • Balance training

  3. Listen to your body

    • Don’t ignore persistent ankle pain
    • Address symptoms early

  4. Maintain a healthy weight

    • Reduces stress on your tendons

  5. Vary your activities

    • Don’t overdo high-impact exercises
    • Cross-train with low-impact activities

Conclusion

Early detection of posterior tibial tendon dysfunction gives you the best chance of successful treatment without surgery. Watch for these early warning signs:

  • Pain behind the inner ankle
  • Swelling along the tendon
  • Morning stiffness
  • Weakness when pushing off
  • Subtle arch changes
  • Difficulty with activity
  • Feelings of instability

If you notice any of these symptoms persisting for more than a few weeks, consult a healthcare professional. Early intervention can make a significant difference in your outcome.

Curious about how PTTD relates to flatfoot? Read our article: Flatfoot vs. PTTD - What’s the Difference?