PTTD and Diabetes: What You Need to Know About This Connection

If you have diabetes, you’re probably already aware that you need to pay extra attention to your feet. From regular check-ups to careful footwear choices, managing diabetic foot health becomes part of daily life. But here’s something you might not know: diabetes significantly increases your risk of developing posterior tibial tendon dysfunction (PTTD).

Understanding this connection isn’t about worrying—it’s about giving yourself the knowledge to catch problems early and take preventive steps.

The diabetes-PTTD connection

The American Academy of Orthopaedic Surgeons lists diabetes among the key risk factors for developing PTTD, also known as progressive collapsing foot deformity. Research consistently shows that people with diabetes are more likely to develop foot deformities, including adult-acquired flatfoot [1][2].

But why does this connection exist? Several factors come into play:

Circulation issues. Diabetes can damage blood vessels, reducing blood flow to the feet. Poor circulation means tissues don’t get enough oxygen and nutrients, making tendons and ligaments slower to heal and more prone to injury.

Neuropathy complications. Diabetic neuropathy (nerve damage) is notorious for causing numbness in the feet. This is particularly tricky with PTTD because you might not feel the early warning signs—like pain or discomfort when walking—that would normally prompt you to seek help.

Inflammation response. Diabetes can alter how your body handles inflammation. Since PTTD often starts with tendon inflammation, this altered response can potentially speed up damage or make it harder to treat early.

Connective tissue effects. High blood sugar can affect collagen and other proteins in tendons and ligaments, potentially making them stiffer and less resilient over time.

Unique challenges for diabetics

If you have both diabetes and PTTD, you face some specific challenges that others might not experience.

Masked symptoms

Perhaps the biggest danger is that neuropathy can hide PTTD symptoms. While most people feel pain along the inner ankle or arch as PTTD develops, you might not notice anything until the condition has significantly progressed. By then, the tendon damage may be more extensive.

Slower healing

Any treatment or surgery becomes more complicated when you have diabetes. Small cuts or incisions take longer to heal, and the risk of infection is higher. This is why doctors often take a more conservative approach with diabetic patients when possible.

Higher complication risk

Once PTTD develops, diabetes can accelerate the progression. The combination of weakened connective tissues, poor circulation, and altered sensation creates a perfect storm for rapid deterioration. Many diabetics who develop PTTD find it progresses faster than in non-diabetic patients.

Foot structure changes

Diabetes can cause ligamentous laxity (looseness) in the feet, which compounds the arch collapse that happens with PTTD. This means even minor tendon damage can have bigger consequences.

Warning signs you can’t afford to miss

Since pain might not alert you, watch for these other signs:

  • Swelling along the inside of your ankle or arch that doesn’t go away
  • Changes in foot shape—the arch looking lower, or your heel turning outward
  • Difficulty walking or a feeling that your foot is “rolling” inward
  • Warmth over the posterior tibial tendon area
  • Calluses forming in unusual places, especially under the arch
  • Balance issues or feeling unsteady on your feet

If you notice any of these, see a podiatrist promptly. For diabetics, early intervention isn’t just helpful—it’s essential.

Prevention strategies that work

The good news is that being vigilant can significantly reduce your risk or catch problems early.

Control your blood sugar

This is foundation number one. Consistent blood sugar management helps protect all your tissues, including tendons and ligaments. Work with your healthcare team to keep your A1C in a healthy range.

Inspect your feet daily

Get in the habit of checking your feet every single day—look for swelling, redness, calluses, or changes in shape. Use a mirror if needed, or ask someone to help. With neuropathy, you can’t rely on pain to alert you, so visual inspection becomes critical.

Choose supportive footwear

Skip the flip-flops and unsupportive sandals. Look for shoes with good arch support, firm heel counters, and adequate cushioning. Many diabetics benefit from custom orthotics prescribed by a podiatrist.

Stay active—smartly

Low-impact exercises like swimming, cycling, and walking are great for overall health without stressing your feet. Avoid high-impact activities that jar your arches until you’ve discussed exercise guidelines with your doctor.

See a podiatrist regularly

For diabetics, annual (or more frequent) foot exams should be non-negotiable. Ask your podiatrist to specifically evaluate your arch support and tendon health.

Treatment considerations for diabetics

If you do develop PTTD, treatment follows similar principles—but with extra caution.

Conservative approaches first

Most doctors will recommend aggressive conservative treatment before considering surgery. This includes:

  • Custom orthotics to support your arch and reduce tendon stress
  • Ankle braces or AFOs (ankle-foot orthoses) for more advanced cases
  • Physical therapy to strengthen supporting muscles
  • Anti-inflammatory medications (check with your doctor—some can affect blood sugar)
  • Weight management to reduce stress on your feet

Surgery requires extra planning

If surgery becomes necessary, your medical team will need to carefully coordinate your care. This might include:

  • Pre-surgical blood sugar optimization
  • Choosing surgical techniques that minimize incision size
  • Extended monitoring during recovery
  • Aggressive infection prevention protocols

The decision to operate on a diabetic patient is never taken lightly, and recovery typically takes longer.

When to seek care immediately

Certain symptoms warrant urgent attention:

  • Any foot wound that isn’t healing
  • Signs of infection (redness, warmth, pus, fever)
  • Sudden, severe pain in your foot or ankle
  • A foot that suddenly looks different
  • Numbness that’s new or worsening

For diabetics, these aren’t things to wait and watch. Contact your healthcare provider right away.

The bottom line

Having diabetes doesn’t mean you’ll definitely develop PTTD, but it does mean you need to be more vigilant. The connection is real—diabetes increases your risk through multiple pathways, from circulation to nerve function to tissue health.

The key messages are straightforward:

  1. Know your risk and understand why it exists
  2. Check your feet daily since pain might not warn you
  3. See a podiatrist regularly and mention any changes
  4. Act early if you notice problems—the earlier PTTD is caught, the easier it is to manage
  5. Control your blood sugar—this helps everything

Your feet carry you through life, and diabetes asks you to be their careful guardian. With attention and proactive care, you can protect yourself from the complications that diabetes and PTTD can create together.

Sources

Disclaimer: This article is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider for diagnosis and treatment of any medical condition.