Why Does My Ankle Hurt Behind My Medial Malleolus? Causes and Solutions

That bony bump on the inside of your ankle—the medial malleolus—is an important landmark. When it hurts, it’s often a signal that something in the area needs attention.

Pain behind the medial malleolus is one of the most common symptoms we see, and it can stem from several different conditions. Let’s explore what’s behind this type of ankle pain.

Anatomy of the Area

First, let’s understand what’s located behind the medial malleolus:

Key Structures

Posterior tibial tendon (PTT): The main tendon that supports your arch
Tibialis posterior muscle: Muscle that powers the tendon
Flexor digitorum longus: Muscle that flexes your toes
Posterior tibial artery and vein: Blood supply to the foot
Tibial nerve: Provides sensation and muscle control
Deltoid ligament: Medial ankle ligament that stabilizes the joint

Because these structures are closely packed together, pain in this area can have several causes.

Common Causes of Pain Behind the Medial Malleolus

1. Posterior Tibial Tendon Dysfunction (Most Common)

This is the most frequent cause of medial ankle pain.

What it is: The posterior tibial tendon becomes inflamed, damaged, or degenerated, losing its ability to support the arch.

Symptoms:

Pain behind and below the medial malleolus
Pain that worsens with activity (walking, standing, stairs)
Swelling along the tendon
Weakness when pushing off
Progressive flattening of the arch

Why it hurts: The damaged tendon becomes inflamed and can’t handle the stress of supporting your weight.

2. Posterior Tibial Tendonitis

An acute inflammatory condition of the PTT.

What it is: Inflammation of the tendon, usually from recent overuse or injury.

Symptoms:

Sudden-onset pain
Visible swelling
Warmth over the area
Pain with specific movements
Improves with rest

Why it hurts: Acute inflammation irritates the sensitive tissues around the tendon.

3. Posterior Tibial Tendonosis

Chronic degeneration of the tendon.

What it is: Long-term wear and tear causing structural breakdown of the tendon.

Symptoms:

Gradual onset of dull ache
Chronic swelling (mild)
Morning stiffness
Weakness that’s developed over time
May not respond well to rest

Why it hurts: Degenerated tissue is irritated by normal use and doesn’t heal properly.

4. Tarsal Tunnel Syndrome

Compression of the tibial nerve in the tarsal tunnel.

What it is: Similar to carpal tunnel syndrome, but in the ankle. The tibial nerve gets compressed as it passes behind the medial malleolus.

Symptoms:

Burning or tingling sensation
Numbness in the sole of the foot
Pain that can radiate up the leg
Symptoms worse at night or with activity
Feeling of “pins and needles”

Why it hurts: The compressed nerve causes pain, tingling, and numbness.

5. Flexor Digitorum Longus Tendinitis

Inflammation of the flexor digitorum longus tendon (helps flex your toes).

What it is: Less common than PTT issues, but can occur in dancers and runners.

Symptoms:

Pain behind the medial malleolus
Pain when flexing the toes
Localized tenderness
May accompany PTT problems

Why it hurts: The tendon becomes inflamed from overuse.

6. Deltoid Ligament Sprain

Injury to the medial ankle ligaments.

What it is: The deltoid ligament on the inside of the ankle gets stretched or torn, usually from an ankle sprain.

Symptoms:

Pain on the inside of the ankle
Swelling and bruising
Tenderness over the deltoid ligament
Difficulty bearing weight
Instability

Why it hurts: Torn or stretched ligament causes pain, especially with movement.

7. Tibial Stress Fracture

A hairline crack in the tibia near the ankle.

What it is: Often from overuse or osteoporosis.

Symptoms:

Deep, aching pain
Pain with weight-bearing
Localized tenderness over the bone
Swelling
Pain that worsens with activity

Why it hurts: The fracture causes bone pain that worsens with pressure.

8. Posterior Ankle Impingement

Compression of structures at the back of the ankle.

What it is: Often seen in dancers or with conditions causing posterior bone spurs.

Symptoms:

Pain at the back of the ankle
Pain when pointing toes (plantarflexion)
Limited range of motion
Feeling of blockage

Why it hurts: Soft tissues or bones are compressed when the ankle is in certain positions.

How to Identify the Cause

While this isn’t a substitute for professional diagnosis, here are some clues:

Symptom	Likely Cause
Pain + swelling along tendon	PTT tendonitis/tendonosis
Pain + arch collapse	PTTD
Burning + tingling + numbness	Tarsal tunnel syndrome
Pain after twisting ankle	Deltoid ligament sprain
Pain with toe flexing	Flexor digitorum longus tendinitis
Deep bone pain + activity worsening	Stress fracture

When to See a Doctor

Seek professional evaluation if you have:

Persistent pain lasting more than 2-3 weeks
Significant swelling
Difficulty walking or bearing weight
Numbness or tingling
Pain that doesn’t improve with rest
Visible changes in foot shape
Weakness in the foot or ankle
Pain that’s getting worse

Diagnosis: What to Expect

When you see a healthcare provider:

They’ll Ask About:

Your symptoms and when they started
What makes the pain better or worse
Your activity level
Any recent injuries
Previous foot or ankle problems

They’ll Examine:

The painful area for swelling and tenderness
Your range of motion
Your strength
Your foot mechanics (how you walk)
Your arch structure

They May Order:

X-rays: To check bones and alignment
MRI: To visualize tendons and soft tissues
Ultrasound: To see tendon in motion
Nerve studies: If tarsal tunnel is suspected

Treatment Options

Treatment depends on the specific cause:

For PTT/Tendon Problems

Rest and Activity Modification
- Reduce aggravating activities
- Cross-train with low-impact exercise
Ice and Medications
- Ice to reduce inflammation
- NSAIDs for pain relief
Physical Therapy
- Eccentric exercises
- Strengthening
- Gait training
Orthotics
- Custom orthotics for arch support
- Supportive footwear
Bracing
- Ankle brace for severe cases

For Tarsal Tunnel Syndrome

Rest and Ice
Anti-inflammatory medications
Orthotics to reduce nerve compression
Physical therapy for nerve gliding exercises
Corticosteroid injections to reduce inflammation
Surgery (release of the tarsal tunnel) if conservative treatment fails

For Ligament Sprains

RICE (Rest, Ice, Compression, Elevation)
Bracing or taping
Physical therapy for strengthening
Gradual return to activity

For Stress Fractures

Rest (often 6-8 weeks)
Possible cast or boot
Gradual return to activity
Address bone health if needed

Self-Care Tips

While you’re waiting for your appointment (or alongside treatment):

Rest the affected area
Ice for 15-20 minutes, several times daily
Elevate when possible
Wear supportive shoes—avoid flats
Consider OTC arch supports
Avoid activities that worsen the pain
Gentle stretching if it doesn’t increase pain

What Not to Do

Don’t ignore the pain—it won’t go away on its own
Don’t stretch aggressively if it causes pain
Don’t return to high-impact activities too quickly
Don’t assume it’s just a sprain if it’s not improving

Prevention

Reduce your risk of medial malleolus pain:

Wear supportive footwear
Increase activity gradually
Strengthen your lower leg muscles
Address flat feet with orthotics if needed
Listen to your body and rest when needed

Conclusion

Pain behind the medial malleolus is a common symptom with several potential causes. While posterior tibial tendon problems are the most frequent culprits, other conditions like tarsal tunnel syndrome and ligament sprains can cause similar pain.

The key is to pay attention to your symptoms:

Sudden onset + swelling = likely tendonitis
Gradual onset + weakness = likely tendonosis/tendonosis
Burning + tingling = likely nerve involvement
After injury = possible ligament damage

If you’re experiencing persistent pain behind your medial malleolus, don’t wait—see a healthcare professional for an accurate diagnosis and appropriate treatment. Early intervention leads to better outcomes.

Remember: This article is for educational purposes. Always consult a healthcare professional for proper diagnosis and treatment of any foot or ankle condition.