Seven patients with Stage I posterior tibial tendon dysfunction were treated with synovectomy, with or without tendon debridement. At the 11-month followup, six patients were completely pain free. The one patient who eventually required flexor digitorum longus transfer and lateral column lengthening because of progression to Stage II disease had significant intrasubstance tendinous degeneration. Early diagnosis and aggressive treatment are imperative to prevent progression of Stage I posterior tibial tendon dysfunction. Operative treatment is indicated if a reasonable trial of casting or bracing does not relieve symptoms.