Posterior Tibial Tendon Dysfunction Michigan
Posterior tibial tendon dysfunction (PTTD) is the most common cause of adult-acquired flatfoot deformity. It occurs when the posterior tibial tendon — the primary dynamic support of the longitudinal arch — degenerates, stretches, and ultimately fails. Left untreated, PTTD progresses from tendon pain to collapsed arch to rigid, arthritic flatfoot. Dr. Tom Biernacki DPM at Balance Foot & Ankle provides comprehensive PTTD care in Michigan at our Howell, Brighton, and Bloomfield Hills locations.
Stages of PTTD
- Stage I: Tendon inflammation (tenosynovitis) with preserved arch height and flexible flatfoot. Single-leg heel rise is painful but possible.
- Stage II: Tendon elongation and partial tear; flexible flatfoot deformity (collapsing arch). Single-leg heel rise is weak or impossible (“too many toes” sign).
- Stage III: Fixed (rigid) flatfoot deformity with hindfoot valgus. Subtalar joint arthritis.
- Stage IV: Fixed flatfoot with deltoid ligament insufficiency and valgus ankle tilt. Ankle arthritis.
Symptoms
- Pain and swelling along the inner ankle and foot (medial longitudinal arch)
- Gradual flattening of the arch
- “Too many toes” sign — extra toes visible from behind due to forefoot abduction
- Difficulty rising on the toes of one foot
- Hindfoot valgus (heel tilts outward)
- Lateral foot pain in advanced stages from fibular impingement
Diagnosis
Dr. Biernacki performs a complete clinical examination including single-leg heel rise test, gait analysis, hindfoot alignment assessment, and arch height measurement. Weight-bearing X-rays quantify talo-first metatarsal angle, calcaneal pitch, and hindfoot alignment. MRI evaluates tendon degeneration, partial tears, and spring ligament integrity. In Stage III–IV, CT assesses subtalar and ankle arthritis severity for surgical planning.
PTTD Treatment
Stage I: Immobilization in a CAM boot for 4–6 weeks to quiet tenosynovitis. After pain subsides, a custom-molded UCBL (University of California Biomechanics Laboratory) orthotic or rigid ankle foot orthosis (AFO) supports the arch long-term. Physical therapy strengthens the posterior tibial tendon and Achilles tendon complex.
Stage II: Aggressive bracing with an Arizona AFO or similar custom molded brace plus aggressive physical therapy. Surgical reconstruction is offered for young, active patients or those failing 3–6 months of conservative care. Dr. Biernacki performs medial displacement calcaneal osteotomy, flexor digitorum longus (FDL) tendon transfer, and spring ligament repair — the gold standard flatfoot reconstruction procedure for Stage IIB deformity.
Stages III–IV: Surgical arthrodesis (fusion) of the subtalar, talonavicular, and/or calcaneocuboid joints (triple arthrodesis) restores a plantigrade, pain-free foot. Ankle arthritis in Stage IV may require simultaneous ankle fusion or ankle replacement.
Frequently Asked Questions
Can posterior tibial tendon dysfunction be treated without surgery?
Stage I and many Stage II cases respond well to bracing, custom orthotics, and physical therapy. Early diagnosis is key — the earlier treatment begins, the better the chance of avoiding surgery. Stages III–IV require surgical reconstruction.
What is the recovery from PTTD flatfoot reconstruction surgery?
Recovery from Stage II reconstruction (calcaneal osteotomy + FDL transfer) typically involves 6 weeks non-weight-bearing, followed by progressive weight-bearing over 6–8 weeks. Return to normal activity occurs at 4–6 months; athletic activity at 6–12 months.
📧 Get Dr. Tom’s Free Lab Test Guide
Discover the 5 lab tests every person over 35 should ask their doctor about — explained in plain English by a board-certified physician.
Schedule your PTTD evaluation at Balance Foot & Ankle in Howell, Brighton, or Bloomfield Hills, Michigan.
Join 950,000+ Learning About Foot Health
Dr. Tom shares honest medical advice, supplement reviews, and treatment guides you won’t find anywhere else.
Subscribe on YouTube →📍 Located in Michigan?
Our board-certified podiatrists treat this condition at two convenient locations. Same-day appointments often available.
Dr. Tom Biernacki, DPM is a board-qualified podiatrist and foot & ankle surgeon serving Southeast Michigan at Balance Foot & Ankle Specialists. A Michigan native, Dr. Biernacki earned his undergraduate degree from Michigan State University and his Doctor of Podiatric Medicine (DPM) from Kent State University College of Podiatric Medicine. He completed a three-year comprehensive surgical residency in foot and ankle surgery in the Detroit metro area.
Dr. Biernacki specializes in the treatment of heel pain, bunions, hammertoes, diabetic foot care, sports injuries, flatfoot correction, and minimally invasive foot surgery. He is dedicated to providing evidence-based, patient-centered care that helps people of all ages stay active and pain-free.
He sees patients at multiple convenient Metro Detroit locations and is committed to community education through the MichiganFootDoctors.com resource library. Dr. Biernacki is a member of the American Podiatric Medical Association (APMA) and the Michigan Podiatric Medical Association (MPMA).