Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

What Is Posterior Tibial Tendon Dysfunction (PTTD)?

Posterior tibial tendon dysfunction (PTTD) is the progressive degeneration and failure of the posterior tibial tendon — the primary structure supporting your arch. It’s the leading cause of adult-acquired flatfoot deformity and affects millions of Americans, most commonly women over 40 and individuals who are overweight, diabetic, or have had prior ankle injuries.

At Balance Foot & Ankle in Howell and Bloomfield Township, Michigan, our podiatrists — Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin — treat PTTD at all stages, from early tendon inflammation to advanced reconstructive surgery.

The Function of the Posterior Tibial Tendon

The posterior tibial tendon runs from the calf muscle, around the inside of the ankle, and attaches to bones in the midfoot. Its primary jobs are to support the arch, invert the foot, and help push off during walking. When this tendon is damaged or overloaded, the arch collapses and the foot gradually flattens and rolls inward (pronation), the heel drifts outward (valgus), and the forefoot splays.

Four Stages of PTTD

Stage I: Tendon Inflammation

The tendon is inflamed and painful but still functional — the arch and heel alignment remain relatively normal. This is the ideal stage for conservative treatment. Pain is felt along the inside of the ankle and foot.

Stage II: Flexible Flatfoot

The tendon begins to lengthen and partially fail. The arch is visibly flattened when standing but the deformity is still flexible — meaning the arch can be corrected manually. The heel tilts outward. “Too many toes” sign is positive (more than 2 toes visible behind the heel when viewed from behind). Single-leg heel raise is painful or impossible.

Stage III: Rigid Flatfoot

The deformity becomes fixed — the foot can no longer be corrected to a neutral position. Arthritis develops in the subtalar and midfoot joints. Pain is now present on the outer side of the ankle as well (subfibular impingement). Conservative care has limited effectiveness at this stage.

Stage IV: Ankle Involvement

The progressive flatfoot has stressed the ankle joint itself, causing the ankle to tilt (valgus tilt) and develop arthritis. This is the most advanced and complex stage to treat.

Symptoms of PTTD

• Inner ankle or arch pain and swelling
• Flatfoot that was not present previously
• Difficulty standing on tiptoe on one foot
• Gradual outward drift of the heel
• Outer ankle pain in later stages
• Fatigue with walking or standing

Conservative Treatment (Stages I–II)

• Immobilization: Walking boot or cast for 6–8 weeks to rest the tendon acutely
• Custom orthotics (UCBL or ankle-foot orthosis): Essential for arch support and reducing tendon stress long-term
• Physical therapy: Posterior tibial tendon strengthening and calf stretching
• NSAIDs: Reduce acute inflammation
• Weight management: Significantly reduces mechanical load on the tendon
• Proper footwear: Motion control or stability shoes

Surgical Treatment (Stages II–IV)

When conservative care fails or deformity is advanced, surgery restores foot alignment and tendon function. Procedures depend on stage:

• Stage II: Medializing calcaneal osteotomy + flexor digitorum longus tendon transfer (FDL) + possible lateral column lengthening
• Stage III: Triple arthrodesis (fusion of subtalar, talonavicular, calcaneocuboid joints)
• Stage IV: Triple arthrodesis + ankle correction or total ankle replacement

Don’t Wait on PTTD

This condition worsens progressively — what can be managed with orthotics and physical therapy in Stage I may require major reconstruction in Stage III. If you’ve noticed your arch flattening, inner ankle pain, or difficulty with single-leg activities, seek evaluation early. The podiatrists at Balance Foot & Ankle have extensive experience with PTTD management and can stop progression before surgery becomes necessary.

Foot or Ankle Pain? We Can Help.

Balance Foot & Ankle — Howell & Bloomfield Township, MI

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When to See a Podiatrist for Flat Feet

Posterior tibial tendon dysfunction (PTTD) is the most common cause of adult-acquired flatfoot deformity. Without treatment, it progresses through stages that eventually require surgery. Dr. Tom Biernacki at Balance Foot & Ankle provides comprehensive PTTD management at every stage.

Learn About Our Flat Feet Treatment Options | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Myerson MS. “Adult acquired flatfoot deformity.” Journal of Bone and Joint Surgery. 1996;78(5):780-792.
2. Alvarez RG, et al. “Stage I and II posterior tibial tendon dysfunction treated by structured nonoperative management.” Foot and Ankle International. 2006;27(1):2-8.
3. Deland JT. “Adult-acquired flatfoot deformity.” Journal of the American Academy of Orthopaedic Surgeons. 2008;16(7):399-406.

Your Board-Certified Podiatrists

Dr. Tom Biernacki, DPM

Board-Certified · FACFAS

Dr. Carl Jay, DPM

Board-Certified Podiatrist

Dr. Daria Gutkin, DPM

Podiatrist

Dr. Tom Biernacki, DPM

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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.