Medically reviewed by Dr. Tom Biernacki, DPM · Board-Certified Podiatric Surgeon · Last reviewed: April 2026 · Editorial Policy
Quick Answer
Posterior Tibial Tendon Dysfunction (PTTD): Staging, Orthoti relates to orthotic fitting — typically caused by biomechanical foot needs. Most patients improve in 2 weeks to break in with conservative care. Same-week appointments in Howell + Bloomfield Twp: (810) 206-1402.
Medically reviewed by Dr. Tom Biernacki, DPM — Board-certified foot & ankle surgeon, 3,000+ surgeries performed. Updated April 2026 with current clinical evidence. This article reflects real practice experience from Balance Foot & Ankle Specialists in Howell and Bloomfield Hills, Michigan.
Treatment at Balance Foot & Ankle: Custom 3D Orthotics →
Quick Answer
Custom orthotics are prescription inserts made from a 3D scan of your foot. They address the structural cause of plantar fasciitis, flat feet, or metatarsalgia rather than just cushioning symptoms. Most patients feel improvement within 2-4 weeks. Covered by most PPO plans and Medicare when medically indicated.
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Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.
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Medically Reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatrist, Balance Foot & Ankle Specialists, Michigan. Last updated April 2026.
Posterior tibial tendon dysfunction (PTTD) — the most common cause of adult-acquired flatfoot deformity — is a progressive condition characterized by degeneration of the posterior tibial tendon, loss of its arch-supporting function, and gradual collapse of the medial longitudinal arch. Understanding the Johnson-Strom staging system is essential for selecting the correct treatment — the management approach differs dramatically across the four stages, and early-stage PTTD treated appropriately avoids the need for complex reconstructive surgery.
Johnson-Strom Staging
Stage I: posterior tibial tendon tendinopathy without deformity — the tendon is inflamed and weakened but the arch is maintained; single-leg heel rise is possible but painful. Stage II: tendon has functionally failed, flexible flatfoot deformity is present — the hindfoot is in valgus but corrects passively; single-leg heel rise is impossible. Stage IIa: deformity is mild and flexible. Stage IIb: significant abduction of the forefoot and peritalar subluxation. Stage III: rigid hindfoot valgus — the subtalar joint has collapsed into fixed valgus that does not correct passively; degenerative changes present in the subtalar joint. Stage IV: ankle valgus from deltoid ligament attenuation — the talus is tilted in the ankle mortise; tibiotalar arthritis present.
Treatment by Stage
Stage I: aggressive immobilization (short-leg cast or CAM walker for 6–8 weeks), followed by custom UCBL or Arizona-style brace for arch and hindfoot support, combined with posterior tibial tendon eccentric strengthening — the most important intervention to halt progression. Stage II: custom articulated AFO (ankle-foot orthosis) or UCBL orthotic with a 4–6mm medial heel wedge for flexible deformity; surgery (medializing calcaneal osteotomy + flexor digitorum longus tendon transfer) for patients who fail 6 months of orthotic management. Stage IIb: lateral column lengthening (Evans osteotomy) added to the medializing osteotomy to address forefoot abduction. Stage III: subtalar arthrodesis or triple arthrodesis. Stage IV: tibiotalar-calcaneal arthrodesis. Dr. Biernacki at Balance Foot & Ankle stages PTTD with weight-bearing X-rays and clinical examination, providing stage-specific treatment from custom bracing through reconstructive surgery. Call (810) 206-1402 at our Bloomfield Hills or Howell office.
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Our board-certified podiatrists treat this condition at two convenient locations. Same-day appointments often available.
When to See a Podiatrist
Many foot conditions can be managed conservatively at home, but some require professional evaluation. See a podiatrist promptly if you experience:
- Pain that persists for more than 2 weeks despite rest
- Swelling, redness, or warmth that isn’t improving
- Numbness, tingling, or burning in the feet
- A wound or sore that is not healing within 2 weeks
- Any foot concern if you have diabetes or poor circulation
- Nail changes that suggest fungal infection or other problems
At Balance Foot & Ankle, our three board-certified podiatrists — Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin — provide comprehensive foot and ankle care at our Howell and Bloomfield Township offices. Most insurance plans are accepted.
Related Conditions & Resources
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Board-certified podiatrists Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients daily at our Howell and Bloomfield Township, MI offices.
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📞 (810) 206-1402
PTTD Treatment by Stage: Orthotics to Surgery in Michigan
Posterior tibial tendon dysfunction treatment depends entirely on the stage. Our podiatrists accurately stage your PTTD and match the treatment intensity — from custom orthotics for early stages to complex surgical reconstruction for advanced deformity.
Explore Flatfoot & PTTD Treatment | Book Your Appointment | Call (810) 206-1402
Clinical References
- Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop Relat Res. 1989;(239):196-206.
- Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. J Bone Joint Surg Am. 1996;78(5):780-792.
- Kulig K, Reischl SF, Pomrantz AB, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise. Phys Ther. 2009;89(1):26-37.
Insurance Accepted
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Howell Office
3980 E Grand River Ave, Suite 140
Howell, MI 48843
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Bloomfield Hills Office
43700 Woodward Ave, Suite 207
Bloomfield Hills, MI 48302
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Differential Diagnosis: What Else Could It Be?
Not every case of posterior tibial tendon dysfunction (pttd) is straightforward. In our clinic we routinely rule out three look-alike conditions before confirming the diagnosis. If your symptoms don’t match the classic presentation, one of these may explain the pain — which is why physical exam matters more than self-diagnosis.
| Condition | How It Differs |
|---|---|
| Congenital flat foot | Lifelong, usually bilateral, no pain, normal single-leg heel-rise test. |
| Tarsal coalition | Rigid flat foot, adolescent/young adult onset, peroneal spastic flat foot, coalition visible on CT. |
| Charcot arthropathy | Diabetic with neuropathy, warm swollen midfoot, progressive collapse, temperature differential >2°C — URGENT. |
Red Flags — When to See a Podiatrist Now
Seek same-day evaluation at Balance Foot & Ankle if you notice any of the following:
- Sudden collapse of the arch in an adult
- Inability to perform a single-leg heel-rise
- Warm red swollen midfoot (rule out Charcot)
- Progressive deformity over weeks-months
Call (810) 206-1402 or request an appointment. Our Howell and Bloomfield Hills offices reserve same-day slots for urgent foot and ankle issues.
If home care isn’t resolving your your foot or ankle concern, a visit with a board-certified podiatrist is the fastest path to accurate diagnosis and a personalized plan. At Balance Foot & Ankle Specialists, Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin offer same-day and next-day appointments at both our Howell and Bloomfield Hills offices. We perform on-site diagnostic ultrasound, digital X-ray, conservative care, advanced regenerative treatments, and minimally invasive surgery when indicated.
Call (810) 206-1402 or request an appointment online. Most insurance plans accepted, including Medicare, Blue Cross Blue Shield, Aetna, Cigna, and United Healthcare.
In Our Clinic
The patients we see for custom orthotic consultations usually fall into two groups. First are athletes — runners, hikers, basketball players — looking to correct a biomechanical asymmetry they’ve identified themselves or their coach has flagged. Second are middle-aged patients with chronic plantar fasciitis, metatarsalgia, or early arthritis who have exhausted over-the-counter inserts. Our process begins with a 3D foot scan plus a gait-video analysis on our in-office treadmill. We select materials based on activity — a stiffer carbon composite for performance running, a softer plastazote top cover for diabetic patients, a semi-rigid polypropylene for everyday wear. Most patients adapt in 2–4 weeks.
Most Common Mistake We See
The most common mistake we see is: Wearing new orthotics all day from day one. Fix: break-in schedule of 2 hours on day one, adding 2 hours per day until full-day tolerance.
Warning Signs That Need Same-Day Care
Seek immediate evaluation at Balance Foot & Ankle if you experience any of the following:
- New sharp pain under the arch that did not exist before
- Skin breakdown over pressure points
- Diabetic patient with any new pressure spot
- Worsening of original symptoms after 4 weeks
Call (810) 206-1402 — same-day and next-day appointments at our Howell and Bloomfield Hills offices.
More Podiatrist-Recommended Orthotics Essentials
PowerStep Pinnacle
- The Pinnacle Full length insoles for men & women provide maximum cushioning, from high activity to moderate support. The PowerStep arch support shape provides stability to the foot and ankle, helping to relieve foot pain.
- When you spend all day on your feet, every step counts. PowerStep insoles are a podiatrist-recommended orthotic to help relieve & prevent foot pain related to athletes, runners, Plantar Fasciitis, heel spurs & other common foot, ankle & knee injuries
- The Pinnacle plantar fasciitis insoles offer superior heel cushioning and arch support. The dual-layer cushioning is designed to reduce stress and fatigue, while PowerStep premium arch support is designed for plantar fasciitis relief.
- The PowerStep Pinnacle arch support inserts for men & women can be worn in a variety of shoe types such as; athletic, walking, running, work & some casual shoes. Orthotic Inserts are ordered by shoe size, no trimming required.
- Made in the USA & backed by a 30-day money-back guarantee. PowerStep orthotic inserts for men & women are designed for shoes where the factory insole can be removed. HSA & FSA Eligible
The podiatrist-recommended OTC orthotic — arch support + heel cup.
CURREX RunPro Insole
- FEEL BETTER, PERFORM BETTER: Flexible support and shock absorbing cushioning from heel to toe help reduce fatigue, prevent common running injuries such as shin splints, and boost performance everywhere you run, from the trails to the track; the insoles also fold at the flex point, enabling maximum flexibility with movement
- 3D Dynamic Arch Technology & Multiprofile Arch Support: Our dynamic arch support insoles come in low, medium and high arch support profiles; they feature a deep decoupled heel cup that fits, wraps and locks the heel in place, improving stability, reducing pressure, and providing a perfect fit
- Engineered to Energize Your Running: Rebound cushioning and controlled power transmission provide faster regeneration and powerful propulsion with every stride; plus, a zero heel drop provides a great fit in most running shoes with optimized motion for all running foot strikes (insoles can also be trimmed to fit for the perfect fit)
- Moisture Management & Breathability: Top layer mesh and PORON premium foam design help dehumidify the inside of shoe, keeping the feet dry and running shoes fresh throughout exercise; note you should replace your CURREX insoles after 500+ miles or 12 months, whichever comes first
- Made for What Moves You: CURREX is the only insole company that offers a full line of activity-specific insoles customized to help improve how you move; whatever you or your family loves to do, from the workday through the weekend, CURREX makes moving more comfortable, leading to better performance and more fun
Performance insole for runners — reduces fatigue and prevents injuries.
Tuli’s Heel Cups
- ✶ALLEVIATES HEEL PAIN – Tuli’s Heavy Duty Heel Cups provide heel pain relief caused by plantar fasciitis, Sever’s disease, excessive pronation, Achilles tendonitis, etc. Ideal for those on their feet for most of the day or those looking for added comfort.
- ✶PODIATRIST PREFERRED – In an independent study conducted by M3 Global Research, podiatrists chose Tuli’s as the clear winner of recommended heel cup brands.
- ✶SHOCK-ABSORBING DESIGN – The multi-cell, multi-layer design absorbs shock and impact energy, mimicking the natural shock-absorbing system of your feet. As you walk or run, the design reduces the stress on your feet.
- ✶DOCTOR RECOMMENDED & APMA ACCEPTED – Tuli’s Heel Cups were designed by a leading podiatrist and have the honor of being accepted by the American Podiatric Medical Association.
- ✶FITS MOST LACE-UP SHOES – Best used in spacious lace-up shoes like athletic shoes / sneakers.
Shock-absorbing heel cushion — adds lift and relief under painful heels.
As an Amazon Associate, Balance Foot & Ankle earns from qualifying purchases. Product recommendations are based on clinical experience; prices and availability shown above update live from Amazon.
When to See a Podiatrist
Off-the-shelf inserts help 70% of patients — but if you’ve tried several without relief, custom orthotics molded to your specific foot mechanics are usually the next step. Balance Foot & Ankle makes custom orthotics in-office and most major insurance plans cover them. We’ll cast or scan your feet and have them ready in about 2 weeks.
Call Balance Foot & Ankle: (810) 206-1402 · Book online · Offices in Howell & Bloomfield Hills
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Podiatrist-recommended products
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Stage I-II arch support.
View on Amazon →PTT offloading.
View on Amazon →Conservative PTTD rehab.
View on Amazon →Inflammation control.
View on Amazon →Related resources
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Same-week appointments · Howell & Bloomfield Hills · 4.9★ (1,123+ reviews)
☎ (810) 206-1402Book Online →Pros & Cons of Conservative Care for orthotics
Advantages
- ✓ Custom orthotics 80%+ improvement
- ✓ Most insurance covers
- ✓ Lasts 3-5 years
Considerations
- ✗ 2-week break-in
- ✗ Custom can be $400-700
- ✗ OTC limits effectiveness
Dr. Tom’s Recommended Products for orthotics
Affiliate disclosure: As an Amazon Associate, Balance Foot & Ankle earns from qualifying purchases. We only recommend products we use with patients.
PowerStep Pinnacle Maxx Dr. Tom’s Pick
Best for: High-arch + severe plantar fasciitis
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Same-day appointments in Howell + Bloomfield Twp. Most insurance accepted. Dr. Tom Biernacki, DPM & team.
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About Your Care Team at Balance Foot & Ankle
Dr. Tom Biernacki, DPM · Board-Certified Foot & Ankle Surgeon. Specializes in conservative-first care, minimally invasive bunion surgery, and complex reconstruction.
Dr. Carl Jay, DPM · Accepting new patients. Specializes in sports medicine, athletic injuries, and routine podiatric care.
Dr. Daria Gutkin, DPM, AACFAS · Accepting new patients. Specializes in surgical reconstruction and pediatric podiatry.
Locations: 4330 E Grand River Ave, Howell, MI 48843 · 43494 Woodward Ave Suite 208, Bloomfield Twp, MI 48302
Hours: Mon–Fri 8:00 AM – 5:00 PM · (810) 206-1402
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.
- Plantar Fasciitis: Diagnosis and Conservative Management (PubMed)
- Plantar Fasciitis (APMA)
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)
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