Tibialis Posterior Tendon Reconstruction: FDL Transfer, Calcaneal Osteotomy, and Spring Ligament Repair

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

Stage II posterior tibial tendon dysfunction (PTTD) — the most common surgical indication for adult acquired flatfoot — has undergone significant surgical evolution. The contemporary standard procedure for flexible stage II flatfoot combines flexor digitorum longus (FDL) tendon transfer, medializing calcaneal osteotomy, and spring (calcaneonavicular) ligament repair into a single reconstructive procedure that addresses the biomechanical failure of each component of the medial column support system.

Rationale for Combined Reconstruction

The posterior tibial tendon alone cannot support the medial longitudinal arch — the spring ligament complex (superomedial calcaneonavicular ligament) and the plantar fascia provide 80% of the static arch support. When the posterior tibial tendon fails (stage II), it does so in the context of concurrent spring ligament attenuation — reconstructing only the tendon without addressing the spring ligament produces high recurrence rates. Similarly, the FDL tendon transfer restores active supination force but cannot correct the fixed hindfoot valgus deformity — the medializing calcaneal osteotomy shifts the heel beneath the mechanical axis of the leg, restoring the lever arm for the reconstructed tendon.

Surgical Technique and Recovery

FDL tendon transfer: the FDL is harvested from its musculotendinous junction proximally and transferred through a drill hole in the navicular, restoring active arch supination force. Medializing calcaneal osteotomy (Koutsogiannis): a lateral oblique osteotomy through the calcaneal body shifts the tuberosity 8–10mm medially, correcting hindfoot valgus alignment. Spring ligament imbrication or reconstruction with graft augmentation addresses the medial passive restraint component. Recovery: non-weight-bearing cast for 6 weeks, gradual weight-bearing in boot from weeks 6–12, custom orthotic support for 6–12 months after surgery. Return to normal shoes typically at 4–6 months. Dr. Biernacki at Balance Foot & Ankle performs stage II flatfoot reconstruction including FDL transfer and calcaneal osteotomy for patients with symptomatic posterior tibial tendon dysfunction. Call (810) 206-1402 at our Bloomfield Hills or Howell office.

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In-Office Treatment at Balance Foot & Ankle

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.

Frequently Asked Questions

When should I see a podiatrist?

See a podiatrist for any foot or ankle pain that persists more than 2 weeks, doesn’t improve with rest, limits your daily activities, or is accompanied by swelling, numbness, or skin changes. People with diabetes or circulation problems should see a podiatrist regularly even without symptoms.

What does a podiatrist treat?

Podiatrists diagnose and treat all conditions of the foot, ankle, and lower leg including plantar fasciitis, bunions, hammertoes, toenail problems, heel pain, nerve pain, diabetic foot care, sports injuries, fractures, and foot deformities — both surgically and non-surgically.

What can I expect at my first podiatry visit?

Your first visit includes a full medical history, physical examination of your feet and gait, and in-office diagnostic imaging if needed (X-rays, ultrasound). We’ll discuss your diagnosis and create a personalized treatment plan. Most visits take 30–45 minutes.

Need Treatment at Balance Foot & Ankle?

Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients at our Howell and Bloomfield Township offices.

Book Online or call (810) 206-1402

FDL Tendon Transfer & Flatfoot Reconstruction in Michigan

When the posterior tibial tendon fails, FDL tendon transfer combined with calcaneal osteotomy restores arch support and foot function. Our podiatric surgeons perform this proven reconstruction to correct flexible adult-acquired flatfoot deformity.

Explore Flatfoot Surgery Options | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Guyton GP, Jeng C, Krieger LE, Mann RA. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for posterior tibial tendon dysfunction. Foot Ankle Int. 2001;22(8):627-632.
2. Myerson MS, Corrigan J, Thompson F, Schon LC. Tendon transfer combined with calcaneal osteotomy for treatment of posterior tibial tendon insufficiency. Foot Ankle Int. 1995;16(11):712-718.
3. Hiller L, Pinney SJ. Surgical treatment of acquired flatfoot deformity: what is the state of practice? Foot Ankle Int. 2003;24(9):701-705.

Most Common Mistake We See

The most common mistake we see is: Waiting too long before seeking care. Fix: any foot pain lasting more than 4 weeks, or any sudden severe symptom, deserves a professional evaluation rather than more rest.

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