You've been diagnosed with posterior tibial tendon dysfunction. Now what?
The treatment path depends entirely on what stage you're in, how aggressive the deformity is, and what your goals are. This page walks through every option—from basic conservative care to advanced surgery—so you know what's available.
The Treatment Hierarchy
Here's the big picture:
| Stage | Primary Treatment | When Surgery Is Considered |
|---|---|---|
| Stage 1 | Conservative | Almost never |
| Stage 2 | Conservative first | If progress stalls |
| Stage 3 | Usually surgical | Almost always |
| Stage 4 | Surgical | Definitely |
Conservative (Non-Surgical) Treatments
For Stage 1 and many Stage 2 patients, surgery isn't necessary. These approaches work:
1. Activity Modification
What it is: Adjusting how you move to reduce stress on the tendon.
What to do:
- Reduce high-impact activities (running, jumping)
- Switch to low-impact options (swimming, cycling)
- Avoid prolonged standing when possible
- Take breaks throughout the day
When it helps: Stage 1 is the obvious choice. Stage 2 with mild symptoms.
2. Supportive Footwear
What it is: Shoes that actually support your arch and stabilize your foot.
What to look for:
- Motion control shoes — Rigid soles that prevent excessive pronation
- Good arch support — Whether built-in or with orthotics
- Stable heel counter — The back of the shoe should be firm
- Firm midsole — Some stiffness underfoot
What to avoid:
- Flip-flops and flats (zero support)
- Worn-out shoes
- Shoes that bend in the middle
When it helps: This is foundational for every stage. Cheap, easy, effective.
3. Orthotics and Arch Supports
What it is: Devices placed in your shoes to support your arch and correct alignment.
| Type | What It Is | Best For |
|---|---|---|
| Over-the-counter | Generic arch supports from the store | Early Stage 1 |
| Custom orthotics | Podiatrist-made, molded to your foot | Stage 1-2, or ongoing management |
How they work:
- Reduce strain on the posterior tibial tendon
- Support the arch so the tendon doesn't have to work as hard
- Improve overall foot alignment
When it helps: Stage 1-2. Won't fix a rigid deformity, but can significantly slow progression.
4. Physical Therapy
What it is: Targeted exercises to strengthen the tibialis posterior and related muscles.
What exercises help:
- Tibialis posterior strengthening — Inversion against resistance (resistance band)
- Calf stretches — Tight calves worsen PTTD mechanics
- Intrinsic foot muscle exercises — Toe yoga, short foot exercise
- Proprioception training — Balance on one foot, balance board
What a PT session looks like:
- Initial assessment of strength and flexibility
- Personalized exercise program
- Gait analysis and correction
- Progression as you improve
When it helps: Stage 1-2. The earlier you start, the better. In Stage 3+, the tendon is too damaged for exercise to restore function.
5. Medications
What it is: NSAIDs (non-steroidal anti-inflammatory drugs) for pain and swelling.
Common options:
- Ibuprofen (Advil, Motrin)
- Naproxen (Aleve)
- Meloxicam (prescription)
What to know:
- Reduce inflammation and pain
- Don't fix the underlying problem
- Use short-term, not chronic
- Can have side effects (stomach, kidneys)—follow directions
When it helps: During flare-ups or early in treatment to manage symptoms while you implement other changes.
6. Immobilization
What it is: A walking boot or cast to completely rest the tendon.
When used:
- Severe inflammation or pain
- After an acute injury
- When other conservative measures aren't working
What it involves:
- Typically 4-8 weeks in a walking boot
- Crutches may be needed initially
- Followed by structured rehabilitation
When it helps: Acute inflammation (Stage 1), or to calm things down before starting PT.
7. Injections
What it is: Corticosteroid injections into the tendon sheath.
The reality:
- Can reduce inflammation and pain temporarily
- Some concern about potential tendon weakening
- Usually not a long-term solution
When it helps: As a tool to facilitate other treatment, not as a standalone fix.
Surgical Treatments
When conservative treatment isn't enough—or when the deformity is too advanced—surgery becomes necessary. The type of surgery depends on your stage and specific problem.
Tendon Procedures
Tendon debridement
- Cleaning up damaged tissue
- Removing inflammation
- Best for early Stage 2 with isolated tendon damage
Tendon repair
- Stitching a partially torn tendon back together
- For Stage 2 with a significant tear
Tendon transfer
- Taking another tendon (often the flexor digitorum longus) to do the PTT's job
- Common for Stage 3
- Preserves motion while replacing function
Bone Procedures (Osteotomies)
Calcaneal osteotomy
- Cutting the heel bone and shifting it to support the arch
- Often combined with tendon procedures
- For moderate deformity (Stage 2-3)
Medial column osteotomy
- Realigning the bones in the middle of the foot
- For more significant collapse
Fusion Procedures (Arthrodesis)
When needed:
- Stage 3-4 with rigid deformity
- Joint damage that's too severe to repair
- When other procedures won't provide stability
Types:
- Triple arthrodesis — Fuses three joints in the backfoot
- Subtalar arthrodesis — Fuses the subtalar joint
- Ankle arthrodesis — For severe Stage 4 with ankle arthritis
What to know:
- Eliminates pain by removing the damaged joint
- Reduces flexibility in the foot
- Long recovery (6-12 months to full)
Staged Procedures
For advanced cases, you might need more than one surgery:
Common sequence:
- First: Address soft tissue and tendon
- Second (later): Correct bone alignment
- Third (if needed): Fuse joints if arthritis is severe
This spreads out the surgical stress and allows for better recovery.
What Treatment Is Right For You?
Here's a practical decision guide:
Choose Conservative Treatment If:
- You're Stage 1 or early Stage 2
- The deformity is flexible (can be manually corrected)
- Your symptoms are manageable
- You're committed to long-term management
- Surgery feels too aggressive for your situation
Consider Surgery If:
- You've tried 3-6 months of conservative care without progress
- You're Stage 3 or 4
- The deformity is rigid
- Your activity level is limited by the condition
- You want a more definitive solution
The Conversation to Have With Your Doctor
Ask these questions:
- What stage am I in?
- Is my deformity flexible or rigid?
- What conservative options haven't we tried yet?
- If I do need surgery, what would the recovery look like?
- What's the realistic outcome I can expect?
Recovery Realities
Let's be honest about what recovery involves:
Conservative Treatment
- 4-8 weeks to see initial improvement
- 3-6 months for significant progress
- Ongoing maintenance (exercises, proper shoes) for life
Surgery
- 6-12 weeks non-weight-bearing (crutches, scooter)
- 3-4 months before returning to normal activities
- 6-12 months for full recovery
- Physical therapy essential
Starting Your Treatment Journey
Wherever you are in the PTTD journey, here are your next steps:
If you're newly diagnosed:
- Get proper footwear today
- Schedule PT—starting exercises now
- Consider orthotics if Stage 1-2
If conservative isn't working:
- Get current imaging (X-ray, possibly MRI)
- Get a second opinion if needed
- Discuss surgical options realistically
Whatever you do:
- Don't ignore the pain
- Stay active within your limits
- Do your exercises consistently
Ready to Take Action?
Our Exercises Guide has specific movements you can start today.