My arch is dropping and the inside of my ankle hurts. Is this actually treatable without surgery?

In early stages, yes, and the evidence is surprisingly strong on this. Alvarez and colleagues reported in Foot and Ankle International that a structured non-operative protocol combining a short articulated brace or orthosis with high-repetition tibialis posterior strengthening produced a good outcome in roughly 89 percent of patients with stage I or II disease. Kulig and colleagues in Physical Therapy showed that adding eccentric or concentric resistive exercise to orthoses and stretching further reduced pain and improved function. The common thread is early recognition and consistent orthotic use paired with a real strengthening program, rather than rest alone.

Why cannot I rise up on my toes on the painful side anymore?

A single-leg heel rise depends on the posterior tibial tendon inverting the heel and locking the midfoot so the calf can push through a stable lever. When the tendon has failed, the heel cannot invert, the midfoot stays mobile, and the calf pushes into a collapsing arch rather than a rigid foot. The heel rise falters or does not happen at all. It is one of the most reliable signs in the clinic, and the gradual return of that movement is one of the first things I track as rehab progresses.

Do I really have to wear the orthotic all the time?

In the early months, largely yes. The orthotic is doing the work the tendon currently cannot, which is what gives the tendon a chance to adapt without the arch continuing to collapse under it. Alvarez's protocol used a short articulated brace for the early phase before transitioning to a functional foot orthosis. Long term, many patients taper down to wearing the orthosis only during higher-demand standing and walking, but this is a stepwise reduction as strength returns, not an immediate choice.

What is the difference between posterior tibial tendon dysfunction and plantar fasciitis?

Plantar fasciitis sits in the heel under the sole and is worst on the first steps in the morning. Posterior tibial tendon dysfunction sits along the inside of the ankle and arch, can ache throughout a long day of standing rather than just in the morning, and is often paired with a visibly dropping arch and difficulty rising onto the toes. The two can coexist, which is part of why a careful exam matters more than self-diagnosis from a search engine.

How did this even start? I do not remember an injury.

That is typical. Johnson and Strom's original 1989 description and most subsequent work describe an insidious onset, often in women over 40, sometimes triggered by a modest increase in standing or walking, a weight gain, or a stretch of unsupportive footwear. Diabetes, inflammatory arthritis, and prior ankle trauma raise the risk. The tendon does not fail in a single moment. It fails slowly under cumulative load until the arch begins to give and the pain pattern becomes recognisable.

Will the arch come back once I start strengthening?

Not usually. Once the spring ligament and surrounding tissues have stretched, the shape of the foot rarely reverses fully even with successful rehab. The realistic goal is to halt further collapse, regain function, and get the pain down. Many people return to long walks, hiking, and standing-intensive work with a flatter foot that is strong, controlled, and comfortable, which is a very different situation from one that is flattening further every year.

When is surgery actually on the table?

Surgery enters the conversation when the deformity becomes rigid, when the hindfoot no longer corrects passively, or when conservative care has been done well for at least six months without meaningful improvement. Stage III and IV disease, where the subtalar or ankle joint is involved, typically exceeds what rehabilitation alone can address. Before that point, the priority is giving a well-structured orthotic and loading program a genuine trial, because most stage I and II patients do not end up in the surgical path.

Posterior Tibial Tendon Dysfunction Treatment in Burlington

Posterior Tibial Tendon Dysfunction

Adult-acquired flatfoot, progressive foot deformity

Treating posterior tibial tendon dysfunction at my Burlington clinic. Convenient for Waterdown and Flamborough residents.

Important: When to seek immediate medical attention

Rigid flatfoot deformity that fails to correct with non-weight bearing

Indicates Stage III disease requiring urgent orthopedic evaluation for surgical reconstruction before further progression

Severe lateral ankle impingement with inability to ambulate

Suggests Stage IV disease with ankle involvement requiring immediate orthopedic consultation

Acute onset of severe pain with warmth and swelling in diabetic patient

Requires urgent evaluation to rule out Charcot arthropathy or infection

Progressive neurological symptoms or vascular compromise

Immediate medical evaluation needed to assess for compartment syndrome or nerve entrapment

Inability to bear weight following trauma with visible deformity

Emergency evaluation required to rule out fracture-dislocation

Pathophysiology and contributing factors.

Inside Overview

The Science of Posterior Tibial Tendon Dysfunction

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Posterior tibial tendon dysfunction (PTTD), now commonly termed Progressive Collapsing Foot Deformity (PCFD), represents a complex, progressive condition involving failure of the posterior tibial tendon and associated ligamentous structures. The posterior tibial tendon serves as the primary dynamic stabilizer of the medial longitudinal arch and controls hindfoot motion during the stance phase of walking. The condition begins with inflammation and degenerative changes within the tendon substance (tendinosis), often triggered by repetitive microtrauma or acute overload. As the tendon's structural integrity compromises, its eccentric strength diminishes, particularly during the loading response and terminal stance phases of gait. This leads to progressive loss of the tendon's ability to resist pronation forces and maintain arch integrity. Secondary to tendon failure, supporting ligamentous structures become progressively incompetent. The spring ligament complex (calcaneonavicular ligament) stretches and eventually fails, followed by attenuation of the superficial deltoid ligament, long and short plantar ligaments, and plantar fascia. This cascade creates a characteristic pattern of deformity: hindfoot valgus, forefoot abduction, midfoot collapse, and eventual ankle valgus in advanced cases. The condition progresses through distinct stages: Stage I involves tendinosis without deformity, Stage II presents flexible deformity that corrects with non-weight bearing, Stage III shows fixed deformity with subtalar joint arthritis, and Stage IV involves ankle valgus and deltoid ligament failure. Understanding this progression is crucial as treatment options and prognosis differ significantly between stages.

Posterior Tibial Tendon Dysfunction

The Science of Posterior Tibial Tendon Dysfunction

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