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Posterior Tibial Tendon Dysfunction Pathology

Posterior Tibial Tendon Dysfunction Pathology


Posterior tibial tendon dysfunction (PTTD) is a tendinopathy which may be due to chronic overpronation or overstretching of the posterior tibialis tendon.


Although the posterior tibialis tendon plays a significant role, this pathology has recently been recognized as involving failure of other interosseous ligaments, such as the spring ligament. Due to the complexity of this pathology, PTTD is now referred to as adult acquired flatfoot (AAF). Severe flatfoot associated with AAF can lead to other problems, such as plantar fascial tension, tendon pain, rearfoot subluxation, and ankle osteoarthritis.

Clinical Goal for Orthotic Treatment

Foot orthoses prescribed to treat AAF should reduce the excessive pronatory forces acting across the subtalar joint (STJ) axis. The orthoses must be very controlling with significant surface area contacting the foot. The modifications should increase supinatory torque across the STJ axis. Custom foot orthoses are appropriate for treatment in the early stages of AAF (Stage I and II). As this pathology progresses, foot orthoses are not an appropriate treatment and practitioners can consider ankle-foot orthoses (AFOs) for nonsurgical treatment. ProLab clients can discuss appropriate treatment options with a Medical Consultant.


To prescribe this device, check “Posterior Tibialis Dysfunction” under the Pathology Specific Orthoses portion of Part 1 of the prescription form.

PTTD Prescription Recommendations

  • Polypropylene Shell – semirigid
  • Deep Heel Cup
    • The deep heel cup increases surface area medial to the STJ axis applying a supinatory torque
  • Wide Width and Medial Flange
    • A wider distal width combined with a medial flange significantly increases surface area under the arch. This effectively supports the arch and limits excessive pronation.
  • Standard Cast Fill
    • Standard fill is used since many of these patients also have equinus. If no equinus is present, use minimum fill for greater control.
  • Medial Heel Skive – 4mm or 6mm
    • The medial heel skive increases force medial to the STJ axis to reduce excessive STJ pronation and heel eversion. Either a 4mm or 6mm skive is appropriate.
  • 0/0 Rearfoot Post
    • The rearfoot post helps stabilize the orthosis in the shoe
  • EVA Cover to Toes


This orthosis is designed to reduce the extreme pronatory forces associated with the AAF and to attempt the realignment of the rearfoot. The combination of increased width, deep heel cup and the medial heel skive increase supinatory force across the STJ axis. ProLab clients can contact a Medical Consultant with any questions.


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  2. Alvarez RG, Marini A, Schmitt C, et al: Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol – an orthosis and exercise program. Foot Ankle Int 27(1):2 – 8, 2006
  3. Augustin JF, Lin SS, Berberian WS, et al: Nonoperative treatment of adult acquired flatfoot with the Arizona brace. Foot and Ankle Clinics North America 8:491-502, 2003.
  4. Beals TC, Manoli I. An unusual cause of posterior tibial tendon degeneration. Foot Ankle Int, 19(3):177,1998
  5. Goldner JL, Keats PK, Bassett FH, et al: Progressive talipes equino valgus due to trauma or degeneration of the posterior tibial tendon and medial plantar ligaments. Orthopedic Clinics North America 5:39, 1974
  6. Hintermann B, Gachter A: The first metatarsal rise sign- A simple sensitive sign of tibialis posterior tendon dysfunction. Foot Ankle 17:237,1966
  7. Imhauser CW, Abidi NA, Frankel DZ, et al: Biomechanical evaluation of the efficacy of external stabilizers in conservative treatment of acquired flatfoot deformity. Foot Ankle Int 23(8), 2002
  8. Johnson KA, Strom DE: Tibialis posterior dysfunction Clinical Orthopedics and Related Research 239:196, 1989
  9. Kettlecamp DB. Spontaneous rupture of the posterior tibial tendon. J Bone Joint Surg, 51A(4):759,1969
  10. Kirby KA .The medial heel skive technique: Improving pronation control in foot orthoses. JAPMA 82:177, 1992
  11. Myerson MS. Adult acquired flatfoot deformity. J Bone Joint Surg, 78A:780, 1996
  12. Richie DH. A new approach to adult-acquired flatfoot. Podiatry Today 17(5):32-46, 2004

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