Posterior Tibial Tendonitis

Here's what most people don't understand about PTTD: it's progressive. Catch it early with the right orthotics, and you can often avoid surgery. Wait too long, and surgery becomes your only option.

Posterior tibial tendon dysfunction requires medial heel posting (3-5°) to reduce tendon strain by controlling excessive pronation and supporting the medial longitudinal arch.

Understanding PTTD: Why Your Tendon is Failing

The posterior tibial tendon is the primary dynamic stabilizer of your medial longitudinal arch—it's the main muscle-tendon unit keeping your arch from collapsing. When your foot pronates (rolls inward excessively), this tendon works overtime trying to maintain the arch against your body weight.

What happens over time:

• Tendon inflammation (tendinitis)
• Tendon degeneration (tendinosis)
• Progressive tendon failure
• Eventual arch collapse (flatfoot deformity)

Critical Orthotic Features for PTTD

1. Medial Heel Posting (Most Important)

A 3-5° medial heel wedge is the foundation of PTTD treatment. This wedge brings the heel from its abnormal valgus (outward) tilt to a neutral position, immediately reducing the eccentric load on the posterior tibial tendon.

Think of it like this: When your heel tilts outward, the posterior tibial tendon is constantly pulling to try to tilt it back inward. The medial heel post does this work mechanically, allowing the inflamed tendon to rest and heal.

2. Firm Arch Support

Supporting the medial longitudinal arch reduces the "sag" that overstretches the posterior tibial tendon. The arch support acts like a prop under a sagging bridge, taking load off the failing support structure (the tendon).

3. Structured Materials (Cork Amalgam)

Cork amalgam or semi-rigid materials are essential for PTTD. Soft foam orthotics compress under body weight, losing their corrective geometry exactly when you need it most—during weight-bearing. The tendon needs consistent support throughout the day.

4. Deep Heel Cup

A deep heel cup enhances stability by controlling heel motion in all planes. This reduces the "wobble" that creates additional tendon strain during walking.

Clinical Approach by PTTD Stage

Stage 1 - Early PTTD (Tendinitis):

• Symptoms: Medial ankle pain, mild swelling, pain with activity
• Orthotic: Type 1 with 3° medial posting
• Prognosis: Excellent with early intervention
• Key: Consistent wear allows tendon inflammation to resolve

Stage 2 - Flexible Flatfoot:

• Symptoms: Arch begins to collapse but can be manually corrected
• Orthotic: Type 1 with 3-5° medial posting, aggressive arch support
• Prognosis: Good with orthotic use, prevents progression
• Key: Higher degree of posting may be needed

Stage 3 - Rigid Flatfoot:

• Symptoms: Fixed arch collapse, cannot be manually corrected
• Orthotic: Custom orthotics or bracing typically required
• Prognosis: Orthotics for symptom management, may need surgery
• Key: Focus shifts from correction to accommodation

Stage 4 - Ankle Involvement:

• Symptoms: Ankle arthritis develops
• Orthotic: Bracing or surgical intervention typically needed
• Key: Orthotic intervention should occur before this stage

Why Early Intervention Matters

This is critical: PTTD is progressive. Stage 1-2 can often be successfully managed with appropriate orthotics, preventing the need for surgery. Once Stage 3-4 develops, surgical options become limited and more complex.

Research support: Studies show that medial heel wedging combined with arch support significantly reduces posterior tibial tendon strain, with success rates of 60-80% in early-stage PTTD when combined with activity modification and strengthening exercises.

Type 1 Orthotics for PTTD

The Arches Type 1 orthotic provides the essential features for PTTD treatment:

• 3° medial heel post to control pronation
• Firm cork amalgam base for consistent support
• Structured arch support to offload the tendon
• Deep heel cup for stability

For most Stage 1-2 PTTD patients, Type 1 orthotics provide the biomechanical control needed to allow tendon healing while preventing progression.

The honest answer from an orthopedic surgeon: For most early-stage PTTD, prefabricated orthotics work just as well as custom—at a fraction of the cost.

Prefabricated orthotics work well for Stage 1-2 PTTD with flexible deformities, while custom orthotics become necessary for Stage 3+ PTTD, rigid deformities, or failed prefabricated trials.

Stage-Based Orthotic Decision

Stage 1 PTTD - Prefab Recommended:

• Deformity: Minimal or no arch collapse
• Flexibility: Normal foot flexibility
• Orthotic: Type 1 prefabricated with 3° medial posting
• Success Rate: 70-80% with prefab orthotics
• Cost-Benefit: Save $300-500 with similar outcomes to custom

Stage 2 PTTD - Prefab Often Sufficient:

• Deformity: Visible arch collapse but flexible (can manually correct)
• Flexibility: Arch can be pushed back up with hand pressure
• Orthotic: Start with Type 1 prefab; if insufficient control, progress to custom
• Success Rate: 60-70% with prefab orthotics
• Trial Period: Give prefab 8-12 weeks before considering custom

Stage 3 PTTD - Custom Typically Required:

• Deformity: Fixed arch collapse, cannot manually correct
• Flexibility: Rigid flatfoot deformity
• Orthotic: Custom orthotics or ankle bracing
• Goal: Accommodation rather than correction
• Surgical Consideration: Many Stage 3 patients eventually need surgery

Clinical Decision Framework

Try Prefab First If:

• Stage 1 or early Stage 2 PTTD
• Foot shape is relatively standard (not extremely wide/narrow)
• Flexible deformity (arch can be manually corrected)
• Cost is a significant concern
• New diagnosis, haven't tried orthotic treatment yet

Go Directly to Custom If:

• Stage 3 or 4 PTTD with rigid deformity
• Previous failed trial of appropriate prefab orthotics (wore consistently for 3+ months)
• Unusual foot shape that doesn't fit standard sizing
• Surgeon specifically recommends custom for your severity
• Post-surgical need for precise biomechanical control

My Clinical Approach as an Orthopedic Surgeon

I recommend starting with high-quality prefabricated orthotics like Type 1 for most Stage 1-2 cases. Here's why:

1. Cost-Effective Trial: Saves $300-500 while providing 70-80% benefit of custom for appropriate patients
2. Immediate Availability: Start treatment today instead of waiting 2-3 weeks for custom fabrication
3. Diagnostic Value: Response to prefab helps determine if custom is truly needed

When to Progress from Prefab to Custom

Consider upgrading to custom orthotics if:

• No symptom improvement after 8-12 weeks of consistent wear
• Pain worsening or arch collapse progressing despite prefab use
• Orthotic doesn't fit foot shape properly (too narrow/wide)
• Stage progression from 1→2 or 2→3 during treatment

What "Failed Prefab Trial" Really Means

Before concluding prefabs "don't work," ensure:

• ✓ Correct type (Type 1 for PTTD, not Type 2 or 3)
• ✓ Consistent wear (minimum 6-8 hours daily)
• ✓ Appropriate footwear (supportive shoes, not flip-flops or heels)
• ✓ Adequate trial period (minimum 8-12 weeks)
• ✓ Activity modification (reduced high-impact activities during healing)

Many "failed" prefab orthotics are actually cases of incorrect type selection or inconsistent compliance.

Red Flags for Immediate Custom

• Severe pain unresponsive to initial prefab trial (2-3 weeks)
• Rapid progression of arch collapse
• Inability to fit Type 1 prefab due to extreme foot shape
• Surgeon recommendation based on examination findings

Cost-Benefit Analysis

• Prefab Type 1: $72
• Custom Orthotics: $400-600
• Difference: $328-528 saved if prefab works
• Success Rate: 70-80% of Stage 1-2 PTTD responds to prefab

Bottom Line

For most early-stage PTTD patients, start with Type 1 prefabricated orthotics. If symptoms don't improve after a proper 8-12 week trial, then custom orthotics are warranted. This approach is both cost-effective and clinically sound.

Remember: PTTD is progressive. The earlier you intervene with appropriate orthotics (whether prefab or custom), the better your chances of avoiding surgery.