Question 1

I'm a 52-year-old woman with diabetes and I've noticed my right foot is getting flatter over the past year. I have pain along the inside of my ankle. My GP diagnosed posterior tibial tendon dysfunction and referred me to an orthopedic surgeon who says I have 'Stage II PTTD' and need surgery. Can't I just use insoles and avoid surgery?

Accepted Answer

Your surgeon's recommendation for surgery is evidence-based for Stage II PTTD, though a trial of conservative management is reasonable before committing to surgery. Here's the full picture: WHAT IS STAGE II PTTD: Stage II means: your posterior tibial tendon has failed (you cannot perform single heel raise test on affected foot), you have developed flexible flatfoot deformity (arch collapsed, heel tilted outward), deformity can still be passively corrected (surgeon can manipulate foot back to normal position). Stage II is the 'window of opportunity' for joint-preserving surgery (tendon reconstruction and bone cuts to restore arch). If you progress to Stage III (fixed rigid flatfoot), you'd need major fusion surgery (much worse outcomes, permanent stiffness). CONSERVATIVE MANAGEMENT FOR STAGE II: Your GP's approach (insoles/orthotics) can be tried, but: Success rate only 30-40% for Stage II (vs 80-90% for Stage I). Most Stage II patients who try conservative management end up needing surgery within 1-2 years anyway—during which time deformity often progresses. Conservative management for Stage II: custom UCBL orthotic or AFO (ankle-foot orthosis)—not simple insoles, needs molded orthotic providing arch support and controlling heel valgus, 3-6 month trial (minimum 4-6 months before declaring failure), immobilization in walking boot for first 6-8 weeks if acute pain. If after 4-6 months you have: persistent pain limiting activities, progressive deformity (foot flattening more, heel tilting more outward), difficulty walking—then surgery indicated. WHY SURGERY RECOMMENDED FOR STAGE II: Prevents progression: Stage II typically progresses to Stage III (fixed rigid flatfoot) within 2-5 years if not surgically corrected. Once Stage III, need fusion surgery (much bigger operation, permanent stiffness, worse outcomes 70-80% vs 85-90% for Stage II surgery). Better outcomes: Stage II surgery (tendon transfer + osteotomies) restores arch, realigns foot, preserves joint motion. Most patients (85-90%) achieve good function, walk comfortably, wear normal shoes with orthotic. Diabetes consideration: diabetes is risk factor for PTTD progression. Your tendon healing capacity may be impaired, making conservative management less likely to succeed. SURGERY FOR STAGE II: FDL tendon transfer (using flexor digitorum longus tendon to replace failed posterior tibial tendon) + medial displacement calcaneal osteotomy (cutting and shifting heel bone to correct valgus) ± other procedures depending on deformity specifics. Recovery: non-weight-bearing 6-8 weeks, walking boot 8-12 weeks, return to activities 4-6 months. DECISION-MAKING: Reasonable approach: (1) trial custom UCBL orthotic or AFO for 4-6 months (not simple insoles—needs proper molded orthotic prescribed by orthopedic surgeon or orthotist), (2) if pain and deformity controlled, continue orthotic long-term with close monitoring (X-rays every 6-12 months to ensure not progressing), (3) if pain persists, deformity worsens, or quality of life significantly impacted, proceed to surgery. However, don't delay surgery indefinitely hoping conservative management will work—if clearly failing at 4-6 months, proceeding to surgery while still Stage II is much better than waiting until Stage III. BOTTOM LINE: You can try orthotic for 4-6 months, but be realistic about expectations (only 30-40% success for Stage II conservative management). If failing, don't delay surgery—Stage II surgery has excellent outcomes (85-90%) and prevents progression to Stage III which requires much bigger surgery with worse results. Diabetes increases importance of not delaying treatment.

Question 2

I had Stage II PTTD surgery (FDL transfer and heel bone osteotomy) 4 months ago. I'm walking in shoes now with my custom orthotic but my foot still feels stiff and I can't walk on uneven ground easily. Is this normal or did the surgery not work properly?

Accepted Answer

What you're experiencing is NORMAL at 4 months after Stage II PTTD reconstruction. The surgery was successful in reconstructing your arch and realigning your foot, but the recovery involves permanent changes to your foot biomechanics. Here's what to expect: EXPECTED RECOVERY TIMELINE: Months 0-2: non-weight-bearing in cast (bone osteotomies healing, tendon transfer healing to bone). Months 2-3: progressive weight-bearing in walking boot. Months 3-4 (where you are now): walking in shoes with orthotic. Foot feels stiff, uneven ground difficult. This is NORMAL. Months 4-6: progressive improvement in walking comfort, balance, stair climbing. Still some stiffness. Months 6-9: approaching maximal improvement. Stiffness persists but adapting better. Most daily activities comfortable. Month 12+: final result. Residual stiffness permanent but functional for daily activities. WHY FOOT FEELS STIFF: Subtalar joint stiffness: medial displacement calcaneal osteotomy (heel bone cut and shifted) alters subtalar joint mechanics. This joint normally allows foot to adapt to uneven ground (inversion/eversion). After osteotomy, subtalar motion reduced 30-50% compared to pre-surgery. This is EXPECTED trade-off—necessary to correct heel valgus and maintain arch. Soft tissue healing: FDL tendon transfer creates scar tissue at new insertion site. Surrounding ligaments (spring ligament) repaired. Gastroc recession if performed creates calf tightness. All contribute to stiffness during healing (12+ months). Proprioception loss: your brain needs time to adapt to 'new' foot position and mechanics. Takes 6-12 months to fully adapt balance and walking patterns. UNEVEN GROUND DIFFICULTY: This is the most common complaint after PTTD reconstruction. Normal subtalar joint allows: inversion (foot tilting inward) and eversion (outward) to adapt to uneven surfaces. After osteotomy, subtalar motion LIMITED—foot cannot adapt as easily to rocks, curbs, slopes. Coping strategies: walk more carefully on uneven ground (slower, watch footing), use walking poles or trekking poles for bushwalking if needed, strengthen ankle muscles with proprioception exercises (balance board, single-leg standing) to compensate for stiffness, continue wearing supportive shoes with orthotic. Most patients adapt over 6-12 months and can manage uneven ground adequately (though never as easily as before). WHAT IS ABNORMAL (WOULD SUGGEST PROBLEM): Cannot bear full weight on foot at 4 months (suggests nonunion of osteotomy—need X-rays). Severe ongoing pain (suggests hardware problem, infection, or under-correction). Foot deformity recurring (arch collapsing again—suggests inadequate correction or fixation failure). Numbness/tingling (suggests nerve injury). If you have any of these, see surgeon urgently. EXPECTED FINAL OUTCOME: Most patients (85-90%) achieve: pain-free or minimal pain with normal daily activities (walking, shopping, stairs), restored arch and improved foot appearance, ability to wear normal shoes with custom orthotic, comfortable walking on flat ground. Permanent limitations: reduced subtalar motion (stiffness), difficulty on very uneven terrain, cannot return to running or high-impact sports (most patients), requires orthotic support long-term (cannot walk barefoot comfortably). BOTTOM LINE: At 4 months, you're on track. Stiffness and difficulty on uneven ground are EXPECTED and NORMAL after PTTD reconstruction. Continue physiotherapy focusing on: ankle ROM exercises, proprioception/balance training, gradual increase in walking distance and terrain difficulty. Expect progressive improvement over next 2-6 months, reaching final result at 12 months. The residual stiffness is trade-off for correcting your flatfoot deformity and preventing progression to Stage III (which would have required major fusion surgery). Most patients feel the trade-off is worthwhile despite permanent subtalar stiffness.

Medical Disclaimer

Adult Flatfoot (Posterior Tibial Tendon Dysfunction)

📖What is Adult Flatfoot (Posterior Tibial Tendon Dysfunction)?

🔬What Causes It?

⚠️Risk Factors

You may be at higher risk if:

🛡️Prevention