PTTD Stages Explained

Not all cases of posterior tibial tendon dysfunction are the same. That's why doctors use a classification system—the Johnson & Strom classification—to describe where you are in the progression of PTTD.

Understanding what stage you're in matters. It directly determines what treatment options make sense.

The Four Stages of PTTD

Here's the quick overview before we dive into each stage:

Stage 1: Tendon Inflammation

Also called: Tendonitis, early PTTD

What's Happening

The posterior tibial tendon is irritated and inflamed, but it's still intact and functioning—mostly. Think of this as the "warning sign" stage.

Symptoms You Might Notice

• Pain and tenderness along the inside of the ankle
• Mild swelling around the tendon
• Pain that increases with activity, decreases with rest
• Some fatigue in the foot, especially after being on your feet

What the Doctor Finds

• Tendon feels thickened or tender to touch
• Single heel rise might be possible but painful
• Foot alignment looks normal or nearly normal
• No visible arch collapse yet

Treatment (Highly Successful)

This stage responds extremely well to conservative care:

• Rest and activity modification — Cut back on aggravating activities
• Ice — Reduces inflammation
• NSAIDs — Ibuprofen, naproxen for pain/swelling
• Supportive footwear — Motion-control shoes, avoid flats
• Orthotics — Arch support to reduce tendon stress
• Physical therapy — Eccentric exercises for the tibialis posterior
• Immobilization — Sometimes a walking boot for 4-6 weeks

Stage 2: Tendon Degeneration

Also called: Early rupture, flexible flatfoot

What's Happening

The tendon has deteriorated significantly. It's stretched out and weakened, unable to properly support the arch. But here's the key: the foot is still flexible. You (or a doctor) can manually correct the alignment.

Symptoms You Might Notice

• More pronounced pain along the inside of the ankle
• Noticeable swelling that's more constant
• Foot is visibly flatter than before
• Difficulty or inability to stand on tiptoes
• Pain is starting to affect daily activities

What the Doctor Finds

• Significant tendon thickening
• Foot appears flattened
• When you stand on your foot, the arch collapses (but can be manually corrected)
• Single heel rise is difficult or impossible

Treatment (Often Avoids Surgery)

This is the critical stage where treatment decisions get nuanced:

Conservative options still work for many:

• All Stage 1 treatments, but more aggressive
• Custom orthotics—more substantial support
• Bracing—some people benefit from an ankle brace
• Extended physical therapy

Surgery becomes a consideration when:

• Conservative treatment fails after several months
• Deformity is progressing despite treatment
• Your activity level demands more than conservative care can provide

Surgical options at this stage:

• Tendon repair or transfer
• Osteotomy (cutting and repositioning bone)
• Usually preserves the joints

Stage 3: Tendon Rupture

Also called: Rigid flatfoot, tendon failure

What's Happening

The posterior tibial tendon has essentially snapped or deteriorated to the point where it can't function at all. The foot deformity is now rigid—it cannot be manually corrected.

Symptoms You Might Notice

• Severe pain or complete loss of function
• Foot is visibly and permanently flat
• Significant difficulty walking
• Pain now on the outside of the ankle too (from the altered mechanics)
• Swelling is more constant

What the Doctor Finds

• No active tibialis posterior muscle—you can't flex your foot inward against resistance
• Rigid foot deformity—can't manually reposition the arch
• Significant gait abnormalities

Treatment (Usually Surgical)

At Stage 3, conservative management is unlikely to restore normal function:

• Conservative treatment may help manage pain
• But it won't correct the deformity or restore the tendon

Surgery is typically necessary:

• Multiple procedures often needed
• Tendon transfer + bone realignment
• Possible joint fusion

Stage 4: With Ankle Arthritis

Also called: End-stage PTTD

What's Happening

Years of misalignment have damaged the ankle joint itself. Arthritis has set in. This is the most advanced and complex stage.

Symptoms You Might Notice

• Pain throughout the foot and ankle
• Stiffness that limits motion
• Significant difficulty with any weight-bearing activities
• The deformity is severe and obvious

What the Doctor Finds

• Rigid flatfoot deformity
• Arthritis visible on X-ray in the ankle joint
• Significant joint damage

Treatment (Complex Surgery)

The damage is extensive:

• Conservative care can help manage symptoms but won't fix the underlying problems
• Surgery is more extensive—often fusing multiple joints
• Recovery is longer

Why Staging Matters

Here's the honest reality:

• Stage 1 → 2 can happen in months or slowly over years
• Stage 2 → 3 represents a point of no return for the tendon
• Stage 3 → 4 adds the complexity of arthritis

The earlier you address PTTD, the more treatment options you have and the better your outcomes.

What Should You Do?