How to Use Nonoperative Physical Therapy for Posterior Tibial Tendinosis (PTTD) by Dr. Nicholas Strasser, MD

Clinical Background

Posterior tibial tendon dysfunction (PTTD) is a progressive condition characterized by inflammation, degeneration, and eventual elongation or rupture of the posterior tibial tendon. It often leads to progressive collapsing foot deformity (PCFD), most commonly presenting as hindfoot valgus, forefoot abduction, and medial arch collapse.

Rationale for TayCo Brace Use in PTTD

The TayCo® Acute XAB ankle brace provides medial and hindfoot stabilization by externally supporting the ankle and midfoot without encasing the foot within a rigid in-shoe device, which can be painful or restrictive in PTTD patients.

Key benefits of using the TayCo Acute XAB Brace:

• Supports the medial longitudinal arch externally, reducing strain on the posterior tibial tendon
• Controls hindfoot valgus, slowing deformity progression
• Allows custom footwear options, improving compliance
• Patients report improved comfort and tolerance compared to custom AFOs
• Enables early return to weight-bearing activities with controlled loading

Phase 1: Pain Control & Mechanical Offloading

(Weeks 0–4)

• Brace: Initiate full-time use of the Acute XAB Brace locked in neutral
• Weight-Bearing: As tolerated with brace and supportive shoe
• Footwear: Supportive sneaker with firm heel counter and arch support
• Modalities: Ice, iontophoresis, or phonophoresis as indicated
• Therapy Focus: Calf and hamstring stretching (limit subtalar eversion), ankle isometrics, non-weight-bearing foot intrinsic activation
• Avoid: Single-leg heel raises or overuse of the posterior tibial tendon

Phase 2: Strengthening & Dynamic Support

Weeks 4–8

• Brace: Continue the Acute XAB Brace during all weight-bearing activities
• Weight-Bearing: Progress to full weight-bearing in brace with daily activities
• Therapy Focus: Theraband ankle exercises, foot doming and short foot exercises, double-leg heel raises, balance/proprioceptive work
• Manual Therapy: Joint mobilization for subtalar or midfoot stiffness

Phase 3: Functional Reconditioning (Weeks 8–12)

• Brace: Continue Acute XAB Brace for longer activities or uneven terrain
• Therapy Focus: Single-leg heel raises, closed-chain strengthening, gait retraining, low-impact cardio

Phase 4: Return to Full Activity (Weeks 12–16+)

• Brace: Wean Acute XAB Brace use to longer walks, hikes, or sport as needed
• Therapy Focus: Full single-leg heel raises, dynamic balance drills, return to impact activities, footwear assessment and orthotics
  

Key Reminders

• Bracing is most effective when combined with therapy and proper shoe wear
• Patient compliance is key — particularly with activity modification and wearing the brace
• If pain persists or deformity progresses despite conservative care, surgical referral may be indicated

Important: This protocol is a general guideline. All patients should follow the specific instructions provided by their surgeon. Always consult your physician before beginning or progressing with rehabilitation exercises.