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Health & Exercise Forum

Flat Feet and Tendon Injury - Part 2 of 3 on Flat Feet and PTTD

Aug 20, 2012

Guest Columnist: Janet Caputo, PT, DPT, OCS

“Flat feet,” considered the most common foot deformity, affects 60 million people in the United States (approximately 25% of Americans).  Posterior tibial tendon dysfunction (PTTD) results from flat feet or may develop from an accumulation of prolonged, repetitive over-pronation of the foot. If not managed properly, PTTD can progress over time and interfere with work and recreational activities.

How can you tell if your PTT is dysfunctional? “Too Many Toes Sign” and “Jack’s Test” can help determine the integrity of your PTT.  “Too Many Toes Sign” tests for flat-foot deformity or over-pronation and “Jack’s Test” determines if the PTT can correct this abnormal position.  If one or both of these tests are positive, your PTT is at risk, and you may have PTTD!

To perform “Too Many Toes Sign,” stand facing away from someone and have them draw an imaginary line from the center of your calf to the floor. This test is positive if your heel lies outside this line and if more than two of your toes can be observed.To perform “Jack’s Test,” lift your good leg off the floor, rise up on the toes of your bad leg, and hold that position. A diagnosis of PTTD is confirmed if you are unable to perform this one-legged heel-raise or if your heel remains turned outward in the tip-toe position.

The primary goal in PTTD management is to prevent progression to the next stage by correcting the over-pronation or flat foot deformity. Treatments for PTTD include orthoses, exercises, and surgery.

Orthotic management can be considered “first-line defense” against the progression of PTTD, because it targets and corrects or accommodates the CAUSE: improper alignment from a flat foot or over-pronation.  Because orthoses align the foot and ankle joints, they reduce pain by eliminating abnormal stresses on compensatory structures (e.g. PTT).  If the flat foot position is flexible, the orthosis corrects deformity, but if the flat foot position is fixed and rigid, the orthotic design accommodates and supports deformity. Improving alignment with orthoses allows the PTT and other accessory muscles to work better, which improves foot/ankle mechanics.

“Orthoses” include supportive foot-wear, taping techniques, shoe inserts, and a variety of custom-molded braces.  Stability running shoes (picture A) control over-pronation with a post on the inner side of the foot made of dual density foam which is easily recognizable as a darker piece of foam on the inside of the midsole.  Motion control running shoes (picture A) support the flat foot with similar technology plus a special sole unit/upper construction for enhanced support.  Taping techniques (picture B) lock the heel inward which reduces excessive flattening of the arch.  Shoe inserts (picture C), over-the-counter or custom-molded, either control abnormal pronation with a post on the inner side of the heel that tilts the heel inward or accommodate the flat foot deformity.  A variety of custom-made “braces” (i.e. ankle-foot-orthoses; e.g. double upright AFO, gauntler style AFO, low articulated AFO; (picture D) are used to manage severe flat-foot deformities.  Because the arch of your foot is not a weight bearing structure, placing a pad in the arch of your foot to correct alignment is not recommended. For proper orthotic prescription, consult with a licensed professional (e.g. podiatrist, physical therapist, prosthetist/orthotist).

Join us next week to discover exercises that strengthen key foot and ankle muscles to enhance the dynamic support for the over-pronated or flat foot, and to discuss several surgical options that are warranted if conservative treatment fails.

Source: Lower Extremity Review. 2011

Visit your doctor regularly and listen to your body.

CONTRIBUTING AUTHOR: Janet Caputo, PT, DPT, OCS is clinical director of physical therapy at Mackarey & Mackarey Physical Therapy Consultants, LLC in downtown Scranton where she practices orthopedic and neurological physical therapy.


James Haggerty, DPM: Dr. Haggerty is a podiatrist in private practice in Dunmore, PA.

Vincent Grattolino, DPM: Dr. Grattolino is a podiatrist in private practice in Scranton, PA.


Jennifer Hnatko, Mackarey & Mackarey Physical Therapy  Consultants, LLC.

"Picture A: Motion Control Running Shoes" from ""

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in the Scranton Times-Tribune. Next Week: Flat Feet -Part III of III.

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email:

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice in Scranton, PA. He is an associate clinical professor of medicine at The Commonwealth Medical College.