Tendon Transfer Surgery for PTTD: What You Need to Know

When posterior tibial tendon dysfunction progresses beyond what conservative treatments can address, surgery becomes an option. Tendon transfer surgery is one of the most effective procedures for restoring foot function in advanced PTTD cases. Let’s explore what this procedure involves.

What Is Tendon Transfer Surgery?

Tendon transfer surgery involves taking a functioning tendon from one location and redirecting it to serve a new purpose. In PTTD treatment, the goal is to replace the damaged posterior tibial tendon with another tendon that can perform its stabilizing function.

The most common tendon used is the flexor digitorum longus (FDL) tendon—a tendon that helps curl your toes. Since you have multiple toe-curling tendons, losing one doesn’t significantly impact function, but gained stability dramatically improves your foot mechanics.

Why Tendon Transfer Is Done

Your surgeon might recommend tendon transfer when:

  • The posterior tibial tendon is severely damaged or degenerated
  • Conservative treatments (physical therapy, orthotics, braces) haven’t provided relief
  • The foot has progressed to flexible flatfoot deformity
  • There’s ongoing pain that affects daily activities
  • The condition is limiting your mobility

Think of it as rerouting a backup player to fill in for an injured team member—the FDL tendon steps in to do the PTT’s job.

The Surgical Procedure

Step-by-Step Overview

  1. Anesthesia – You’ll receive either general anesthesia or regional anesthesia (spinal or nerve block)

  2. Incision – Your surgeon makes an incision along the inside of your ankle and foot

  3. Tendon Harvest – The FDL tendon is identified and carefully separated from its attachment

  4. Tendon Transfer – The harvested tendon is routed to the navicular bone (where the PTT normally attaches)

  5. Fixation – The transferred tendon is securely attached to the bone using anchors, screws, or sutures

  6. Additional Procedures – Often performed alongside other surgeries:

    • Calf lengthening (if tight Achilles contributes to the problem)
    • Osteotomy (cutting and repositioning bone)
    • Ligament repair

The procedure typically takes 2-3 hours depending on complexity.

Recovery Timeline

First 2 Weeks

  • Strict non-weightbearing (no standing or walking on the foot)
  • Cast or splint worn continuously
  • Keep foot elevated to reduce swelling

Weeks 2-6

  • Transition to a walking boot
  • Begin gentle ankle range of motion exercises
  • Still no weightbearing on the surgical foot

Weeks 6-12

  • Gradually transition to weightbearing as directed
  • Physical therapy begins to strengthen the transferred tendon
  • Transition from boot to supportive shoe

Months 3-6

  • Increased physical therapy focus
  • Return to most normal activities
  • Swelling gradually resolves

Months 6-12

  • Continued strengthening
  • Return to high-impact activities
  • Final tissue maturation

Success Rates and Outcomes

Tendon transfer surgery has good success rates when performed on appropriate candidates:

  • Pain relief: 80-90% of patients experience significant pain reduction
  • Function improvement: Most patients regain the ability to walk without pain
  • Return to activities: Many return to recreational sports within 6-12 months
  • Long-term stability: The transferred tendon typically provides durable support

Factors that improve outcomes include:

  • Patient adherence to post-operative protocols
  • Early surgical intervention (before severe deformity)
  • Combined procedures when needed
  • Quality physical therapy rehabilitation

Risks and Complications

As with any surgery, tendon transfer carries some risks:

  • Infection – Less than 5% of cases
  • Nerve injury – Transient numbness possible; permanent damage rare
  • Tendon failure – Rare when proper rehabilitation is followed
  • Non-union or delayed healing – Especially in smokers or those with poor circulation
  • Stiffness – Some loss of ankle motion is common
  • Flare-ups – Occasionally the transferred tendon can fail over time

Is Tendon Transfer Right for You?

Your surgeon will consider several factors:

  • Stage of PTTD – Tendon transfer is typically for stage II-III PTTD
  • Age and activity level – Younger, active patients often benefit most
  • Foot flexibility – The foot should still be flexible, not rigidly deformed
  • Overall health – Conditions like diabetes affect healing
  • Lifestyle goals – Your surgeon will discuss realistic expectations

The Bottom Line

Tendon transfer surgery is a well-established procedure for treating advanced PTTD. By using the flexor digitorum longus tendon to replace the damaged posterior tibial tendon, surgeons can restore foot stability and function in properly selected patients. While recovery takes time, the procedure offers excellent outcomes for those who’ve exhausted conservative treatments.

If you’re considering this surgery, discuss all your options with a foot and ankle specialist who can evaluate your specific condition and recommend the best approach for your situation.

Sources

  • American Academy of Orthopaedic Surgeons – PTTD surgical treatment options
  • Journal of Foot and Ankle Surgery – Tendon transfer outcomes research
  • Evidence-based reviews of FDL tendon transfer procedures