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Background: Lateral column lengthening procedures have been extensively reported either as primary procedures or adjuncts to combined soft tissue procedures and osteotomies for the correction of the pes planovalgus deformity. There is also considerable debate as to the ideal procedure that is not followed by recurrence and obviates the need for revision surgeries and minimizes complications. We describe a technique and present the clinical results of lateral column lengthening that provides a powerful correction to restore normal foot alignment. Methods: We retrospectively reviewed 26 feet in 21 patients with a mean age of 35.4 years (range, 12-75) over an average follow-up period of 71 months (range, 12-147) who underwent reconstructive surgery for flexible pes planovalgus foot. The reconstructive procedures included a central calcaneal osteotomy in all patients, a medial column stabilization procedure, flexor digitorium transfer (FDL), and a gastrocnemius or Achilles tendon lengthening. Clinical evaluation was carried out with the AOFAS ankle-hindfoot scores. Standard weight-bearing anterior posterior (AP) and lateral radiographs before surgery and at follow-up were analyzed for radiographic parameters of correction. Results: The median AOFAS score increased from 50 to 90.Two patients reported dissatisfaction with the result. There were no nonunions nor complications related to hardware. Radiographic improvement of the talonavicular coverage angle was a 74% change from baseline value. All radiographic parameters improved (P < .001) except the lateral talocalcaneal angle (P = .48). No secondary subsidence of the arch was observed within the follow-up time. Conclusion: Correction of flexible pes planovalgus deformity with a central calcaneal osteotomy was an effective, reproducible method to restore normal foot alignment and good function. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

Posterior tibial tendon (PTT) dysfunction is recognized as an etiology leading to acquired flatfoot in adults, causing significant functional loss. Many risk factors and systemic conditions have been proposed in literature. However, many patients present PTT dysfunction without any of these characteristics. This suggests that there could be a genetic influence associated with posterior tibial tendinopathy. The purpose of the present study is to investigate the association of the −1607 polymorphism in the promoter gene of MMP-1 and posterior tibial tendinopathy. The test group included 50 women, who presented PTT dysfunction grade 2 or 3, and who were submitted to surgical treatment, with histopathological examination of the tendon and magnetic resonance image (MRI) confirming tendinopathy, while the control group was 100 asymptomatic women who presented intact PTT at MRI. The results were analyzed using the chi-square test. The data showed a 75% incidence of the allele 1G and 62% of the genotype 1G/1G at the control group while, at the test group, they showed a 78% incidence of the allele 2G and 72% of the genotype 2G/2G ( p < 0.001). The −1607 polymorphism of promoter gene of MMP-1 is associated with the posterior tibial tendinopathy in the studied population. © 2013 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 31:1103-1107, 2013 [ABSTRACT FROM AUTHOR]

Objective: To determine the incidence of injuries to the flexor and peroneal retinacula in hindfoot fractures as demonstrated on ankle computed tomography (CT). Materials and methods: Study patients were identified via review of CT records at a single institution. CT scans were retrospectively reviewed and compared with surgical reports. Results: Hindfoot fractures undergoing CT showed flexor retinacular injuries in 23.7% of cases and peroneal retinacular injuries in 10.2%. The posterior tibial tendon was partly torn in 4.2% of cases, and entrapped between fracture fragments in 16.1%. The peroneal tendon was rarely injured, being entrapped in 1.7% of cases. Pilon, distal tibial shaft, malleolar, talar, and calcaneal fractures were all associated with retinacular injuries. CT findings correlated well with surgical findings; there were no false-positive CT findings, and only 1 false-negative finding, a posterior tibial tendon that was entrapped at surgery, but in a normal position on the CT. Conclusions: Retinacular injuries are commonly demonstrated on CT in patients with ankle fractures. The contribution of these injuries to fracture outcomes is unknown. [ABSTRACT FROM AUTHOR]

Abstract: Background: Posterior tibial tendoscopy was codified in 1997 by Van Dijck, who described a portal between 1.5 and 2cm proximally and distally to the tip of the medial malleolus. However, this approach does not allow proximal exploration of the posterior tibial tendon (PTT). We here describe an accessory portal 7cm proximal to the medial malleolus, enabling complete PTT exploration. Methods: Posterior tibial tendoscopy was performed on 12 cadaver specimens, mapping PTT exploration and vascularization. Results: The accessory portal enabled the whole PTT to be explored, from the myotendinous junction to the entry into the retromalleolar groove. PTT observation quality was improved compared to using a submalleolar portal. Dissection confirmed systematic presence of a vincula on the posterior side of the tendon, connected to the flexor digitorum longus (FDL) tendon, containing collateral vessels of the posterior tibial artery. None of these elements were damaged by the tendoscopy as long and the scope and motorized instruments were not rotated on the posterior side of the supramalleolar part of the PTT. Conclusions: This accessory entry portal provides complete PTT exploration without the risk of neurovascular bundle lesion. [Copyright &y& Elsevier]

Background: Lateral column lengthening (LCL) is used to address the forefoot abduction associated with the adult acquired flatfoot. This opening wedge osteotomy can be filled with either allograft or autograft bone. Questions/Purposes: The investigators sought to determine union rates and any loss of correction in patients undergoing LCL with autograft versus allograft. Methods: Over a 3-year period, 126 LCLs performed by five surgeons in 120 patients were reviewed. Autograft was used in 51 patients, allograft in 75 patients. Times to clinical and radiographic union were established for these patients. Any loss of correction of forefoot abduction as manifested by talonavicular uncoverage was recorded for those grafts that healed. Failure was defined as nonunion or loss of 50% or greater correction. The size of the implanted graft was assessed as a risk factor for failure. Results: There were 20 total failures: seven in patients with autograft and 13 in patients with allograft ( p = 0.63). The size of the implanted graft was larger in those patients that did fail ( p = 0.04). Conclusions: The rate of nonunion and loss of correction for LCL was not significantly different between allograft and autograft. The overall rate of nonunion may be higher than has previously been reported. [ABSTRACT FROM AUTHOR]

Objective: To examine the effectiveness of a new technique for reattaching the posterior tibial tendon (PTT) using a bone tunnel and interference screw after resection of the accessory navicular for painful accessory navicular (type II) in adult athletes. Methods: Ten adult athletes (7 male, 3 female; mean age 30 years, range 23-45) underwent reconstruction using a bone tunnel with an interference screw for a painful accessory navicular. All patients complained of pain on the medial aspect of the foot after eversion sprain during sports activities and radiographs revealed type II accessory navicular. Clinical evaluation with the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and visual analogue scale (VAS) before surgery was compared with that at most recent follow up (mean 30 months, range 24-39). Results: Mean AOFAS score improved from a preoperative 62.8 ± 2.9 points (range 61-82) to a postoperative 92.1 ± 7.0 points (range 83-100; p < 0.01). Furthermore, mean VAS score improved from a preoperative 92.5 ± 5.4 points (range 85-100) to a postoperative 4.5 ± 3.8 points (range 0-10; p < 0.01). All patients could return to full sports activity at a mean of 14 weeks (range 12-18) after surgery. Conclusions: The presented technique reconstructs the bone-tendon interface of the PTT at the primary navicular with sufficient fixation after resection of the accessory navicular, which preserves the strength of the PTT in adult athletes with an intractably painful accessory navicular. [ABSTRACT FROM AUTHOR]

The article reports on research which was conducted to evaluate stage II posterior tibial tendon deficiency (PTTD) functional recovery in patients who have undergone tendon balancing and calcaneal lengthening osteotomy. Researchers evaluated 17 feet in 13 patients. They found that the balancing and osteotomy procedure resulted in functional recovery in patients with stage II PTTD.

The article reports on research which was conducted to assess and provide prospective outcome data following reconstruction of stage II posterior tibial tendon insufficiency and to evaluate the effect of reconstruction with gastrocnemius recession on plantarflexion strength. Researchers evaluated 24 patients who underwent reconstruction. They found that the reconstruction yielded excellent results.

The article presents a case study of a 60-year-old woman with posterior tibialis (PT) tendonitis linked with type II accessory navicular (AN) bone. It states that high-resolution ultrasonography was used for the PT tendonitis using a Voluson 730 expert scanner with a linear-array transducer. Moreover, results show that ultrasonography determine a synchondrosis between the AN bone and the main navicular bone.

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The article focuses on the anatomy of the common peroneal nerve (CPN) palsy together with the treatment options, pathophysiology, and evaluation for drop foot. It says that CPN palsy is a debilitating complication and its occurrence has been reported as high as 50%. It states that CPN palsy is more usual compared with rotatory dislocations and open dislocations. It adds that some of the viable options for its treatment include neurolysis, nerve grafting, and posterior tibialis tendon transfer.

Copyright of Der Orthopäde is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Patients with flexible stage IV flatfoot present with valgus ankle deformity in addition to medial arch collapse, resulting in hind foot valgus and midfoot abduction. The ankle deformity is best addressed at the time of flatfoot reconstruction. In this article, we describe a method of reconstructing the deltoid ligament complex by using an Achilles allograft tendon. The graft is prepared with a bone block that is placed in a talar tunnel and secured to a screw post in the lateral talar body. The graft is passed through an oblique tibial tunnel, drilled from medial to lateral starting at the medial malleolus and exiting out the lateral tibia above the level of the ankle. The reconstruction is indicated in cases in which ankle valgus can be passively reduced and there is no bone on bone contact in the ankle joint. A previous report showed promising results in a small cohort of patients using a peroneus longus autograft. [Copyright &y& Elsevier]

Abstract: Flatfoot deformity is a common complaint with various etiologies. It causes confusion as to when and how to treat it. Unnecessary treatment is a problem, especially in asymptomatic flexible paediatric flatfoot. The human foot is a sophisticated biomechanical structure. Interference with this complicated system of joints, ligaments, tendons and muscles has to be based on a sound knowledge of anatomical structures and their interactions. It is therefore important for every doctor dealing with this condition to be able to differentiate between cases needing treatment and cases that simply need reassurance. Historically, flatfoot deformities have been over treated with the aim to correct deformity, in the process not only failing to achieve the desired correction but also creating symptoms in previously symptom free individuals. A lot has been learned about flatfoot deformity and a more sensible approach based on symptoms and expected disability has been adopted. The adult acquired flatfoot is a complex condition, commonly caused by posterior tibial tendon deficiency (PTTD). Management of these patients is based on a thorough assessment of the underlying pathology. In this article we give an overview of the condition, with emphasis placed on assessment and management of the more common causes. [Copyright &y& Elsevier]

Copyright of Operative Orthopädie und Traumatologie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction/Purpose: We report the case of a 23-year-old male who underwent a posterior tibial tendon (PTT) transfer after suffering foot drop secondary to a traumatic knee dislocation five years earlier. The common peroneal nerve is a commonly injured peripheral nerve due to its anatomic location. Peroneal nerve palsy leads to the inability to clear the foot during the swing phase of gait due to paralysis of the tibialis anterior-the strongest dorsiflexor of the foot. In the event that nerve function does not spontaneously return, tendon transfer surgeries are an established definitive treatment. Despite this, the optimal method of tendon transfer has not yet been determined. Thus, pre-operative assessment and planning remains crucial in determining which method is to be used. Conclusion: Surgeons must decide which tendon to transfer, which route to utilize, and where to insert in effort to maximize biomechanical outcomes. Careful consideration must be made to ensure maximum strength and optimal forefoot balance to allow patients undergoing tendon transfer to become brace free. Our patient underwent a PTT transfer via the interosseous route to the lateral cuneiform-a common option for those with traumatic peroneal nerve injury. By three months post-operation, our patient achieved adequate dorsiflexion to clear swing phase. By one year post-operation and beyond, our patient has participated in physical activity brace free without any complications. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: To assess whether 2-mm-diameter operative tendoscopy of the tibialis posterior, peroneal, and Achilles tendons was safe and effective in a cadaveric model. Methods: A 2-mm-diameter arthroscopic system was used to perform a tendoscopic procedure in 10 nonpaired, freshfrozen, human ankles. Standard tendoscopic portals were utilized. Visual examination and operative reach with tailored tendoscopic instruments within the tendon sheaths were recorded and documented. Adhesiolysis and vincula resections were performed. After dissection, distances between portal tracts and neurovascular structures were measured and the tendons were inspected for signs of iatrogenic damage. Results: The entire tendon sheath and tendon of the tibialis posterior, peroneus brevis, and Achilles tendons were visualized and reached with tailored operative instruments. The proximal part of the peroneus longus tendon was visible and reachable from proximally up to the cuboid bone distally. Adhesiolysis and vincula resections were successfully performed in all specimens. The mean distances between portal tracts and local neurovascular structures ranged between 9.4 and 19.2 mm and there were no cases of contact. None of the tendons showed signs of iatrogenic damage. Conclusion: Two-millimeter-diameter operative tendoscopy provided safe and effective visualization and operative reach of the tibialis posterior, peroneal, and Achilles tendons. [ABSTRACT FROM AUTHOR]

Abstract: Aim: The purpose of this cadaver study was to test feasibility and safety of a new technique for harvesting the FDL tendon through a plantar incision placed directly overlying the FDL division and to define the relevant surgical anatomy. Methods: In eight cadaver feet the FDL tendon was exposed in the midfoot through a plantar incision. In four of these feet this was done after localization of the FDL division site using a probe inserted through a wound in the hindfoot within the sheath of FDL tendon. The exact location was measured in relation to the geometry of the foot and was found to be midway between the back of the heel and the base of the second toe and about 4cm medial to the lateral border of the foot. Using these determinants FDL was exposed on the contralateral matching four feet without use of the probe. The FDL tendon was divided and pulled proximally and the length of the tendon was determined. Results: The FDL division lies midway between the back of the heel and the base of the second toe and about 3.7cm medial to the lateral border of the foot. The medial and the lateral plantar neurovascular bundles are, respectively, about 0.43cm and 0.86cm away from the FDL division. The average length of the retrieved tendon was about 9cm. Conclusions: This cadaver study suggests that the FDL tendon can be safely harvested through a plantar incision. The adjacent neurovascular structures remained undamaged. Plantar surface anatomy guides placement of the plantar incision so that the incision can overlie directly over the FDL division. [Copyright &y& Elsevier]

Abstract: Flexor Digitorum Longus (FDL) transfer and medial displacement calcaneal osteotomy has become one of the most popular modes of treatment for posterior tibial tendon dysfunction (PTTD). The purpose of this study is to show the outcome in 16 patients as well as to analyze the relationship between different radiographic parameters and the clinical outcome. Sixteen patients with an average age of 58 years were studied. Radiographical analysis included different angles measured pre- and postoperatively. Spearman''s rho test was performed to evaluate the relationship between clinical and radiographic parameters. The preoperative AOFAS score was 45.9 and the postoperatively was 93.5. This study suggests that this technique is an effective and safe procedure for PTTD (Stage II) and that the talo-first metatarsal angle (AP) and the talo-navicular coverage angle (AP) have a good correlation with the clinical outcome, so they may be considered to predict the clinical evolution of these groups of patients. [Copyright &y& Elsevier]

Posterior tibial tendon insufficiency is the commonest cause of adult onset flatfoot deformity. The treatment of stage 2 posterior tibial tendon insufficiency is still controversial. Different combination of open procedures of tendon transfer, calcaneal osteotomy and hindfoot arthrodesis has been described. We describe an endoscopic approach of posterior tibial tendon reconstruction. By means of anterior and posterior tibial tendon tendoscopies, the medial half of the anterior tibial tendon is then transferred to the posterior tibial tendon. The construct is then augmented by side-to-side anastomosis with flexor digitorum longus tendon. This is supplemented with subtalar arthroereisis with a bioresorbable arthroereisis implant. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: There is limited literature on patient reported outcomes after tendon transfer for traumatic foot drop. The purpose of this study was to determine long-term patient reported functional outcomes after posterior tibialis tendon (PTT) transfer in patients with foot drop resulting from a traumatic common peroneal nerve injury. Methods: Between August 2006 to January 2019, 31 patients underwent PTT transfer for foot drop secondary to a traumatic injury to their common peroneal nerve at our institution. The average follow-up was 14 months. A retrospective chart review was performed to document physical exam measures and to review postoperative radiographs for changes in foot alignment. There were 17 out of the initial 31 patients available at a mean follow-up of 5.9 years who responded to a phone questionnaire, including the Foot and Ankle Ability Measure (FAAM) questionnaire, and questions on brace and assistive device use, activity level, and satisfaction with surgery. Results: Preoperatively, all patients had an equinus contracture with no dorsiflexion strength, abnormal gait, and used an anklefoot orthosis (AFO) or pneumatic boot for ambulation. Postoperatively, the average ankle dorsiflexion strength was 4/5 with 28/31 patients reporting a normal gait and 26/31 not using a brace for ambulation. Postoperative radiographs did not show changes in alignment or progression to flatfoot deformity. For the subset of 17 patients who responded to the phone questionnaire, the mean FAAM ADL subscale score was 68.1 and the Sport subscale score was 52.1 at an average of 5.9 years after surgery. The majority of patients (76%) were very or quite satisfied with the outcome of surgery and 15/17 (88%) patients reported they would undergo the PTT transfer procedure again. Conclusion: Posterior tibialis tendon transfer for patients with foot drop secondary to a traumatic injury to their common peroneal nerve showed a high satisfaction rate and improvement in function after surgery without the need for brace or assistive device use at long-term follow-up at an average of 6 years. Additionally, there was no progression to flatfoot deformity after posterior tibialis tendon transfer at 1 year postoperatively. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is a three-dimensional (3D) and complex pathology that is characterized by peritalar subluxation (PTS) of the hindfoot. Measuring the amount of subluxation of the subtalar joint at the posterior facet was described and utilized for many years as a marker of PTS. The subluxation of the middle facet was recently proposed as possibly a more accurate and reliable early marker of pronounced deformity, with almost 100% sensitivity and specificity for symptomatic AAFD. The objective of this study was to compare the amount of subluxation of both the medial and posterior facets in patients with increased hindfoot valgus and controls. Methods: In this IRB-approved retrospective comparative study, we included a total of 91 patients with AAFD (108 feet) who underwent standing weightbearing CT (WBCT) as a standard baseline assessment of their foot deformity. One blinded Fellowship-Trained Orthopedic Foot and Ankle Surgeon with more than 10 years of experience performed WBCT measurements regarding the amount of subluxation of the subtalar joint (percentage of uncoverage) at the posterior and middle facet, as previously described in the literature (Please see attached Figure). Measurements were performed at the sagittal midpoint of the articular facets using Coronal Plane WBCT images. The inter-method agreement between the posterior and middle facet subluxation was assessed using Spearman's Correlation and Bivariate Analysis. A paired comparison of the measurements was performed using Wilcoxon. P-values of <0.05 were considered significant. Results: The inter-method Spearman's correlation between the subluxation of posterior and middle facets was measured 0.69. In a bivariate analysis, both measurements were found to be significantly and linearly correlated (P<0.0001), (R2=0.5). The mean/median value and 95% Confidence Interval (CI) for subluxation of the subtalar joint facets were found to be more pronounced in the middle facet (29.8%/26.8%, CI 25.7% to 33.9%) when compared to the posterior facet (12.5%/15.1%, CI 8.4% to 16.6%), p-value <0.0001. The median difference between the measurements (Hodges-Lehman factor) was found to be 12.8% higher subluxation in the middle facet (CI 6.6 to 21.2%). We also found that for each 1% increase in the amount of posterior facet subluxation, a 1.7 times higher subluxation could be expected in the middle facet. Conclusion: This study is the first to compare measurements of the amount of subluxation of the posterior and middle facets of the subtalar joints as markers of peritalar subluxation in patients with AAFD. We found a positive and linear correlation between the measurements, with the middle facet subluxation being significantly more pronounced than the posterior facet by an average of almost 13%. Our results are consistent with the idea that the middle facet subluxation might represent an earlier sign of pronounced and progressing peritalar subluxation in patients with adult acquired flatfoot deformity. [ABSTRACT FROM AUTHOR]

Posterior tibialis tendon dysfunction is the most common cause of acquired flatfoot deformity in adults. It is most commonly caused by chronic tendinopathy with subsequent functional impairment from elongation or rupture and it is most often seen in patients with obesity, diabetes mellitus, hypertension, and systemic inflammatory diseases. Degenerative tears occur most often distal and posterior to the medial malleolus in the critical zone of hypovascularity. There is a characteristic deformity consisting of hindfoot valgus, forefoot abduction, loss of the longitudinal arch, and, with increasing hindfoot valgus, a compensatory forefoot supination. The diagnosis is usually clinical. There is medial pain and swelling, pain or inability to perform a single heel rise, loss of the medial longitudinal arch, hindfoot valgus, and forefoot abduction identified by a positive “too many toes sign.” It is classified from stages I through IV based on the amount and flexibility of deformity. Radiograph findings are consistent with flatfoot deformity. Magnetic resonance imaging is not necessary for the diagnosis. Initial treatment should be conservative using cast immobilization for acute pain and dysfunction, and orthotics in the subacute and chronic cases. Surgery is indicated only when conservative measures fail, and the goal is restoration of normal foot alignment. Surgical decision making is influenced by the amount of deformity, as well mobility of the joints. Particularly important is the assessment of forefoot supination. Procedures include FDL reconstruction, calcaneus osteotomy, and arthrodesis, including isolated subtalar fusion, talonavicular fusion, double arthrodesis, and triple arthrodesis. [Copyright &y& Elsevier]

Copyright of Der Orthopäde is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Irreparable sciatic nerve palsy is a cause of foot drop and resulting in absent or weak most of the muscles in leg. There may be dysfunctions of all tendons in the leg excepting Achilles tendon and plantaris tendon. The treatment of this atypical neurologic injury has not been defined. I reported a case of foot drop following irreparable sciatic nerve palsy in which there was a dysfunction of all tendons in leg excepting Achilles tendon and plantaris tendon. The medial gastrocnemius tendon and plantaris tendon were transferred into the anterior tibialis tendon, the extensor digitorum longus tendon and extensor hallucis longus tendon. The lateral gastrocnemius tendon was transferred into the peroneus brevis. Four months post-operative, he reported no pain and became capable of walking without the assistance of an orthosis or a crutch and without steppage gait. Anterior transfer of the tibialis posterior tendon was the preferred procedure. If no posterior tibial tendon function was presented, then in order of preference, the extensor hallucis longus, extensor digitorum longus, peroneal, flexor hallucis longus tendon, medial gastrocnemius, lateral gastrocnemius and plantaris tendon would be used. The atypical dysfunction of all tendons in the leg excepting Achilles tendon and plantaris tendon following irreparable sciatic nerve palsy was presented. Tendon transfer using medial gastrocnemius tendon, lateral gastrocnemius tendon and plantaris tendon seemed to be a good choice for treatment of this injury. It allowed reconstruction of a stable, painless, plantigrade foot. Case report. • Irreparable sciatic nerve palsy is one of the causes of foot drop. • It may be resulting in dysfunction of all tendons in the leg excepting Achilles tendon and plantaris tendon. • The treatment of this atypical neurologic injury has not been defined. • Tendon transfer using gastrocnemius tendon, plantaris tendon was a good choice for treatment of this injury. [ABSTRACT FROM AUTHOR]

Posterior tibial tendon dysfunction (PTTD) is an important cause of acquired pes planus that frequently observed in adults. Factors that play a role in the development of PTTD such as age-related tendon degeneration, inflammatory arthritis, hypertension, diabetes mellitus, obesity, peritendinous injections and more rarely acute traumatic rupture of the tendon. PTT is the primary dynamic stabilizer of medial arch of the foot. Plantar flexion and inversion of the foot occurs with contraction of tibialis posterior tendon, and arch of the foot becomes elaveted while midtarsal joints are locked and midfoot-hindfoot sets as rigid. Thus, during the walk gastrocnemius muscle works more efficiently. If the PTT does not work in the order, other foot ligaments and joint capsule would be increasingly weak and than pes planus occurs. We present a 10-year-old female patient diagnosed as PTTD and conservative treatment with review of the current literature. [ABSTRACT FROM AUTHOR]