1. Posterior Tibial Tendon Dysfunction
The Role of
Extra-Osseous TaloTarsal Stabilization
Michael E. Graham, D.P.M., F.A.C.F.A.S.
Inventor, HyProCure
Founder: GraMedica, Graham International Implant Institute
Private Practice: Shelby Township, Michigan, USA

2. Why?
• We need to take a critical look at this very
common condition.
• We need to take action to prevent the
progression of the disease progression.
• Why does PTTD occur?
• What are the best viable treatment options.

3. Patient presents with symptoms or concerns
due to excessive rearfoot motion.
Is this normal or is this pathologic?
This foot has a mechanical disadvantage.

4. This excessive pronatory motion has been
named as the most common etiology of the
majority of foot & ankle conditions.

5. This patient was not born with her
foot looking like this.
This is the result of years of “conservative” treatment.
Her specialists thought that they were “doing no harm”
in reality they have caused great harm.

6. What should we do with this
patient’s foot?

7. If we do nothing (conservative care) it will
most likely end up like this.

8. Getting back to basics
It all begins with a stable
osseous foundation.
The average person takes between
6,000 to 10,000 steps a day,
depending on their activity level.

9. Normal TaloCalcaneal Position

10. Osseous alignment determines how/where
the transfer of the weight from the body above
transfers through the foot to the ground below.
This is how the osseous foot structures
should be aligned.

11. It all begins with the
TaloTarsal Mechanism

12. Normal TaloTarsal Alignment
• Talus is sitting on top
of the calcaneus.
• The articular facets are
aligned.
• The two bones are
balanced.
• Sinus tarsi is in its
natural open position.

13. TaloTarsal Mechanism Talus acting on the
articulations with the
calcaneus and navicular
Talus
Navicular Facet
Calcaneus
Posterior Facet
Middle & Anterior Facet

14. TaloTarsal Motion:
You cannot talk about the motion of the subtalar joint without
also discussing the talonavicular joint as even though there are 4
separate anatomical joints they function as
one.

15. The articulations of the
talus on the
tarsal mechanism
With the TTM in
NEUTRAL POSITION
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16. Malposition of the
posterior
articulation results
in malposition of
the middle/anterior
facets and also
talonavicular joint.
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17. Ligament Support
• Ligaments function as a
supportive tissue to
assist in the alignment
of the osseous
structures.
• The alignment of the
talotarsal mechanism is
so important that there
is a major complex of
supporting ligament
attachments.

18. Remember
• The talus is the only
“foot” bone that does
not have a tendon
attachment.
• Its motion is dependent
on the articular facets of
the tarsal mechanism,
capsular and ligament
tissues.

19. Ligament
Contains
mechanicoreceptors to
send a signal to the
CNS which in response
sends a signal to the
muscle to contract to
provide support to the
joint.

20. Tibialis Posterior Muscle/Tendon Complex
• Functions to
supinate the foot.
• Strongest supinator
of the mid-foot
• Has to over-come
pronatory forces to
lift the foot for toe-
off.

21. Additional Important Supportive
Structures to Tibialis Posterior Function
• Tendon sheath- helps the tendon glide behind the medial
malleolus and within the flexor retinaculum.
• Flexor retinaculum- keeps the tendon aligned for
optimum function.

22. Tibialis Posterior Tendon Insertions
Primary insertion in the navicular
tuberosity and secondary insertions
plantar aspects of the medial column of
the foot.

23. THIS IS VERY IMPORTANT
Tibialis posterior inserts into the
medial/plantar aspect of the mid-foot
to supinate the medial column at late
mid-stance to toe off.

24. Tibialis Posterior Tendon
Dysfunction
Why do good tendons go bad?

25. Every “effect”
has
its “cause”

26. There is an underlying etiology to every
symptom.
The goal is not to solely treat the symptom
but to eliminate
the cause.

27. People are not born with
pathologic tendons.
At birth our tendons are very
healthy.

28. However, if the talotarsal
mechanism is not properly aligned
as a child a good healthy posterior
tibial tendon will slowly but surely
continue to become diseased.

29. Let’s take a closer look at the
talotarsal mechanism and how it
can significantly implant the
function of tibial posterior

30. Normal TTM
Remember- talus is sitting on top of
the calcaneus, sinus tarsi is open, and
there is a normal cyma.
The articular facets of the talus are
perfectly aligned with the articular
facets of the calcaneus and navicular.

31. Abnormal TTM
The talus slid off its normal position
off of the calcaneus. The articular
facets are not aligned. Sinus tarsi is
partially collapsed. The talus is
plantarflexing on tarsal mechanism.
Excessive abnormal forces are acting
on the medial column of the foot.

32. TaloTarsal Instability

33. The problem isn’t with the calcaneus or the bottom
of the foot.
Its talar position on the tarsal mechanism.
RCSP NCSP

34. Due to abnormal talar motion on the
tarsal mechanism excessive strain is
placed on the medial column.

35. Abnormal TTM
• This is not just a
sagittal plane
deformity but also
transverse.
• Excessive motion in
one plane of the
talotarsal mechanism
results in excessive
motion in all 3
cardinal planes.

36. Navicular Drop-
Normal TTM Abnormal TTM

37. Navicular Drop
Resting Balanced
Stance TaloTarsal
Joint
The navicular is forced out of position due to the excessive abnormal
forces from the talar displacement. This is a dynamic deformity occurring
with every step taken.

38. Navicular Drop
• Imagine that during the walking cycle with no weight on the
talotarsal mechanism- it is in alignment. At heel strike the
talus quickly displaces on the tarsal mechanism, it partially
dislocates anteriomedially to push the navicular down which
is forced to “drop”.

39. Navicular Drop
• Not only is the
navicular pushed
forward it is also
forced plantar.
• The talus is
responsible to transfer
the entire weight of
the body from the leg
above to the foot
below.

40. Use your imagination.
Do you think will have a negative effective on the posterior tibial tendon? With
every step excessive abnormal forces are acting on the posterior tibial tendon.

41. Effect of navicular drop to the
tibialis posterior tendon

42. Posterior Tibial Tendon Strain

43. Posterior Tibial Tendon Strain

44. Ill-effects of Excessive Strain to a tendon.
• There is an
entrapment of the
tendon within the
flexor retinaculum
just like there is
with entrapment of
the tibial posterior
nerve.

45. Posterior Tibial Tendon
Compression
• Flexor retinaculum turns from
a friend to an enemy when the
talus slips off its normal
alignment on the tarsal
mechanism.

46. Normal Cylindrical Shaped Tendon

47. Abnormally Shaped Tendon
due to compression

48. Tendon Strain
Normal
Abnormal

49. Effect of navicular drop
on tibialis posterior.
The poor tendon doesn’t have a chance, think about the damage being inflicted
thousands of times a day, day after day, week after week, month after month, year
after year, decade after decade.

50. Talus slips off the calcaneus resulting in partial
dislocation of the talotarsal mechanism.
This forces the navicular to eventually “drop”.
Tibialis posterior tendon is immediately
strain/elongated which decreases blood flow within
the tendon.
The strain is continually placed on the tendon until
more and more damage ensues.

51. What are the treatment options for
these patients?
• Nothing?
• Orthotics?
• Injections?
• Oral meds.?
• External braces?
• Calcaneal osteotomy?
• Talonavicular
Arthrodesis?
• Triple Arthrodesis?

52. Foot Orthotics
• Cannot stabilize the talus
• Cannot prevent the excessive talar motion
• Have to be used in shoes
• Have to find shoes to fit the device
• Not covered by most insurance companies
• Gives a false sense of correction
• Provides only minimal support
• The list goes on …..

53. Medial Displacement Osteotomy?
Just doesn't make a lot of sense.
There isn’t a deformity within the
calcaneus its above…the partial
displacement of the talus on the
Tarsal mechanism-remember.

54. Sinus Tarsi

55. Extra-Osseous, Extra-Articular TaloTarsal
Stabilization Devices
Talus Type I Type II
Laterally
anchored
HyProCure
Medially Anchored

56. Anatomically Shaped
Biomechanically Functional

57. Comparison

58. “Lifted” Navicular = Decreased strain on Tib. Posterior

59. Before/After

60. Closer look- repositioned talotarsal mechanism.

61. Right foot isolated E.O.T.T.S.
procedure with HyProCure.
BEFORE
Not Yet AFTER

62. 3 days post op- Right foot
Before
After

63. Extra-Osseous TaloTarsal Stabilization
Why Not?
• It addresses the deformity
• Completely reversible
• Not dependent on external factors-shoes
• Can be performed on a wide age-range of
patients
• Fast recovery, dependable results

64. The goal
• Early ambulation
• Effective correction
• Least amount of down time
• Least amount of complications
• Return to normal function
• Do no harm
• Why wait until they need a major
rearfoot reconstructive procedure?

65. Fix the cause,
don’t ameliorate the symptom(s).

66. What would YOU rather have
done to your foot?

67. HyProCure®
• FDA 510(k) Sept 2004, CE 2006
• Routinely used in pediatrics, adults, geriatrics.
• Can be a stand alone or used in conjunction
with other surgical procedures (depending on
secondary deformities)
• Thousands have been successfully placed
globally
• Placed in athletes of almost every sport

68. Extra-Osseous
TaloTarsal Stabilization
• When orthotics don’t give enough
correction
• Prior to more radical rearfoot surgery
• Think
• E.O.T.T.S.
• There are limitations…foot must be
flexible.

69. HyProCure
Please visit:
www.hyprocure.com
For further information