We had a couple of cases of posterior tibial tendon dysfunction (PTTD) today. Both older patients; both will be scheduled for surgery; both should have had more aggressive orthotic therapy sooner. PTTD is a very disabling condition if it is not caught early enough. It almost always progresses to the need for a surgical reconstruction if not caught early. Both these ladies are not the best surgical candidates, but with the surgery, their ability to ambulate will be severely impaired with other consequences on the health and well-being. That is going to impact in their quality of life.