Stage II posterior tibial tendon dysfunction encompasses a wide range of patients with varying degrees of deformity and function. The spectrum of patients can be difficult to treat with a single surgical approach, as evidenced by the wide range of techniques present in the literature. Severity of the deformity, patient functional level, age, and comorbidities must be considered to determine the best course of treatment. This article examines when fusion versus reconstruction is the appropriate treatment of patients with severe stage II posterior tibial tendon dysfunction and its subclassifications.