Tenotomy





Definition

Tenotomy is the cutting of a tendon. This and related procedures are also called tendon release, tendon lengthening, and heel-cord release (for tenotomy of the Achilles tendon).


Purpose

Tenotomy is performed in order to lengthen a muscle that has developed improperly, or become shortened and is resistant to stretch.

Club foot is a common developmental deformity in which the foot is turned inward, with shortening of one or more of the muscles controlling the foot and possibly some bone deformity as well.

A muscle can become shortened and resistant to stretch when it remains in a shortened position for many months. When this occurs, the tendon that attaches muscle to bone can shorten, and the muscle itself can develop fibrous tissue within it, preventing it from stretching to its full range of motion. This combination of changes is called contracture.

Contracture commonly occurs in upper motor neuron syndrome following spinal cord injury; traumatic brain injury; stroke; multiple sclerosis; or cerebral palsy. Damage to the nerves controlling muscles lead to an imbalance of opposing muscle forces across a joint, which may allow one muscle to pull harder than another. For instance, excess pull from the biceps, unless opposed by the triceps, can bend the elbow joint. If the shortened bicep remains in this position, it will develop contracture, becoming resistant to stretching. Tenotomy is performed to lengthen the tendon, allowing the muscle to return to its normal length and allowing the joint to straighten.

When one muscle pulls much more strongly than its opposing muscle, it may cause the joint to become partially dislocated, which is called subluxation. Tenotomy is also performed to prevent or correct subluxation, especially of the hip joint in cerebral palsy.

Chronic pain or bone deformity may prevent a person from moving a joint through its full range of motion, leading to contracture.

Contracture also occurs in a variety of neuromuscular diseases, including muscular dystrophies and polio. Degeneration of one muscle can allow the opposing muscle to pull too hard across the joint, shortening the muscle.


Demographics

Tenotomy is performed in infants with clubfoot, and in older patients who develop contractures or subluxations from neuromuscular disease, the upper motor neuron syndrome, or other disorders.

Description

During a tenotomy, the tendon is cut entirely or partway through, allowing the muscle to be stretched. Tenotomy may be performed through the skin (percutaneous tenotomy) or by surgically exposing the tendon (open tenotomy). The details of the operation differ for each tendon.

During a percutaneous lengthening of the Achilles tendon, a thin blade is inserted through the skin to partially sever the tendon in two or more places. This procedure is called a Z-plasty, and is very rapid, requiring only a few minutes. It may be performed under local anesthesia.

More severe contracture may be treated with an open procedure. In this case, the tendon may be cut lengthwise, and the two pieces joined lengthwise to form a single longer tendon. This procedure takes approximately half an hour. This type of tenotomy is usually performed under general anesthesia.

If multiple joints are to be treated (for example, ankle, knee, and hip), these are often performed at the same time.


Diagnosis/Preparation

Patients requiring tenotomy are those with contracture or developmental deformity leading to muscle shortening that has not responded sufficiently to treatment with casts, splints, stretching exercises, or medication. Tests performed before surgery include determining the range of motion of the joint involved, and possibly x rays to determine if there is a bone deformity impeding movement or subluxation.

Patients undergoing general anesthesia will probably be instructed not to eat anything for up to 12 hours before the procedure.


Aftercare

After tenotomy, the patient may receive pain medication. This may range from over-the-counter aspirin to intravenous morphine, depending on the severity of the pain. Ice packs may also be applied. The patient will usually spend the night in the hospital, especially children with swallowing or seizure disorders, who need to be monitored closely after anesthesia.

Casts are applied to the limb receiving the surgery. Before the cast is applied, the contracted muscle is stretched to its normal or near-normal extension. The cast then holds it in that position while the tendon regrows at its extended length. Braces or splints may also be applied.

After the casts come off (typically two to three weeks), intensive physical therapy is prescribed to strengthen the muscle and keep it stretched out.

Risks

Tenotomy carries a small risk of excess bleeding and infection. Tenotomy performed under general anesthesia carries additional risks associated with the anesthesia itself.


Normal results

Tenotomy allows the muscle to stretch out, proving more complete range of motion to the affected joint. This promotes better posture and movement; and may improve the ability to walk, stand, reach, or perform other activities, depending on the location of the procedure. Pain may be reduced as well. Club foot is usually completely fixed by proper treatment. Contracture and subluxation may be only partially remedied, depending on the degree of muscle shortening and fibrotic changes within the muscle before the procedure.


Morbidity and mortality rates

Properly performed, tenotomy does not carry the risk of mortality. It may cause temporary pain and bleeding, but these are usually easily managed.


Alternatives

Tenotomy is usually recommended only after other treatments have failed, or when the rate and severity of contracture or subluxation progression indicates no other more conservative treatment is likely to be effective. Aggressive stretching programs can sometimes prevent or delay development of contracture.

See also Rhizotomy .


Resources

PERIODICALS

Robinson, R. "Fight Against Contractures." Quest Magazine (1996). http://www.mdausa.org/publications/Quest/q34contrc.html .

ORGANIZATIONS

Muscular Dystrophy Association. 3300 E. Sunrise Dr. Tucson, AZ 85718. (800) 572-1717. http://www.mdausa.org .

Richard Robinson

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?



Tenotomy is performed by an orthopedic surgeon. It is performed in a hospital.

QUESTIONS TO ASK THE DOCTOR


  • How will any pain be managed?
  • How long will the cast(s) stay on?
  • What will the physical therapy program be like afterward?

User Contributions:

Darcy Figurel
Report this comment as inappropriate
Jun 20, 2007 @ 7:19 pm
This was a very informattive piece. We have heard of the surgery but knew little about it. Our niece is 14 and has MILD CP. would she be a possible canidate for this. Thus far the have been trearing her with a leg/foot brace do too her toe walking.
Thank you,
Darcy Figurel
cj hegenbr
Report this comment as inappropriate
Dec 4, 2007 @ 8:08 am
pls help = last week i underwent a bicep tenotomy and was not given a cast. doctor also requested immediate physical therapy. thank you, still in alot of pain
Kenneth Streck
Report this comment as inappropriate
Sep 14, 2008 @ 8:20 pm
Hi,
I am a 35 yr old male with Mild CP, primarily affecting 1 side. My Achilles tendon is very tight leads to significant foot pain as I walk incorrectly on my toes. I am a very active individual. I work out 3 times a week and hike as much as I can. Currently this is preventing me from even going to the gym as I limp so badly from now foot, knee, hip pain. I stretch my tendon as much as I can, but in a short time it will become very tight. I would like any and all information on a tendon release as an adult who is active and any details on it's success/failures. Thank you very much,
Ken
Lorri
Report this comment as inappropriate
Jan 5, 2009 @ 9:21 pm
My son (11 yrs. old) has mild CP & walks on the side of his foot. Last March he had a heel release and lengthening the tendon. We just found out today that he needs to have more surgery. The doctor mentioned Dwyer Osteotomy and another procedure dealing with the tibual and it involves a "Z" - not much help I know. Can you help me understand these in anyway. As of right now he is schedule to have surgery next month.

Thanks!
Lorri
Ron
Report this comment as inappropriate
May 7, 2009 @ 10:10 am
Had a tendonesis done and have pian at anchor site and bicep now they suggest a tenotomy will this help and what arm and hand functions will be lost? Thanks
Report this comment as inappropriate
May 17, 2010 @ 3:15 pm
I am an adult male who has had tight heel cords all my life. Nono of my dr's ever really mentioned that they could be a real problem - just a passing comment that I had extremely tight heel cords. About a year ago I complained to my current PCP about ankle and knee pain. After x-rays of the ankle he sent me to an orthaeopedic dr. This Dr said that the ankle and kne problems, and possibly cervical spine problems were related to the tight heel cords. He was amazed that I had not had major issues before, and even asked if I had to have special shoes as a child. He sent me to Physical Therapy. THe therapist said I had the tightest heel cords he had ever seen - could not even get me to 0 degrees. After several weeks of PT, I was at about 5 degrees. Starting to have knee and ankle pain again - and neck pain. When I first had the neck pain a few years ago I was sent to a neurologist - one of the dr's that commented on the tight heel cord. After a few months of being treated by him I told him that I bought new shoes and my neck pain was much better - he did not believe me. Adding that incident to the other stuff the ortho doc said is when I came to the conclusion that the two were related.

Long way to the well for this quesion - at my age, would surgery be of benefit?
Report this comment as inappropriate
Jun 17, 2010 @ 2:02 am
My child is 6 yrs old. As a result of CP he is currently walking on his toes (without any pains). The Doctors advised that he need tendo release operation. My self and my wife are worried because of the risk involved. Kindly advise me.
Report this comment as inappropriate
Jul 3, 2010 @ 12:12 pm
my 2year old son is waiting for a date for the operation for lenghthing the tendons in both feet as he is a tip toes walker, we have spoke with the surgeon, yet didnt get the chance to ask questions, can you tell me what the operation entails ?,how long the operation will take ? will he be in alot of pain ?how long will he be in casts ?will he need physio afterwards ?and does the operation have a good chance of stoping the tip toe walking ?

kind regards
julie
Report this comment as inappropriate
Jul 23, 2010 @ 12:00 am
This article gave me clear facts. Thanks. After 53 years of having mild CP, I am having heel cord lengthening surgery done on the foot with the highest heel. I wonder, after the procedure and the cast(s) and PT, if it really is possible for my foot and ankle to be at 90 degrees for the first time that I can remember. How much improvement is possible and what is my part in making the results as positive as possible?
Report this comment as inappropriate
Oct 26, 2010 @ 5:05 am
Because of a severe stroke I suffered I had to have tendon lengthening operation. I was told I would have intensive physic therapy. I have had none. The op was a success but I am concerned that no physical therapy is detrimental to my foot. Can you help with this concern?
Paul
Report this comment as inappropriate
Nov 2, 2010 @ 8:20 pm
I am 46 and had a blodd clot with compartment syndrom in one of my legs 5 months ago. I went through three months of PT for heel chord contracture with minimal results. My heel was 3 inches off the ground. I had the percuntaneous lengthening process last week. I also suffer from a host of other circulartory issues. So far the only problem I have had is pain. The non-weight bearing cast is to be on for two weeks then I switch to a walking cast. not sure when I am to start PT again. Hopefuly this will resolve my toe walking and foot pain.
Report this comment as inappropriate
Oct 17, 2011 @ 1:13 pm
My daughter is 7 years old. She has mild CP and her only difficulty is toewalking. I have done physiotherapy, which helped for while but could not continue it. She is wearing brace on that leg now. I want to correct this problem. I consulted so many doctors, some advised me botox and some zplasty. PPLLLEASE AS A MOTHER, I am very concerned for my daughter. Please guide me what is better for her botox or surgery?
Joellen Emmerick
Report this comment as inappropriate
Jan 17, 2012 @ 9:21 pm
I would love to hear from others about their ankle issues. I am 42 and have been dealing with my right ankle rom issues. I don't know if this is due to a knee injury or if I too had a mild form of CP. I am not sure since I don't remember having walking issues before. Thanks!
Joellen
Report this comment as inappropriate
Feb 2, 2012 @ 9:21 pm
Did anyone here try serial casting?
Looking for information.
Deborah
Report this comment as inappropriate
Feb 24, 2012 @ 7:19 pm
I am an adult with mild CP. I am a veterinary practitioner now so I understand the dynamics behind the bio mechanics. I had "heal-cord lengthening" twice as a child. I am able to put my foot down and achieve neutral position. I however, cannot walk properly with my heel to the ground first, then rolling up on the ball of the foot on that side. So, It helps the gait because you are not on your toes, but the gait is still not normal. I have mild contracture in my left elbow and I plan on getting help in that department with physical therapy. Now that I have 3 children of my own, I can only imagine the stress that you as parents have with deciding. My heel-cord lengthening was done 38 years ago. It was done twice because I was too young the first time and not yet walking. It re-contracted. The second procedure came with a staph infection. I still did great. For the sake of quality of life, you really need to discuss pros and cons with your physician. I cannot imagine not having the procedure done and I am grateful it happened. Recovery time was easy and there is little risk.
judy
Report this comment as inappropriate
May 8, 2012 @ 11:11 am
My two year old grandaughter will be having her tendons cut for the second time the first time she was six days old. She will be put back into cast for a 2 week period this will be her fourth round of casts, she has been walking in the previous casts. Will she be able to walk after the tendons are cut?
arika
Report this comment as inappropriate
Aug 11, 2012 @ 3:03 am
Just got a 8/10 toe flexor tenotomy done today. This was very informative before my operation and I did appreciate the information! I do think that those considering this operation need to keep in mind that it is pretty painful and if done on feet, can be very limiting to your mobility. Both of my legs are in casts for the next month. My surgery was very quick, and smooth, and was also an outpatient surgery, since it is fairly minor. And right now, I wish I could have more pain medication! Ouchie!
caroline greengrass
Report this comment as inappropriate
Aug 13, 2012 @ 2:14 pm
I had flexor tenotomies done on both feet done at the same time, 2nd and 3rd toes, in March 2012 and it was the worst mistake of my life, I was not told at the time that I would not now be able to grip the toes, I don't now walk properly I cannot go onto tip toes, and they are now saying I have have some neurological damage. In my opinion if you have curly toes like I did and are considering this operation, I would think again, as my life is not the same anymore :((
Sherri
Report this comment as inappropriate
Sep 12, 2012 @ 12:12 pm
My daughter is 38 and severely handicapped with CP and brain damage. She is to undergo tendon surgery on her elbows/wrists/one foot and her hands the end of the month. I am very concerned about the pain level she will experience as she can't talk. Does anyone have any info to provide? Thanks so much for your help.
Brad
Report this comment as inappropriate
Sep 25, 2012 @ 11:23 pm
@Sherri
When you cut tendons, there is virtually always at least moderate pain involved for some time...the length of time depending on the procedure, location, any manipulation performed post-surgery, etc. Physical therapy will also likely be required in order to stretch those tendons that need lengthening. After the procedure(s), pain management will be necessary probably for a number of days (usually through the use of oral opoid pain meds...hydrocodone is commonly prescribed along with prescription strength ibuprofen in case the pain is manageable with a non-steroid analgesic). Ice packs are also helpful to control swelling.

Bottom line is that it does definitely hurt. However, especially with someone with special needs, physical therapy is crucial to a successful outcome. It won't be a lot of fun, but stick with it. Do everything the therapist requests, and when it hurts, treat accordingly. Good luck!
George
Report this comment as inappropriate
Oct 6, 2012 @ 9:21 pm
My wife has suffered from Dystonia in one extremity (the left foot). Deep Brain Stimulation has worked but the foot still is turned due to contraction. A tenotomy or achilles release is recommended. Awaiting a scheduling of this procedure.
Brenda
Report this comment as inappropriate
Oct 24, 2012 @ 11:23 pm
My special needs son is having heal cord lengthening surgery next week. He has cp and autism. He is unable to speak. Wondering and concerned about how much pain he will be in. He is 16 years old and his toes are now deformed from toe walking. I can hear his bones making crunching sounds now as he gets out of bed and he is losing some mobility. I don't know anyone who has had this done and wondered about success rate and pain management. Is this the right decision for him. Hoping to improve his quality of life but worried that something might go wrong and lose his ability to walk completely.
ramone
Report this comment as inappropriate
Nov 7, 2012 @ 5:05 am
how much does procedure cost , i have muscle dystropy , i stand on my tip toes about 3 inches off ground , heel dont touch ground ,i can get around good but i'm starting to get knee , back and neck pain , so i want surgery but the docs are not comfortable with me having the surgery cause i move around so good and they dont want to do it , cause they worried that it may cause me problems , but i'm getting tired of standing on my tip toes , i'm 29 yrs old most people dont notice it but i hate it , what should i do ?
Joyce
Report this comment as inappropriate
Dec 30, 2012 @ 8:20 pm
I had a bunion surgery 4 weeks ago and the doctor also lengthened my big toe tendon. Now my toe will not raise at all and the tip is floppy. I am so depressed about this. Can the tendon be shortened again to fix this?
Report this comment as inappropriate
Feb 11, 2013 @ 3:15 pm
I'm a pátient with severe Generalized Dystonia. I've had successful DBS Surgery. It enabled me to move out of the nursing home I'd lived in for 7years! There was one area that was not helped and continues to get progressive worse. The flexor tendons, especially the R. Hand, the index and ring fingers are severely contracted. My Dr. Is concerned because there seems to be a problem developing with the skin on the palm of the hand. Despite washing it regularly with Ketoconzole 2%, there is often a terrible odor from where the long fingernails, which are almost impossible to trim, are digging into the skin. The contracture is so bad I can't bend the 1st joint back in order to trim it. I'm left with trying to find a way to bend the nail back and forth so that the nail breaks off. I kid you not when I tell you I've broken off pieces of my index finger that measured 13/16 inches long. Just for the record, I receive injections of 500 units of Botox in my forehead, eyebrow, eyelids, under the eyes, my checks, jaws, and Mastator neck muscles and both Bi-cepts. This has been very helpful in control the Blepospasms (sp). Without it I become functionally blind and my jaw is pulled almost 1 in. Back making it almost impossible to talk or chew! We tried using Botox on the Ulnar and Medial nerves in my forearm and wrist. This was counter-productive in that it weakened the muscles in my wrist to the point that it was almost impossible to control my silverware. My Hand Docttor has told me I'll need tendon surgery sooner than later. Are there any new surgical techniques, that have had positive outcomes for fixing flexor tendon contracture?
Report this comment as inappropriate
Apr 13, 2013 @ 4:04 am
hi my 19 month old daughter is unable to walk as she is unable to put her feet flat and her heels aren't fully developed , we started physio therapy but they don't believe it will be enogh and have mentioned operations , csats ect , can anyone give me some advice or info please
Lilly
Report this comment as inappropriate
Apr 26, 2013 @ 12:12 pm
My 2yr old son had tenotomy three weeks ago. he walks with the cast, but with his knee bent forward and his toes slightly up. yet to walk on his flat foot. the doc says he should remain in the cast for another 3wks. he asked that I train him to walk on his flat foot while in the cast. I have been trying but its difficult he can only stand on his flat foot. Pls advice on what physical therapy I should employ.
eva johnson
Report this comment as inappropriate
Oct 9, 2013 @ 8:08 am
I am a 27 year old female. I got compartment syndrome and was in the hospital for a while and my foot got the foot drop. I have no motor skills in my left foot and it is stuck and stiff. It will not plant on the floor, i have to use crutches to walk. I had a halo on my foot to try and raise it up but it raised and dropped again. Is this tendon release or tendon stretching appropriate to try and raise it back up?
Rachael
Report this comment as inappropriate
Oct 13, 2013 @ 6:18 pm
Hi my name is Rachael & I had the tendon release in grade 10 now that I have growing my foot is back to tge usual foot dropping the toe on the ground & I'm very right in my ankle & foot & I'm turning 23 this week & my dr thinks I need another tendon heel realese so I am waiting for a specialist date to see a orthapidic surge nan way my question for you is has an of you had it done 2 before ?
Marty Collier
Report this comment as inappropriate
Nov 27, 2013 @ 12:12 pm
My nineteen year old daughter had fibula free flap surgery three years ago. As a result, she developed contracture of all toes on that foot. Physical therapy did not help, so last month she had tenotomy, but only on second and third toes even though big toe was most distressed and painful. She had general anesthesia, incision on bottom of both toes, and metal pins inserted through center of each toe. My question is, was this much procedure really necessary. When we asked about big toe on day of surgery, Dr. said he couldn't do at this time because he did not have the necessary screws available on that day. I am ignorant. Only today I discovered that less invasive procedures are possible. Your thoughts on this, please. Thank you.
Caroline Singh
Report this comment as inappropriate
Apr 22, 2014 @ 10:22 pm
What type of physio is recommended after 6 percutaneous tenotomies?
Dee
Report this comment as inappropriate
May 7, 2014 @ 12:12 pm
How many toes can be repaired at one time and can both feet be done at the same time.
All of my toes are curled and flexable except the great toe.
yogendra dubey
Report this comment as inappropriate
Jun 4, 2014 @ 2:02 am
Thanks for sharing such a detailed information on Tenotomy. Truelly appreciate.

Comment about this article, ask questions, or add new information about this topic:

CAPTCHA


Tenotomy forum