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Is Tendon Lengthening Underused for Diabetic Foot Problems?

J. Monroe Laborde, MD, MS

Diabetes mellitus causes sensory and motor neuropathy.1 Neuropathy in patients with diabetes results in decreased protective sensation and tendon imbalance.1,2 Tendon imbalance, especially Achilles or gastrocnemius-soleus tightness, causes increased mechanical stress in the foot.3,4 This stress can cause foot pain and calluses, which can progress to forefoot ulcers.3 Less commonly, the increased stress in the foot causes the bone and ligaments of the foot to fail before the skin, resulting in the arch collapse of Charcot foot.5 Arch collapse can progress to plantar bony prominence and then midfoot ulceration.5 This increased stress in the foot can be decreased by tendon lengthening, which can resolve foot pain and ulcers.5,6

Foot ulcers commonly become infected and can lead to amputation.7 Approximately 85% of patients with diabetes who have amputations have foot ulcers.7 Healing foot ulcers, preventing their recurrence, and preventing infection can prevent amputations in patients with diabetes. Foot ulcer treatment consists of managing infection, arterial problems, and high mechanical stress in the foot. Decreasing mechanical stress in the foot can be accomplished by methods such as shoe modification, walkers, total contact casts, and tendon lengthenings.3 Tendon lengthening procedures require less patient compliance than other methods.

Achilles tendon lengthening and gastrocnemius-soleus recession (GSR) are primary or adjunctive treatments to optimize healing of foot ulcers.2,5,6,8–12 Treatment of foot ulcers with tendon lengthening has good support in the literature, both for healing ulcers and for preventing recurrence.2,5,6,8–12 Some authors have also recommended tendon lengthening to prevent forefoot ulcers in at-risk patients.3,6,13 For the Charcot foot, there is also evidence that primary GSR contributes to ulcer healing and mitigates progression of deformity, ulceration, and amputation.5 A more detailed literature review of the benefits of tendon lengthening for diabetic foot problems was previously published in this journal.6

Plantar toe ulcers are often treated with percutaneous toe flexor tenotomies.6,10 Ulcers plantar to the metatarsal heads are treated with GSR.6,9 Posterior tibialis tendon lengthening is added to GSR for ulcers plantar to the fifth metatarsal head or base, and peroneus longus lengthening is added for ulcers plantar to the first metatarsal head.6,9 Midfoot ulcers are treated with GSR.6,11 Removal of plantar bony prominence percutaneously with a burr can also be helpful. Posterior tibial lengthening can be added for lateral midfoot ulcers, and peroneal tendon lengthening can be added for medial midfoot ulcers.

Gastrocnemius-soleus recession results in much fewer heel ulcers than does Achilles tendon lengthening.6,13–15 Tendon lengthening heals more ulcers faster than wound care and total contact casts with fewer complications and a much lower recurrence rate.6,8,16–18

High mechanical stress from a tight Achilles tendon commonly causes foot pain.6 Foot pain from Achilles tendinitis, plantar fasciitis, midfoot arthritis, and metatarsalgia can also be relieved by GSR.6 In patients with diabetes, GSR has the advantage over other surgical treatments that it may prevent foot ulcers and Charcot foot.5,6

Patients with diabetes have a higher complication rate with foot and ankle surgery.19 Tendon lengthening in the calf has fewer complications, including ulcers and amputation, than bony procedures in the foot.2,6,9–12,14,15,20,21 Tendon lengthening (GSR) can prevent foot ulcers and can probably prevent Charcot foot from developing in the future.3,5,6,13 Tendon surgery proximal to the foot seems especially preferable to bony procedures in the foot for patients with diabetes, smokers, and patients with foot ulcers, with infection, and/or without pedal pulses.

Belatti and Phisitkul22 noted a 47% decrease in major amputations in Medicare patients with diabetic foot ulcers between 2000 and 2010. In the same period, Achilles tendon lengthening increased 89% and GSR increased 575%. These authors believed that the main reason for the decrease in major amputation was the increase in tendon lengthening. Cychosz et al23 recently performed a literature review of diabetic foot ulcer treatment, giving the highest recommendation (supported by strong evidence) to tendon lengthening.

Available evidence seems to indicate that tendon lengthening is the most effective treatment for plantar diabetic foot ulcers with the least complications.5,6 Tendon lengthening can also relieve foot pain, prevent ulcers and Charcot foot, and stop progression of Charcot arch collapse to rocker bottom foot, midfoot ulceration, and amputation.5 Although tendon lengthening may be combined with other modalities, it should be performed as soon as possible to promote rapid healing before the ulcer becomes infected and to better prevent new, recurrent, and transfer ulcers, progression of deformity, and amputation.5,6 This author recommends tendon lengthening as an initial treatment for diabetic plantar forefoot and midfoot ulcers and Charcot of the midfoot.5,6


  1. Rosenbloom AL, Silverstein JH. Connective tissue and joint disease in diabetes mellitus. Endocrinol Metab Clin North Am. 1996;257(2):473–483. doi:10.1016/S0889-8529(05)70335-2 [CrossRef]
  2. Lin SS, Lee TH, Wapner KL. Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: the effect of tendo-Achilles lengthening and total contact casting. Orthopedics. 1996;19(5):465–474.
  3. Armstrong DG, Stacpoole-Shea S, Nguyen H, Harkless LB. Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg Am. 1999;81(4):535–538. doi:10.2106/00004623-199904000-00011 [CrossRef]
  4. Lavery LA, Armstrong DG, Boulton AJDiabetex Research Group. Ankle equines deformity and its relationship to high plantar pressure in a large population with diabetes mellitus. J Am Podiatr Med Assoc. 2002;92(9):479–482. doi:10.7547/87507315-92-9-479 [CrossRef]
  5. Laborde JM, Philbin TM, Chandler PJ, Daigre J. Preliminary results of primary gastrocnemius-soleus recession for midfoot Charcot arthropathy. Foot Ankle Spec. 2016;9(2):140–144. doi:10.1177/1938640015607051 [CrossRef]
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  7. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990;13(5):513–521. doi:10.2337/diacare.13.5.513 [CrossRef]
  8. Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers: a randomized clinical trial. J Bone Joint Surg Am. 2003;85(8):1436–1445. doi:10.2106/00004623-200308000-00003 [CrossRef]
  9. Laborde JM. Neuropathic plantar forefoot ulcers treated with tendon lengthenings. Foot Ankle Int. 2008;29(4):378–384. doi:10.3113/FAI.2008.0378 [CrossRef]
  10. Laborde JM. Neuropathic toe ulcers treated with flexor tenotomies. Foot Ankle Int. 2007;28(11):1160–1164. doi:10.3113/FAI.2007.1160 [CrossRef]
  11. Laborde JM. Midfoot ulcers treated with gastrocnemius-soleus recession. Foot Ankle Int. 2009;30(9):842–846. doi:10.3113/FAI.2009.0842 [CrossRef]
  12. Dayer R, Assal M. Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing: a prospective cohort study. J Bone Joint Surg Br. 2009;91(4):487–493. doi:10.1302/0301-620X.91B4.21598 [CrossRef]
  13. van Netten JJ, Price PE, Lavery LA, et al. International Working Group on the Diabetic Foot. Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. Diabetes Metab Res Rev. 2016;32(suppl 1):84–98. doi:10.1002/dmrr.2701 [CrossRef]
  14. Rush SM, Ford LA, Hamilton GA. Morbidity associated with high gastrocnemius recession: retrospective review of 126 cases. J Foot Ankle Surg. 2006;45(3):156–160. doi:10.1053/j.jfas.2006.02.006 [CrossRef]
  15. Takahashi S, Shrestha A. The Vulpius procedure for correction of equinus deformity in patients with hemiplegia. J Bone Joint Surg Br. 2002;84(7):978–980. doi:10.1302/0301-620X.84B7.12905 [CrossRef]
  16. Margolis DJ, Kantor J, Berlin JA. Healing of diabetic neuropathic foot ulcers receiving standard treatment: a meta-analysis. Diabetes Care. 1999;22(5):692–695. doi:10.2337/diacare.22.5.692 [CrossRef]
  17. Saltzman CL, Zimmerman MB, Holdsworth RL, Beck S, Hartsell HD, Frantz RA. Effect of initial weight-bearing in a total contact cast on healing of diabetic foot ulcers. J Bone Joint Surg Am. 2004;86(12):2714–2719. doi:10.2106/00004623-200412000-00019 [CrossRef]
  18. Guyton GP. An analysis of iatrogenic complications of total contact cast. Foot Ankle Int. 2005;26(11):903–907. doi:10.1177/107110070502601101 [CrossRef]
  19. Myers TG, Lowery NJ, Frykberg RG, Wukich DK. Ankle and hindfoot fusions: comparison of outcomes in patients with and without diabetes. Foot Ankle Int. 2012;33(1):20–28. doi:10.3113/FAI.2012.0020 [CrossRef]
  20. Weiman TJ, Mercke YK, Cerrito PB, Taber SW. Resection of the metatarsal head for diabetic foot ulcers. Am J Surg. 1998;176(5):436–441. doi:10.1016/S0002-9610(98)00235-9 [CrossRef]
  21. Fleischli JE, Anderson RB, Davis WH. Dorsiflexion metatarsal osteotomy for treatment of recalcitrant diabetic neuropathic ulcers. Foot Ankle Int. 1999;20(2):80–85. doi:10.1177/107110079902000203 [CrossRef]
  22. Belatti DA, Phisitkul P. Declines in lower extremity amputation in the US Medicare population, 2000–2010. Foot Ankle Int. 2013;34(7):923–931. doi:10.1177/1071100713475357 [CrossRef]
  23. Cychosz CC, Phisitkul P, Belatti DA, Wukich DK. Preventative and therapeutic strategies for diabetic foot ulcers. Foot Ankle Int. 2016;37(3):334–343. doi:10.1177/1071100715611951 [CrossRef]
J. Monroe Laborde, MD, MS

The author is from the LSU Health Sciences Center and the University Medical Center New Orleans, New Orleans, Louisiana.

The author has no relevant financial relationships to disclose.

Correspondence should be addressed to: J. Monroe Laborde, MD, MS, 3434 Prytania St, Ste 430, New Orleans, LA 70115 ( jlabo1@lsuhsc.edu).


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