Is Tendon Lengthening The Best Treatment For Diabetic Foot Ulcers?

J. Monroe Laborde, MD, MS

   Treatment of ulcers plantar to metatarsal heads with resection of the metatarsal head, metatarsal osteotomies and partial foot amputation all have high complication rates, including frequent transfer ulcers and amputation of the entire foot.27,31,32 Tendon lengthening heals more ulcers with fewer complications including fewer transfer ulcers and fewer amputations.2,16-28

   Tendon lengthening appears to be an effective treatment and is my treatment of choice for diabetic toe ulcers and ulcers plantar to metatarsal heads and the midfoot.2,16-28 If ulcers recur, one can repeat tendon lengthening with good success.17,24,25 Tendon lengthening also helps heal transmetatarsal amputations and arterial forefoot wounds.18,38-47

Can Tendon Lengthening Have An Impact For Charcot Foot?

In one study on Charcot arthropathy, researchers noted that 36 percent of patients who had non-operative treatment had a progression of the deformity and 37 percent of patients treated with conservative care went on to ulceration.48 Tendon lengthening (gastrocnemius-soleus recession) heals most midfoot ulcers and frequently prevents recurrence and progression of the deformity of Charcot arthropathy.17

   For these reasons, the recommendation that one use tendon lengthening (gastrocnemius-soleus recession) as the initial offloading treatment for Charcot arthropathy seems reasonable.49 In the few patients in whom tendon lengthening via gastrocnemius-soleus recession does not heal midfoot ulcers, or if the foot is unstable or too deformed for custom shoes and inserts, then surgeons can still perform bony procedures (exostectomy or fusion) later.

Further Insights On Tendon Lengthening And Gastroc Recession

General contraindications to Achilles lengthening and gastrocnemius-soleus recession are plantar heel ulcers, extensive necrosis and/or infection that necessitates amputation of the entire foot.

   Increased stress in the foot can also cause deformity and foot pain including corns, calluses, clawtoes, plantar fasciitis, posterior tibial tendinitis, arch collapse, foot and ankle arthritis, Charcot arthropathy, Achilles tendinitis, metatarsalgia, and first metatarsophalangeal arthritis.4,6-8,11,12,17,50-57 Tendon lengthening can help address foot pain and deformity from these conditions.4,6,7,11,14,27,47,50-56 Patients with diabetes have a higher complication rate with foot and ankle surgery.58 Tendon lengthening via gastrocnemius-soleus recession has an advantage over most other surgeries for foot pain in patients with diabetes since it has a low complication rate and can also prevent foot ulcers from developing in the future.8,29,30

How Tendon Lengthening Stacks Up When It Comes To Evidence-Based Medicine

Most of the literature on the treatment of diabetic foot problems involves case series and personal opinion. The evidence for tendon lengthening for foot ulcers plantar to the metatarsal head includes a Level I study.19 There are also Level II studies as well as Level IV studies for tendon lengthening for ulcers plantar to the metatarsal head.2,16,21,23,24,26

   There is lower Level IV evidence for tendon lengthening on plantar ulcers on the toes, midfoot and the distal end of transmetatarsal amputation stumps.17,18,23,25,27 There is similar Level IV evidence for the use of tendon lengthening for pain from plantar fasciitis, Achilles tendinitis, metatarsalgia.11,51,52,54-56 Finally, there are Level V studies on tendon lengthening for arthritis and posterior tibial tendinitis, and for tendon lengthening for calluses, corns, clawtoes and Charcot arthropathy.4,7,8,17,27,46,47,49,50,53

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