Percutaneous Flexor Tenotomy—Office Procedure for Diabetic Toe Ulcerations

Nektarios Lountzis, MD; John Parenti, MD; Gerald Cush, MD; Maria Urick, CRNP, CWOCN; O. Fred Miller III, MD

Lesser toe deformities include, but are not limited to, hammertoes, mallet toes, and claw toes. These deformities are typically characterized by any combination of a plantarflexion deformity of the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints, and are commonly seen in adults with diabetes.1 The pathophysiology appears to be multifactorial with a tendency to affect the second toe or less commonly the third toe.2,3 The projection of the affected toe distal to the other digits can exert excess pressure and friction on either the toe pad and/or the DIP joints of the toe, especially in a shoe that has a narrow or short toe box. Over time, corns or callosities may form at these pressure points, and frequently in insensate patients with diabetes, subsequent ulceration.

Chronic nonhealing toe ulcerations often result in toe amputations. Postamputation foot dynamics are further altered and new pressure points lead to more ulceration and the possibility of subsequent foot or leg amputation. Typical conservative treatment methods, such as extra-depth toe-box shoes, pads, inserts, and splints must be continually employed and in the authors’ experience in patients with diabetes, provide mixed results and recurrent ulcerations on these pressure points. Device expense, shoe wear compliance issues, and incorrectly applied techniques pose ongoing difficulties. Open flexor tenotomy has traditionally been the definitive corrective procedure used by many surgical sub-specialists for severe lesser toe deformities that are often complicated by ulceration when conservative treatment has failed.4 This procedure not only corrects toe deformities, obviating the need for extra-depth shoes and orthotic devices, but also allows for rapid healing of the toe ulcerations after pressure has been relieved. Overall, the “percutaneous” procedure is simple, the outcomes are excellent, and the complications are minimal. The authors routinely perform closed or “percutaneous” flexor tenotomies in insensate patients with diabetes and the procedure—never described in an instructive fashion in the literature—can be performed during a routine office visit.


Preoperative preparation with local anesthesia via digital block or local toe injection can be used but anesthesia is usually not necessary in the insensate diabetic foot. The procedure is comprised of several steps. The first step is to make a target incision between the plantar creases of the metatarsophalangeal (MTP) and PIP joints at the paramedial aspect of the toe (Figure 1). Position a 15-scalpel blade perpendicular to the skin with the blade cutting edge facing toward the toe tip. The stab incision is carried down to bone. Once bone resistance is met, the blade tip should be slid beneath the flexor digitorum longus and brevis tendons and above the plantar surface of the bone (Figure 2). In this position, the scalpel blade is turned counterclockwise so that the cutting edge will face away from the bone (Figure 3). This maneuver creates space between the tendon and bone and simultaneously severs the tendons. The cutting is accomplished in 1 motion with a perceptible rupture or “pop” of the tendons. The toe is then stretched to a neutral position. At times after tenotomy, a persistently rigid deformed toe requires capsulolysis that is accomplished by sustained, firm stretching of the toe in order to release the fibrotic joint capsules and straighten the toe. After completion of the procedure, the small stab wound heals secondarily and does not require primary closure (Figure 4). The patient can mobilize with immediate weight bearing. After correction of the flexion deformity the toe pad is now properly offloaded without orthotic devices and rapid healing of the pressure ulceration follows (Figures 5 and 6).



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9. Coughlin MJ, Kennedy MP. Operative repair of fourth and fifth toe corns. Foot Ankle Int. 2003;24(2):147–157.

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