Digital ulcerations and pre-ulcerative lesions are common in individuals with diabetes mellitus, peripheral neuropathy, and toe deformities. Flexor tenotomy has been recommended to assist in the healing of pre-ulcerative or ulcerative lesions with generally high rates of healing, although variable rates of complications have been reported. This study aimed to evaluate the safety, efficacy, and outcomes of flexor tenotomy for the treatment of pre-ulcerative and ulcerative digital lesions.
Methods
A retrospective chart review was performed for patients who underwent percutaneous flexor tenotomy for treatment of digital ulcerations or pre-ulcerative lesions from January 2020 to January 2023. Outcomes assessed included healing of the index lesion and complications after tenotomy. Univariate analysis was performed to assess associations between clinical factors and outcomes
Results
A total of 50 patients underwent flexor tenotomy, 25 for treatment of an ulceration and 25 for treatment of a pre-ulcerative lesion. The average length of follow-up was 786.32 days (range 36-1654 days). Healing of the index ulcer or pre-ulcerative lesion was noted in 92%. Transfer lesions were noted in 28%, of which 85.7% required a subsequent flexor tenotomy to address the secondary lesion/ulceration. No patients with prophylactic flexor tenotomy developed a transfer lesion.
Conclusion
This study suggests the flexor tenotomy is a safe procedure with reliable rates of ulcer healing; however, it highlights a high risk of transfer lesions. Surgeons should remain vigilant for transfer lesions in the post-procedure period, and patients should be advised of the risk for transfer lesions after index flexor tenotomy.
ArmstrongDGBoultonAJMBusSA.Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367-2375. doi:10.1056/NEJMra1615439
2.
PrompersLHuijbertsMApelqvistJ, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Diabetologia. 2007;50(1):18-25. doi:10.1007/s00125-006-0491-1
3.
HicksCWCannerJKMathioudakisNLippincottCShermanRLAbularrageCJ.Incidence and risk factors associated with ulcer recurrence among patients with diabetic foot ulcers treated in a multidisciplinary setting. J Surg Res. 2020;246:243-250. doi:10.1016/j.jss.2019.09.025
4.
Smith-StrømHIversenMMIglandJ, et al. Severity and duration of diabetic foot ulcer (DFU) before seeking care as predictors of healing time: a retrospective cohort study. PLoS ONE. 2017;12(5):e0177176. doi:10.1371/journal.pone.0177176
5.
ArmstrongDGLaveryLAHarklessLB.Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998;21(5):855-859. doi:10.2337/diacare.21.5.855
6.
KimuraTThorhauerEDKindigMWShoferJBSangeorzanBJLedouxWR.Neuropathy, claw toes, intrinsic muscle volume, and plantar aponeurosis thickness in diabetic feet. BMC Musculoskelet Disord. 2020;21(1):485. doi:10.1186/s12891-020-03503-y
7.
FontaineJCrisologoPALaveryL.Current concepts in curative surgery for diabetic forefoot ulcers. Foot (Edinb). 2019;39:37-44. doi:10.1016/j.foot.2019.01.010
8.
FrykbergRGBevilacquaNJHabershawG.Surgical off-loading of the diabetic foot. J Am Podiatr Med Assoc. 2010;100(5):369-384. doi:10.7547/1000369
9.
QuebedeauxTLLaveryLALaveryDC.The development of foot deformities and ulcers after great toe amputation in diabetes. Diabetes Care. 1996;19(2):165-167. doi:10.2337/diacare.19.2.165
10.
BorkoskySLRoukisTS.Incidence of re-amputation following partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy: a systematic review. Diabet Foot Ankle. 2012;3:12169. doi:10.3402/dfa.v3i0.12169
11.
Dalla PaolaLFagliaECaminitiMClericiGNinkovicSDeanesiV. Ulcer recurrence following first ray amputation in diabetic patients: a cohort prospective study. Diabetes Care. 2003;26(6):1874-1878. doi:10.2337/diacare.26.6.1874
12.
Sanz-CorbalánILázaro-MartínezJLGarcía-ÁlvarezYGarcía-MoralesEÁlvaro-AfonsoFMolines-BarrosoR.Digital deformity assessment prior to percutaneous flexor tenotomy for managing diabetic foot ulcers on the toes. J Foot Ankle Surg. 2019;58(3):453-457. doi:10.1053/j.jfas.2018.09.015
13.
ScherDMMubarakSJ.Surgical prevention of foot deformity in patients with Duchenne muscular dystrophy. J Pediatr Orthop. 2002;22(3):384-391. Accessed March 8, 2026. https://pubmed.ncbi.nlm.nih.gov/11961461/
14.
BoffeliTJCollierRC.Minimally invasive soft tissue release of foot and ankle contracture secondary to stroke. J Foot Ankle Surg. 2014;53(3):369-375. doi:10.1053/j.jfas.2013.06.008
15.
ScirèVLeporatiETeobaldiINobiliLARizzoLPiaggesiA.Effectiveness and safety of using Podikon digital silicone padding in the primary prevention of neuropathic lesions in the forefoot of diabetic patients. J Am Podiatr Med Assoc. 2009;99(1):28-34. doi:10.7547/0980028
16.
IllgnerUBudnyTHoyerMWetzHH.Clinical acceptance, reasons for rejection, and reduction of in-shoe peak pressure with interdigital silicone orthoses. J Am Podiatr Med Assoc. 2014;104(1):30-33. doi:10.7547/0003-0538-104.1.30
17.
MeloMBerneckerTMcCulloughJHongJTrumbauerJSMillerME.A pilot study investigating the utilization of crest pads for treatment of toe callus and ulceration. J Vasc Nurs. 2015;33(4):157-163. doi:10.1016/j.jvn.2015.07.002
18.
SlaterRAHershkowitzIRamotYBuchsARapoportMJ.Reduction of digital plantar pressure by debridement and silicone orthosis. Diabetes Res Clin Pract. 2006;74(3):263-266. doi:10.1016/j.diabres.2006.04.006
19.
JohnsonSBranthwaiteHNaemiRChockalingamN.The effect of three different toe props on plantar pressure and patient comfort. J Foot Ankle Res. 2012;5(1):22. doi:10.1186/1757-1146-5-22
20.
FormosaCGrixtiCGattA.Conservative approach in the management of lesser toe deformities in older adults. J Am Podiatr Med Assoc. 2022;112(3):20-274. doi:10.7547/20-274
21.
van NettenJJRaspovicALaveryLA, et al. Prevention of foot ulcers in persons with diabetes at risk of ulceration: a systematic review and meta-analysis. Diabetes Metab Res Rev. 2024;40(3):e3652. doi:10.1002/dmrr.3652
22.
SchaperNCvan NettenJJApelqvistJ, et al. IWGDF Editorial Board. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3657. doi:10.1002/dmrr.3657
23.
MalkiABaltasar BadayaMDekkerRVerkerkeGJHijmansJM.Effects of individually optimized rocker midsoles and self-adjusting insoles on plantar pressure in persons with diabetes mellitus and loss of protective sensation. Diabetes Res Clin Pract. 2024;207:111077. doi:j.diabres.2023.111077
24.
ArtsMLWaaijmanRde HaartMKeukenkampRNolletFBusSA.Offloading effect of therapeutic footwear in patients with diabetic neuropathy at high risk for plantar foot ulceration. Diabet Med. 2012;29(12):1534-1541. doi:10.1111/j.1464-5491.2012.03770.x
25.
van SchieCUlbrechtJSBeckerMBCavanaghPR.Design criteria for rigid rocker shoes. Foot Ankle Int. 2000;21(10):833-844. doi:10.1177/107110070002101007
26.
AndersenJARasmussenAEngbergS, et al. Effect of flexor tendon tenotomy of the diabetic hammertoe on plantar pressure: a randomized controlled trial. BMJ Open Diabetes Res Care. 2024;12(6):e004398. doi:10.1136/bmjdrc-2024-004398
27.
BusSAArmstrongDGCrewsRT, et al. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3647. doi:10.1002/dmrr.3647
28.
LazzariniPAArmstrongDGCrewsRT, et al. Effectiveness of offloading interventions for people with diabetes-related foot ulcers: a systematic review and meta-analysis. Diabetes Metab Res Rev. 2024;40(3):e3650. doi:10.1002/dmrr.3650
29.
ScottJEHendryGJLockeJ.Effectiveness of percutaneous flexor tenotomies for the management and prevention of recurrence of diabetic toe ulcers: a systematic review. J Foot Ankle Res. 2016;9:25. doi:10.1186/s13047-016-0159-0
30.
BonannoDRGilliesEJ.Flexor tenotomy improves healing and prevention of diabetes-related toe ulcers: a systematic review. J Foot Ankle Surg. 2017;56(3):600-604. doi:10.1053/j.jfas.2017.02.011
31.
SchmitzPSchefferRDe GierSKrolRMVan der VeenDSmeetsL.The effect of percutaneous flexor tenotomy on healing and prevention of foot ulcers in patients with claw deformity of the toe. J Foot Ankle Surg. 2019;58(6):1134-1137. doi:10.1053/j.jfas.2019.03.004
32.
SchepersTBerendsenHAOeiIHKoningJ.Functional outcome and patient satisfaction after flexor tenotomy for plantar ulcers of the toes. J Foot Ankle Surg. 2010;49(2):119-122. doi:10.1053/j.jfas.2009.12.001
33.
AndersenJARasmussenAFrimodt-MøllerMKirketerp-MøllerKRossingP.Long term outcomes after flexor tendon tenotomy of the diabetic foot. Clin Med Insights Endocrinol Diabetes. 2025;18:11795514251314787. doi:10.1177/11795514251314787
34.
TamirEViglerMAvisarEFinestoneAS.Percutaneous tenotomy for the treatment of diabetic toe ulcers. Foot Ankle Int. 2014;35(1):38-43. doi:10.1177/1071100713509604
35.
LabordeJM.Neuropathic toe ulcers treated with toe flexor tenotomies. Foot Ankle Int. 2007;28(11):1160-1164. doi:10.3113/fai.2007.1160
36.
SmithSEMillerJ.The safety and effectiveness of the percutaneous flexor tenotomy in healing neuropathic apical toe ulcers in the outpatient setting. Foot Ankle Spec. 2020;13(2):123-131. doi:10.1177/1938640019843314
37.
TamirEMcLarenAMGadgilADanielsTR.Outpatient percutaneous flexor tenotomies for management of diabetic claw toe deformities with ulcers: a preliminary report. Can J Surg. 2008;51(1):41-44. Accessed March 8, 2026. https://pubmed.ncbi.nlm.nih.gov/18248704/
38.
RasmussenABjerre-ChristensenUAlmdalTPHolsteinP.Percutaneous flexor tenotomy for preventing and treating toe ulcers in people with diabetes mellitus. J Tissue Viability. 2013;22(3):68-73. doi:10.1016/j.jtv.2013.04.001
39.
KearneyTPHuntNALaveryLA.Safety and effectiveness of flexor tenotomies to heal toe ulcers in persons with diabetes. Diabetes Res Clin Pract. 2010;89(3):224-226. doi:10.1016/j.diabres.2010.05.025
40.
van NettenJJBrilAvan BaalJG.The effect of flexor tenotomy on healing and prevention of neuropathic diabetic foot ulcers on the distal end of the toe. J Foot Ankle Res. 2013;6(1):3. doi:10.1186/1757-1146-6-3
41.
López-MoralMMolines-BarrosoRJGarcía-ÁlvarezYSanz-CorbalánITardáguila-GarcíaALázaro-MartínezJL.Safety and efficacy of several versus isolated prophylactic flexor tenotomies in diabetes patients: a 1-year prospective study. J Clinl Med. 2022;11(14):4093. doi:10.3390/jcm11144093
42.
Askø AndersenJRasmussenAEngbergS, et al. Flexor tendon tenotomy treatment of the diabetic foot: a multicenter randomized controlled trial. Diabetes Care. 2022;45(11):2492-2500. doi:10.2337/dc22-0085
43.
Hedegaard AndersenJRasmussenAFrimodt-MøllerMRossingPKirketerp-MøllerKEngbergS. The effect of needle tenotomy on hammer, mallet and claw toe deformities in patients with diabetes, a retrospective study. J Clin Transl Endocrinol. 2019;18:100208. doi:10.1016/j.jcte.2019.100208
