Diabetic foot ulcers are a serious and common complication for people living with diabetes. These ulcers often form on the tips of the toes due to deformities such as claw toes or hammer toes, which increase pressure during walking. When left untreated, these ulcers can become infected and may lead to more severe outcomes, including amputation. Flexor tenotomy is a minimally invasive procedure designed to relieve this pressure, allowing the ulcers to heal quickly and helping prevent future recurrences.
How Common It Is and Who Gets It? (Epidemiology)
Flexor tenotomy is most often performed in patients with diabetes, particularly those with peripheral neuropathy (nerve damage) and toe deformities that cause ulcers at the tip of the toe. These ulcers are frequently resistant to standard care, including wound dressings and off-loading shoes. The procedure has become an increasingly popular and effective solution in diabetic limb preservation programs because it is simple, low-risk, and can be done in an outpatient setting.
Why It Happens – Causes (Etiology and Pathophysiology)
Diabetic neuropathy and poor circulation cause changes in the muscles and tendons of the feet:
- The flexor tendons (which bend the toes downward) tighten and overpower the opposing extensors.
- This leads to claw or hammer toe deformities, where the toe tip presses abnormally against the shoe or ground.
- Constant pressure and friction lead to callus formation, skin breakdown, and ulceration.
By cutting the tight tendon, flexor tenotomy straightens the toe, relieves pressure at the ulcer site, and restores more normal contact during walking.
How the Body Part Normally Works? (Relevant Anatomy)
Each toe is controlled by two main tendons:
- The flexor digitorum longus and flexor digitorum brevis, which bend (flex) the toe.
- The extensor tendons, which straighten the toe.
When the flexors become too tight—often due to diabetic nerve damage—they pull the tip of the toe downward, creating excessive pressure on the front of the toe. Flexor tenotomy releases these tendons, allowing the toe to straighten and reducing this harmful pressure.
What You Might Feel – Symptoms (Clinical Presentation)
Patients who benefit from flexor tenotomy typically experience:
- Pain or ulceration at the tip of the toe.
- Calluses or thickened skin that don’t heal despite regular care.
- Toe deformities such as claw toes or hammertoes.
- Slow-healing or recurrent ulcers, particularly at the distal (tip) end of the toe.
- Reduced sensation in the feet due to diabetic neuropathy.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is made through clinical examination:
- Inspection reveals a curled toe deformity and ulcer or pre-ulcerative callus at the tip.
- The ulcer is often clean and well-defined, typically overlying the bone at the distal phalanx.
- X-rays may be obtained to rule out osteomyelitis (bone infection).
- Vascular assessment ensures adequate blood flow for healing.
Classification
Diabetic foot ulcers are classified based on depth and infection severity (e.g., Wagner or University of Texas classification). Flexor tenotomy is most effective for superficial (Wagner Grade 1–2) ulcers located at the toe tip, especially in patients with neuropathy and flexible deformities.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Corns or calluses without ulceration.
- Ischemic ulcers due to peripheral arterial disease.
- Osteomyelitis or deep infection.
- Pressure ulcers from ill-fitting shoes.
- Gouty tophi or other soft tissue masses.
Treatment Options
Non-Surgical Care
Initial management includes:
- Off-loading: Using shoes or orthotics to reduce pressure on the ulcer.
- Wound care: Regular debridement and moist dressings.
- Infection control: Antibiotics if infection is present.
- Glycemic control: Managing blood sugar to promote healing.
If ulcers persist despite these measures, flexor tenotomy provides a simple surgical solution.
Surgical Care
Flexor Tenotomy (CPT 28010):
- Anesthesia: Local anesthetic only.
- Technique: A small incision (or needle puncture) is made on the underside of the toe at the level of the proximal interphalangeal joint. The tight flexor tendon is identified and cut, allowing the toe to straighten immediately.
- Duration: The entire procedure typically takes 10–15 minutes per toe.
- Setting: Performed in an outpatient clinic; no stitches or hospital stay required.
Benefits:
- Eliminates pressure on the ulcer.
- Promotes rapid healing (within 2–4 weeks for most patients).
- Prevents recurrence of ulcers and reduces risk of amputation.
Recovery and What to Expect After Treatment
- Wound Care: A simple dressing is applied; the site usually heals within a few days.
- Weight-Bearing: Normal walking is allowed immediately, often with a postoperative sandal or soft shoe.
- Healing Time: Most toe ulcers heal within 2–4 weeks; some as quickly as 10 days.
- Follow-Up: Patients are monitored regularly to ensure the ulcer is healing and to prevent transfer lesions.
Possible Risks or Side Effects (Complications)
- Transfer lesions: New ulcers may form on adjacent toes if only one tendon is released. Performing multiple tenotomies when necessary can prevent this.
- Minor infection: Rare and usually managed with antibiotics.
- Residual soreness or stiffness: Temporary and resolves as healing progresses.
Overall, complications are uncommon, and the procedure is considered very safe for diabetic patients.
Long-Term Outlook (Prognosis)
Flexor tenotomy has an excellent success rate, with healing reported in 92–100% of patients and very low recurrence. Patients often experience:
- Faster wound closure compared with conservative care.
- Improved toe position and reduced ulcer risk.
- Better quality of life and reduced need for more invasive amputations.
With ongoing podiatric care and appropriate footwear, most patients maintain long-term ulcer-free outcomes.
Out-of-Pocket Costs for Treatment
Medicare
CPT Code 28010 – Flexor Tenotomy (Single Tendon, Foot): $53.98
Medicare Part B generally covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield typically cover that remaining 20%, reducing or eliminating out-of-pocket expenses for Medicare-approved treatments. These supplemental plans work in coordination with Medicare to fill the coverage gap and minimize patient costs.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans usually cover any remaining coinsurance or small deductibles, which typically range from $100 to $300, depending on your plan and provider network.
Workers’ Compensation
If your flexor tenotomy is needed due to a work-related injury or repetitive motion condition, Workers’ Compensation will cover all related medical expenses, including the procedure, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier covers all approved services directly.
No-Fault Insurance
If your flexor tendon injury was caused or aggravated by an automobile accident, No-Fault Insurance will typically cover the full cost of treatment, including surgery and postoperative care. The only potential out-of-pocket expense may be a small deductible or co-payment based on your policy terms.
Example
Angela Roberts developed toe contractures that required a flexor tenotomy (CPT 28010) to relieve pain and improve mobility. Her estimated Medicare out-of-pocket cost was $53.98. Since Angela had supplemental insurance through Blue Cross Blue Shield, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is Flexor Tenotomy?
A. Flexor Tenotomy is a minimally invasive procedure where tendons in the toes are cut to straighten them and reduce pressure, particularly useful for treating diabetic foot ulcers at the tips of the toes.
Q. How is Flexor Tenotomy performed?
A. The procedure is done in a doctor’s office with a local anesthetic. The tendons responsible for bending the toes are cut to straighten the affected toes, reducing pressure that causes ulcers.
Q. How effective is Flexor Tenotomy for diabetic foot ulcers?
A. Flexor Tenotomy is highly effective, with healing rates ranging from 92% to 100%. Most ulcers heal within 2 to 4 weeks, with some healing in as little as 10 days.
Q. What are the risks associated with Flexor Tenotomy?
A. The main risk is the development of “transfer lesions,” where pressure moves to another toe, possibly causing a new ulcer. Infections are rare but may require antibiotic treatment.
Q. Is Flexor Tenotomy a permanent solution for diabetic foot ulcers?
A. While the procedure is highly effective in healing existing ulcers and preventing new ones, follow-up care is important to ensure proper healing and avoid complications like transfer lesions.
Q. What conditions can Flexor Tenotomy treat?
A. Flexor Tenotomy is primarily used to treat diabetic foot ulcers caused by pressure on the toes, but it can also be beneficial for conditions involving hammertoes or contracted toes.
Q. How long does the Flexor Tenotomy procedure take?
A. The procedure typically takes about 15 to 20 minutes and is performed on an outpatient basis with local anesthesia.
Q. Will I need to stay in the hospital after Flexor Tenotomy?
A. No, Flexor Tenotomy is an outpatient procedure, meaning you can go home the same day after the procedure is completed.
Q. How long does it take to recover from Flexor Tenotomy?
A. Recovery is usually quick, with most patients able to resume normal activities within a few days. The toe may be sore for a short time, but there is typically no need for prolonged rest.
Q. Can Flexor Tenotomy be done on both feet at the same time?
A. Yes, Flexor Tenotomy can be performed on both feet at the same time, but the decision is based on the patient’s health and the extent of the condition being treated.
Q. Will I need any follow-up care after Flexor Tenotomy?
A. Follow-up care typically involves monitoring the healing process, including checking for infection or new pressure points, and ensuring that any ulcers have fully healed.
Q. Are there any long-term complications from Flexor Tenotomy?
A. Long-term complications are rare, but some patients may develop transfer lesions where pressure shifts to other toes. Regular foot care and monitoring are essential to prevent these issues.
Q. Can Flexor Tenotomy help prevent future ulcers?
A. Yes, by correcting the position of the toes and alleviating pressure, Flexor Tenotomy can help prevent the formation of future ulcers, especially in patients with diabetes.
Q. Is Flexor Tenotomy suitable for patients with other foot deformities?
A. Flexor Tenotomy is effective for patients with conditions like hammertoes or toe contractures, especially when they are contributing to foot ulcers or other issues.
Q. Does Flexor Tenotomy affect the function of my toes?
A. The procedure generally does not impair toe function; in fact, it improves the alignment of the toes, which can help improve mobility and reduce pain. However, there is a slight risk of weakness or stiffness after the surgery.
Q. What is flexor tenotomy?
A. A minimally invasive toe surgery that releases the tight tendon causing clawing, relieving pressure on the tip and allowing ulcers to heal.
Q. How successful is it for diabetic ulcers?
A. Healing rates are between 92% and 100%, with most ulcers resolving within 2–4 weeks.
Q. Will I need stitches or hospitalization?
A. No. It’s performed under local anesthesia in the clinic, and patients go home immediately.
Q. What is a transfer lesion?
A. A new ulcer that may develop on a neighboring toe if only one tendon is released. Treating all affected toes helps prevent this.
Q. Is it painful?
A. Discomfort is minimal. Most patients report little to no pain after the procedure.
Q. Can flexor tenotomy prevent future ulcers?
A. Yes. It not only heals existing ulcers but also prevents recurrence by correcting the deformity that caused them.
Summary and Takeaway
Flexor tenotomy is a safe, quick, and highly effective procedure for diabetic toe ulcers and claw toe deformities. It offers rapid healing, minimal discomfort, and lasting protection against recurrence. By straightening the toe and removing excessive pressure, this simple outpatient procedure can prevent severe complications like infection and amputation, significantly improving the quality of life for people with diabetes.
Clinical Insight & Recent Findings
A recent study in Foot & Ankle Orthopaedics introduced a minimally invasive technique combining plantar capsule release with percutaneous flexor tenotomy to treat rigid diabetic hammer toes—a common cause of toe ulcers in people with diabetes.
Traditional treatments like joint fusion or resection arthroplasty often require wires or implants and carry higher risks of infection or poor healing. This new approach, performed through a small plantar incision under local anesthesia, effectively releases the contracted soft tissues that keep the toe rigid.
The study reported significant improvement in toe alignment, better wound healing, and faster recovery, making it a promising alternative for patients at high surgical risk. The authors noted that this technique offers a safe, outpatient solution that can prevent or resolve diabetic toe ulcers while avoiding the complications of more invasive surgery. (“Study on minimally invasive plantar capsule release and flexor tenotomy for diabetic hammer toes – see PubMed.”)
Who Performs This Treatment? (Specialists and Team Involved)
Flexor tenotomy is performed by a podiatrist or orthopedic foot and ankle surgeon specializing in diabetic foot care. The care team includes nurses, wound care specialists, and diabetes educators who help optimize blood sugar and wound healing.
When to See a Specialist?
See a foot specialist if you notice:
- Persistent ulcers or calluses on your toes.
- Toes that are curling or rubbing against shoes.
- Delayed wound healing despite proper care.
When to Go to the Emergency Room?
Seek urgent care if you have signs of infection, including redness, swelling, pus, foul odor, or fever. Early intervention prevents serious complications.
What Recovery Really Looks Like?
Most patients can walk the same day with protective footwear. The ulcer typically closes within weeks, and follow-up visits ensure no new pressure points develop.
What Happens If You Ignore It?
Ignoring diabetic toe ulcers can lead to deeper infection, bone involvement (osteomyelitis), and even toe or foot amputation. Flexor tenotomy offers a simple way to stop this progression.
How to Prevent It?
- Inspect your feet daily for cuts, redness, or ulcers.
- Keep blood sugar under control.
- Wear properly fitted shoes and custom orthotics.
- Seek early care for calluses or toe deformities.
Nutrition and Bone or Joint Health
A diet rich in protein, vitamin C, and zinc promotes wound healing. Good glucose control reduces infection risk and improves outcomes after surgery.
Activity and Lifestyle Modifications
After healing, continue using custom diabetic shoes or inserts to prevent recurrence. Avoid tight footwear and trim nails carefully. Routine podiatric check-ups are essential to maintain lifelong foot health.
Dr. Mo Athar
