The Jones tendon transfer, also known as the Jones Tenosuspension, is a surgical procedure used to correct deformities of the big toe, particularly clawed hallux, which is often associated with high-arched (cavus) feet. First described in 1916 by Sir Robert Jones, the procedure remains an important treatment for restoring balance in the muscles and tendons of the foot. It is especially useful in patients with neuromuscular disorders or idiopathic foot deformities that cause abnormal toe position, pain, or walking difficulty.
How Common It Is and Who Gets It? (Epidemiology)
The Jones tendon transfer is most often performed in patients with pes cavovarus deformities or clawed hallux caused by neurological conditions such as Charcot-Marie-Tooth disease, spina bifida, or muscular dystrophy. It may also be used in idiopathic cases where the deformity develops without a known neurological cause. The procedure is more common in adolescents and adults who experience progressive toe deformities that cause imbalance, pain, or difficulty wearing shoes.
Why It Happens – Causes (Etiology and Pathophysiology)
Clawed hallux results from an imbalance between the muscles controlling the big toe. The extensor hallucis longus (EHL) muscle overpowers the weaker flexor hallucis longus (FHL) and intrinsic foot muscles. This causes the toe to extend at the metatarsophalangeal (MTP) joint and flex at the interphalangeal (IP) joint. Over time, the deformity becomes fixed, leading to pain, callus formation, and ulceration under the toe. The Jones tendon transfer rebalances these forces by rerouting the EHL tendon to the first metatarsal bone, thereby restoring normal alignment and pressure distribution.
How the Body Part Normally Works? (Relevant Anatomy)
The EHL tendon runs along the top of the foot and attaches to the base of the big toe. Its normal function is to lift the toe upward during walking. In clawed hallux, the EHL’s pull becomes excessive, causing hyperextension at the MTP joint. The FHL tendon, which normally flexes the toe, becomes shortened and rigid, increasing downward pressure on the toe tip. The Jones tendon transfer repositions the EHL to the first metatarsal, reducing the deforming extension force while stabilizing the forefoot.
What You Might Feel – Symptoms (Clinical Presentation)
Patients with clawed hallux often experience pain on the top of the toe and under the first metatarsal head. The toe may rub against shoes, creating corns or calluses. Ulcers may develop in severe cases, particularly in patients with neuropathy. The deformity can cause difficulty walking and a feeling of imbalance, especially in those with high-arched (cavus) feet.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is made through physical examination. The surgeon assesses toe flexibility, muscle strength, and foot shape. Radiographs (X-rays) help evaluate bone alignment, identify arthritis, and guide surgical planning. Dynamic testing may be performed to evaluate how the toe moves during walking and to identify associated deformities such as forefoot plantarflexion.
Classification
Clawed hallux deformities are typically classified based on flexibility (flexible or rigid) and cause (neurologic or idiopathic). Flexible deformities can be corrected with tendon transfer alone, while rigid deformities may require additional bone or joint procedures such as IP joint fusion or first metatarsal osteotomy.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that may resemble clawed hallux include hallux valgus (bunion), hallux limitus (restricted movement of the big toe), hammertoe, or hallux varus. Differentiation is based on the direction and flexibility of the deformity, muscle imbalance, and presence of neurological involvement.
Treatment Options
Non-Surgical Care
Early-stage deformities may be managed with orthotic devices, shoe modifications, and toe splints to reduce pressure. Physical therapy may help maintain muscle balance and prevent progression, but non-surgical methods are often ineffective for fixed deformities.
Surgical Care
The Jones tendon transfer (CPT 27691) is performed to restore proper alignment and function of the big toe.
Step-by-step procedure:
- An incision is made along the inside of the big toe from the IP joint to the first metatarsal.
- The EHL tendon is identified, detached from its insertion at the toe, and rerouted through a hole drilled in the first metatarsal neck.
- The tendon is sutured back to itself under proper tension, allowing the toe to rest in a corrected position.
- If the IP joint is contracted, an IP joint fusion may be performed to straighten the toe permanently.
- In cases where the first metatarsal is excessively plantarflexed, a dorsiflexory wedge osteotomy may be performed to realign the bone.
Adjunct procedures may include plantar fascia release, tibialis anterior or posterior tendon transfers, or midfoot and hindfoot fusions for more complex deformities.
Recovery and What to Expect After Treatment
After surgery, the foot is immobilized in a below-the-knee cast for approximately four weeks. Weight-bearing is restricted during this time. The patient transitions to a walking boot after cast removal, with gradual weight-bearing as healing progresses. Physical therapy is started to regain strength and flexibility. Most patients return to normal walking within three months.
Possible Risks or Side Effects (Complications)
Complications are uncommon but may include infection, tendon rupture, stiffness, or recurrence of deformity. Some patients experience pain under the first metatarsal head or delayed healing of the IP joint fusion. Stress fractures or nerve irritation can also occur but are rare with proper postoperative care.
Long-Term Outlook (Prognosis)
The Jones tendon transfer offers reliable correction of clawed hallux deformity, especially when combined with IP joint fusion. Studies report good to excellent outcomes in approximately 80% of patients, with improved alignment, pain relief, and stability. Long-term results are best when the underlying cause, such as neurological imbalance, is properly managed.
Out-of-Pocket Cost
Medicare
CPT Code 27691 – Jones Tenosuspension (Transfer or Transplant of Single Tendon, Leg): $175.25
Medicare Part B generally covers 80% of the approved cost for this procedure after 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 procedures. These plans coordinate with Medicare to fill the coverage gap and minimize the patient’s overall 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 typically cover any remaining coinsurance or small deductibles, which generally range between $100 and $300, depending on your plan and provider network.
Workers’ Compensation
If your Jones tenosuspension is required because of a work-related injury or chronic tendon imbalance caused by occupational strain, Workers’ Compensation will cover all medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket costs, as the employer’s insurance carrier pays for all approved procedures directly.
No-Fault Insurance
If your tendon transfer procedure is needed due to an automobile accident, No-Fault Insurance will typically cover the full cost of your treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment based on your policy terms.
Example
Michael Johnson developed chronic tendon imbalance in his foot and underwent a Jones Tenosuspension (CPT 27691) to restore function. His estimated Medicare out-of-pocket cost was $175.25. Since Michael had supplemental insurance through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the surgery.
Frequently Asked Questions (FAQ)
Q. What is Jones Tenosuspension?
A. Jones Tenosuspension is a surgical procedure used to treat clawed hallux (a deformed big toe) caused by muscular imbalances, typically in individuals with pes cavovarus. The procedure involves transferring the extensor hallucis longus tendon to realign the toe.
Q. How is the Jones Tenosuspension procedure performed?
A. The surgery involves making an incision on the medial side of the big toe, releasing the extensor hallucis longus tendon, rerouting it through a hole drilled in the first metatarsal, and suturing it back under tension to restore toe alignment.
Q. What conditions does Jones Tenosuspension treat?
A. It is primarily used for treating clawed hallux in patients with pes cavovarus or those with a foot deformity resulting from neurological causes that cause the big toe to bend and become rigid.
Q. What adjunct procedures are combined with Jones Tenosuspension?
A. The procedure may be combined with other interventions like tendon transfers, plantar fascia release, or subtalar joint fusion, depending on the severity of the deformity and the patient’s specific needs.
Q. What is the expected recovery time after Jones Tenosuspension?
A. Recovery typically involves a period of non-weight bearing for about four weeks, followed by limited weight-bearing. Full recovery and return to normal activities can take several months depending on individual healing.
Q. What is the success rate of Jones Tenosuspension?
A. The success rate of Jones Tenosuspension is generally high, with most patients experiencing significant improvement in toe alignment and reduction in symptoms, although outcomes depend on the severity of the condition and adherence to post-operative care.
Q. Is Jones Tenosuspension suitable for everyone with a clawed hallux?
A. Jones Tenosuspension is suitable for patients with clawed hallux due to neurological or structural issues like pes cavovarus. It may not be ideal for patients with advanced joint degeneration or severe arthritis in the toe.
Q. How long does the Jones Tenosuspension procedure take?
A. The procedure typically takes about 1 to 2 hours, depending on the complexity of the deformity and any additional procedures being performed during surgery.
Q. Can I walk immediately after Jones Tenosuspension?
A. No, patients will need to refrain from putting weight on the foot for several weeks, typically using crutches or a walking boot. Weight-bearing is gradually introduced as healing progresses.
Q. What is the role of physical therapy after Jones Tenosuspension?
A. Physical therapy is often recommended after the surgery to help restore strength, flexibility, and function in the foot and toe, as well as to improve range of motion and prevent stiffness.
Q. What are the risks and complications of Jones Tenosuspension?
A. Risks include infection, scarring, misalignment of the toe, tendon overuse, or recurrence of deformity. These complications are rare but may require additional treatment if they occur.
Q. Will Jones Tenosuspension affect my foot’s mobility?
A. Jones Tenosuspension aims to correct the deformity while preserving as much toe mobility as possible. However, some patients may experience slight stiffness or reduced motion after recovery.
Q. How soon can I return to normal activities after Jones Tenosuspension?
A. Most patients can return to light activities within 6 to 8 weeks, but high-impact activities should be avoided for several months to ensure full healing and prevent complications.
Q. Are there any alternatives to Jones Tenosuspension?
A. Alternatives to Jones Tenosuspension include conservative treatments like bracing or physical therapy, as well as other surgical options such as tendon transfers or joint fusions, depending on the severity of the condition.
Q. Is Jones Tenosuspension a permanent solution?
A. For most patients, Jones Tenosuspension provides a long-term solution, effectively realigning the toe and preventing recurrence of the deformity. However, follow-up care and rehabilitation are necessary to maintain optimal results.
Summary and Takeaway
The Jones tendon transfer is a valuable surgical technique for correcting clawed hallux and related cavus foot deformities. By rerouting the extensor hallucis longus tendon and stabilizing the toe, it restores alignment, reduces pain, and improves gait. When combined with IP joint fusion or osteotomy, the results are highly effective and long-lasting.
Clinical Insight & Recent Findings
Recent studies highlight the importance of combining Jones tendon transfer with adjunctive procedures in patients with severe cavovarus deformities. Patients with neurologic causes generally experience more predictable outcomes than those with idiopathic deformities. Modern fixation techniques and postoperative rehabilitation protocols have further improved stability and recovery rates.
Who Performs This Treatment? (Specialists and Team Involved)
The procedure is performed by an orthopedic foot and ankle surgeon or a podiatric surgeon specializing in reconstructive foot surgery. The care team may include anesthesiologists, surgical nurses, and physical therapists.
When to See a Specialist?
Consult a specialist if you have a clawed or painful big toe that interferes with walking, causes calluses, or does not improve with orthotics or conservative care.
When to Go to the Emergency Room?
Seek immediate care if you experience severe foot pain, swelling, or infection after surgery, or if you cannot move your toe or bear weight.
What Recovery Really Looks Like?
What Happens If You Ignore It?
Untreated clawed hallux can lead to chronic pain, calluses, and ulceration. The deformity may worsen, increasing the risk of imbalance, falls, and other toe deformities.
How to Prevent It?
Wearing supportive footwear, avoiding high heels, and using orthotics to correct muscle imbalance can help prevent recurrence after surgery. Early intervention for underlying conditions like neuromuscular disorders can also reduce risk.
Nutrition and Bone or Joint Health
A balanced diet with adequate protein, calcium, and vitamin D supports bone healing and tendon recovery. Avoid smoking and excessive alcohol, as these can delay healing and impair circulation.
Activity and Lifestyle Modifications
After recovery, patients should maintain good footwear, continue stretching exercises, and avoid high-impact activities that strain the foot. Regular follow-ups with a foot specialist ensure long-term success and stability.
Dr. Mo Athar
