Section: CME Category: Surgery

Tendon Balancing for Forefoot Ulcers and Foot Pain

James Laborde, MD, MS

James Laborde, MD, MS discusses primary tendon balancing for intervention with specific foot ulcers and for pain relief. Dr Laborde offers specific examples from his practice and from the literature where the procedures have worked better than more traditional methods.

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Goals and Objectives
  1. Explain how tendon imbalance can cause forefoot ulcers and foot pain
  2. Describe tendon balancing techniques
  3. Describe how primary tendon balancing can successfully treat forefoot ulcers, foot pain and prevent recurrence
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  • CPME (Credits: 0.5)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

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    Release Date: 03/16/2018 Expiration Date: 12/31/2020

  • Author
  • James Laborde, MD, MS

    Assistant Professor of Clinical Orthopaedic Surgery
    LSU School of Medicine
    New Orleans, LA

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    James Laborde Dr Laborde has nothing to disclose

  • Lecture Transcript
  • Male Speaker: Our next speaker is new to us and I was intrigued by his approach to many types of foot and ankle disorders. Dr. Laborde is an orthopaedic surgeon from New Orleans in Louisiana State University and I had the pleasure of meeting him earlier this year. Frankly, as I said, I was intrigued by his approach to these types of problems. I therefore asked him to come and discuss his approach to us. First, we'll be approaching diabetic foot disorders through tendon balancing. Let’s welcome Dr. Monroe Laborde.

    Monroe Laborde: There’s been some discussion about Paul Brand. Paul Brand was in Louisiana at Carville which is close to New Orleans and I had the opportunity to meet him and refer patients to him for opinions about diabetic feet. He was actually the one who told me about tendon balancing but never published it. I became interested in it and that’s the results you’re going to see. Basically, I have no financial relationships to disclose. The learning objectives of my talk is to talk about how tendon imbalance causes diabetic foot problems, forefoot ulcers and foot pain and to describe tendon balancing techniques and how they can be used to successfully treat these problems and also to prevent recurrence. The tendon balancing approach requires another paradigm shift. You’ve heard a lot about that changing a way of thinking. Paradigm shifts are generally resisted because they involve effort and changing the way we look at things. An example of resistance to paradigm shift was the fact that Galileo was put in jail and forced to recant when he described the paradigm shift of the earth going around the sun. The paradigm shift that I’m going to add is that tendons actually play a big part in the etiology of diabetic foot problems in addition to bone and vascular etiologies. That’s basically what I’m going to focus on and what the paradigm that you need to understand to be able to approach problems in this way. Basically the theory is, is that the neuropathy causes muscle imbalance, equinovarus and valgus. This causes uneven forces on the foot. It increases the stress in the foot, doubling and tripling forces in the foot. These increase forces are what result in the diabetic foot problems. There's foot ulcers but also Achilles tendonitis, Achilles tendon rupture, plantar fasciitis, arch collapse, posterior tibial tendon dysfunction and tendonitis, foot and ankle arthritis, fractures, metatarsalgia, bunions and claw toes are all related to tendon imbalance. The idea behind the treatment of this problem is that if you can normalize the imbalance, that you decreased the stress in the foot. The decreased stress in the foot results in the improvement of the diabetic foot problems, whatever they may be. There is literature that I listed here that talks about the fact that equinus causes these foot problems, not only foot ulcers but Charcot foot, metatarsalgia, flat foot, all these other problems that I've mentioned. These articles also mentioned the fact that lengthening the Achilles can result in successful treatment of these problems. Another interesting fact is when you look at diabetics that at 90% of the diabetics that were examined in this article were unable to dorsiflex their foot beyond 10 degrees with the knee extended which is the common definition of equinus. That’s the amount of if you can’t extend 10 degrees, then that increases the stress in the foot and prevents normal ambulation. It is common in diabetics if you look for it. Another interesting fact is that most of the diabetics that have amputations have them because of foot ulcers and that the vascular disease is a less a common etiology for amputation in diabetics. The idea here is that if you can heal foot ulcers and prevent their recurrence, you can prevent most of the amputations in diabetics.


    The general treatment for foot ulcers is addressing the infection with debridement and antibiotics and wound care, addressing ischemia with vascular surgery and adjusting forefoot pressure with offloading. I know you’re familiar with the nonoperative methods of offloading shoes and sorts, boots walkers, total contact casts. But I’m going to focus on operative methods of offloading which is tendon balancing. The method that I like to use for lengthening Achilles is called the gastrocsoleus recession or the vulpius procedure. Its advantages over the hook triple cut percutaneous Achilles lengthening are the prevention of the over correction which results in heal ulcers which as other office had said is a catastrophic occurrence and should definitely try and avoid that. It prevents ruptures of the Achilles tendon. The wound problems are minimal even in people with vascular disease. It’s an outpatient procedure and the patient can walk on leg the day of surgery. It has many advantages. One of the things that’s not commonly addressed in the literature is not only correcting the tightness in the Achilles tendon, but you also have to look at the varus and valgus posture of the foot. Frequently, either posterior tibial tendon or peroneus longus tendon also has to be lengthened. If they have a metatarsal head ulcer, the gastrocsoleus recession is always done by me. In addition to that, if they have a first metatarsal head ulcer, I always lengthen the peroneus longus, in addition because the peroneus longus flexes the first metatarsal. If they have a fifth metatarsal head or base ulcer, I also do posterior tibial tendon lengthening using Z-lengthenings for the peroneus longus and posterior tib in the gastrocsoleus recession for the Achilles. These are some before and after pictures of people treated with tendon lengthening. The success rate is extremely high and the healing takes place usually just within a few weeks. This has been published by me in Foot and Ankle International and also in Podiatry Today. The results are extremely good with as you can see, 98% of the ulcers healed and metatarsal head ulcers. A few ulcers that did recur healed after additional tendon lengthenings. This also works well for toe ulcers. These can be done percutaneously in the office, both plantar ulcer and dorsal ulcers. The dorsal ulcer is requiring extensor tenotomy in addition to the flexor tenotomies that are needed for the plantar distal ulcers. This again, a lot of publications about this, this is a successful treatment for toe ulcers. It can also be used in the lower right. It can be used in people who are headed for ulceration and it can be done actually before they get an ulcer, and ulcers can be prevented. These are before and after pictures of toe ulcers. Some of these ulcers were years old when I saw them and yet still, they generally healed just within a few weeks. This is also published in Foot and ankle International and in Podiatry Today. Again 100% of the ulcers healed. There were no recurrences in the lesser toes. There are a few recurrences in the hallux which responded to the additional tendon lengthening. When you compare tendon lengthening to total contact casting, total contact casting heals an average of 80% of the ulcers, whereas tendon lengthening heals about 98%. The complication rate is actually higher with total contact casting than tendon lengthening. The recurrence rate after total contact casting, which does nothing to correct the deformity and the tendon imbalance is very high, 81% recurrence in two years with total contact casting versus 11% recurrence after tendon balancing.


    There’s a good literature support for tendon lengthening. This is not a complete list of the publications advocating this procedure but as you can see, there are level one study and level three studies which show this technique to be beneficial in addition to multiple level four studies. This technique also works in ulcers for transmetatarsal amputation and patients with vascular disease that need debridement of their foot. It will enhance the healing and improve the rates of limb salvage in people who have vascular disease in addition. Patients who have vascular disease though require the team approach including not only tendon lengthening but they need wound care and they need debridement, in many cases they need vascular surgery. But limb salvage in patients with ischemia improves if tendon lengthening is added to those procedures. This study, recently published in Foot and Ankle International describes the fact that in Medicare population, the major amputations have decreased 47% in between 2000 and 2010. During that same time period, the numbers of Achilles lengthenings and gastrocsoleus recessions have increased dramatically and these are felt that there was a connection between the fact that as tendon lengthening increases, the number of major amputations goes down. We're also advocating this procedure. Tendon lengthening also works for foot pain in diabetics who don’t have ulcers. Patients who have posterior tibial tendonitis for instance, if gastrocsoleus recession is done and the posterior tibial tendon is augmented, you can relieve their posterior tibial pain and at the same time, prevent them from getting foot ulcers and Charcot arthropathy. Saying this is true far Achilles tendonitis, these multiple publications demonstrating the effectiveness of gastrocsoleus recession for Achilles tendonitis. Again, it relieves the pain and also prevents the subsequent foot ulceration and I believe Charcot arthropathy. Plantar fasciitis can also be successfully managed with gastrocsoleus recession. The success rates published by multiple authors were in the 90 plus percent which is significantly higher I believe than the success rate for plantar fasciotomy. Also, it can be used in patients who have had failed plantar fasciotomies with persistent pain, and also in patients who have plantar fibromas and masses in the plantar fascia. This can be successfully treated with gastrocsoleus recession without removal of the plantar fibroma. Plantar fibroma is the pain is relieved by the gastrocsoleus recession and they usually gradually decrease in size without excising them, which excision of plantar fibromas is not a very successful procedure in my hands. Metatarsalgia, also I think can be successfully managed with gastrocsoleus recession and according to a recent article, the advantages of gastrocsoleus recession for metatarsalgia over metatarsal osteotomy is that the results are predictable and that it avoids the transfer metatarsalgia which is common with osteotomy and also avoids floating digits and wound problems of osteotomy. I use gastrocsoleus recession routinely for metatarsalgia, both in diabetics and nondiabetics. Let’s see. Also beware of the dark callus. If a patient has a dark callus, if you remove that callus, there’s an ulcer under there. That I think is something that you should look for and if it's present, go ahead and treat that as if it's an ulcer. I also prophylactically do gastrocsoleus recession in patients to try and prevent ulceration if they have a significant callus on their toes, if they have a dark callus, or if they have progressive callus in their forefoot, especially in their midfoot.


    I will go ahead and do gastrocsoleus recession with or without either posterior tibial or peroneus longus lengthening, depending on the location. Basically, I recommend a primary tendon balancing as the approach to most diabetic foot problems. I think there is a level one support for its use in metatarsal ulcers, multiple level four studies for toe ulcers. There's also level four studies documenting its success in transmetatarsal amputations that have ulcers. Also, good results in cases of forefoot pain and the advantage of it I think over other treatments is that not only does it relieve the pain, but it prevents subsequent ulcers and I believe Charcot arthropathy. It can successfully be used in Achilles tendonitis level four studies supporting that plantar fasciitis level four studies. Then also for midfoot arthritis and metatarsalgia, it can successfully be used also, level four studies and posterior tibial tendinitis is still level five. Arterial forefoot wounds, not a lot of literature about this, but just in my own practice it seems to be very helpful. In doing surgical offloading, it helps when combined with wound care and vascular approaches in preventing major amputations. Then I also use it for calluses and corns to prevent progression to ulceration and to relieve pain. These are some of the articles that I've written that are review articles that cover all of these things. If you want to read about that, you can go to these articles, some of which are available online. Okay. Thank you.