What is an Achilles tendon tenotomy?

An Achilles tendon tenotomy is a targeted procedure to cut, release, or micro-debride part of the Achilles tendon to relieve pain or correct deformity. Clinicians use different techniques depending on the problem:
Percutaneous needle tenotomy (microtenotomy): A fine needle (often ultrasound-guided) makes multiple passes or removes degenerative tendon strands to stimulate a healing response. Brand-associated methods include percutaneous ultrasonic tenotomy (often known colloquially as Tenex) and radiofrequency coblation microtenotomy.
Open or mini-open tenotomy/lengthening: Small incisions allow controlled cutting to lengthen a tight tendon (e.g., Z-lengthening, triple hemisection) or to surgically debride thickened insertional disease and calcific deposits.
Heel cord tenotomy in infants: A brief percutaneous cut of the Achilles tendon after serial casting (Ponseti method) to achieve dorsiflexion and correct clubfoot; a final cast is applied for healing, then bracing continues.

Key distinctions you’ll see in this article

Adult tendinopathy: Goal is pain reduction and function by removing diseased tissue and stimulating remodeling while preserving tendon strength and length.
Infant clubfoot: Goal is to correct equinus (tightness) as part of Ponseti casting; the tendon safely regenerates as the foot posture normalizes.
Equinus in adults: In selected cases (e.g., diabetic forefoot ulcers, spasticity), controlled lengthening reduces forefoot pressure but risks over-lengthening and calf weakness if not carefully indicated.

Why and when an Achilles tenotomy is recommended

Your specialist may consider tenotomy when:

• You have chronic Achilles tendinopathy (mid-portion or insertional) not responding to 3–6 months of graded loading exercises, activity modification, and adjuncts like shockwave therapy.
• Ultrasound or MRI shows degenerative changes (tendinosis), neovascularity, or persistent thickening associated with chronic pain and function loss.
• Insertional Achilles pain persists alongside bony prominence (Haglund deformity) or calcific deposits, sometimes with retrocalcaneal bursitis.
• There is function-limiting equinus contracture contributing to forefoot overload or gait dysfunction despite conservative care.
• In infants with idiopathic clubfoot, hindfoot tightness remains after serial casts; heel cord tenotomy is almost always part of a successful correction pathway.
• If you’re exploring surgical options for resistant Achilles tendinopathy, see our detailed overview of minimally invasive approaches on our Achilles Tendinopathy Surgery page at Sports Orthopedics Institute.

Common causes that lead to needing tenotomy

Overuse and training load errors: Rapid mileage spikes, repeated hill sprints, change to minimalist footwear without progression.
Biomechanical drivers: Limited ankle dorsiflexion, flat feet with overpronation, or a rigid high-arched foot causing load concentration.
Degenerative biology: Age-related tendon matrix changes, impaired tendon healing, metabolic factors.
Insertional factors: Bony spurs, Haglund deformity, and friction at the calcaneal insertion.
Medications and systemic contributors: Past fluoroquinolone antibiotic exposure, corticosteroid injections into the tendon, diabetes, inflammatory conditions, or thyroid disease.
Congenital/neuromuscular conditions: Clubfoot in infants (Ponseti pathway) and equinus in cerebral palsy or post-stroke spasticity.
For a broader primer on Achilles-related heel pain and contributing factors, review this explanatory guide from our team: Achilles Tendon and Heel Pain—Relation, Causes & Treatments.

How you’ll be evaluated before tenotomy

Expect a comprehensive assessment:
History and exam: Pain location (mid-portion vs. insertional), morning stiffness, crepitus, load tolerance, calf tightness (Silfverskiöld/gastrocnemius length), and gait.
Imaging: High-resolution musculoskeletal ultrasound for tendon thickness, hypoechoic regions, neovessels; MRI when insertional disease, partial tears, or bony pathology is suspected.
Load audit: Training diary, footwear analysis, surface changes, and recovery habits.
Medical review: Diabetes control, smoking status, thyroid function, and medication history.
Trial of conservative therapy: Eccentric/heavy-slow resistance loading, progressive calf flexibility, isometrics for pain modulation, shockwave therapy, and orthoses/shoe modifications.

Adult procedure options: what actually happens

Ultrasound-guided percutaneous needle tenotomy (microtenotomy)

Setting: Day-care procedure under local anesthesia.
Guidance: Ultrasound identifies degenerated zones to target precisely while protecting healthy tendon.
Technique: Multiple fenestrations or ultrasonic/low-energy coblation disrupt diseased fibers and break up neovascular/scar tissue. Saline irrigation may be used with ultrasonic systems to remove debris.
Duration: Often 10–20 minutes; small adhesive strips or a tiny bandage afterward.
Aim: Convert a chronic “failed healing” state into a controlled, biologically active healing phase with new collagen deposition and improved tendon structure.

Open or mini-open debridement ± lengthening

Indicated for: Bulky insertional disease with calcific deposits/Haglund prominence, recalcitrant bursitis, or when equinus requires controlled lengthening.
Technique: A small incision allows removal of calcific deposits and degenerate tissue; sometimes the tendon is partially detached and repaired with anchors. Z-lengthening or triple hemisection techniques carefully lengthen a contracted tendon when required for equinus.
Duration: Typically less than an hour; anesthesia as appropriate; protected weight-bearing plan afterward.

Heel cord tenotomy in infants (Ponseti method)

Timing: After 4–6 serial casts have corrected the midfoot, residual equinus is corrected by a quick percutaneous tenotomy.
Anesthesia: Local anesthetic; brief procedure; a final long-leg cast holds the corrected dorsiflexion position for 2–3 weeks before bracing (boots-and-bar) begins.
Safety: In experienced hands this is fast, with low risk; tendons regenerate in the weeks following tenotomy as alignment is maintained with bracing.

Side effects and complications you should know

All procedures have risks; with Achilles tenotomy they are usually low but important to understand:

Pain and swelling: Expected for several days; controlled with rest, elevation, ice, and prescribed analgesics.
Bruising and local numbness: Temporary in most cases.
Infection or delayed wound healing: Rare; minimized by sterile technique and careful aftercare.
Sural nerve irritation: Because of its proximity laterally, precise technique and ultrasound guidance reduce risk.
Over-lengthening and calf weakness: A concern in lengthening procedures—proper indication and conservative lengthening help avoid crouch gait or push-off weakness.
Insertional repair-specific risks: Scar sensitivity, anchor irritation, or persistent bursitis if contributing factors remain.
Recurrence or persistent symptoms: Possible if load errors and biomechanics aren’t corrected post-procedure.
Need for re-intervention: Occasionally needed if pain persists or if infants need a second tenotomy to achieve full correction.

Benefits and expected outcomes

Pain relief and function: Many patients see meaningful improvements in pain scores and daily function after microtenotomy when paired with a structured rehab program.
Minimally invasive: Ultrasound-guided needle or ultrasonic tenotomy targets diseased tendon while sparing healthy tissue.
Targeted for clubfoot: In infants, heel cord tenotomy is a cornerstone step in achieving plantigrade, flexible feet within the Ponseti method.
Short procedure, outpatient care: Most adults go home the same day; infants typically spend only a few hours in the clinic.
Low complication rates: Especially for percutaneous, ultrasound-guided techniques in experienced hands.

Your rehabilitation roadmap: adult tendinopathy (typical)

Every program is personalized—your surgeon and physiotherapist will give you exact instructions. A common, evidence-informed outline is:

Days 0–3

Rest, elevation, and ice 10–15 minutes up to 3–4 times/day.
Keep dressing clean and dry; protected weight-bearing as advised.
Gentle ankle pumps in pain-free range if permitted.

Week 1–2

Transition to supportive shoe with heel lift if advised.
Start isometrics for calf (e.g., 5 x 45-second holds) and gentle range-of-motion drills avoiding end-range dorsiflexion if tender.
Short, frequent walks on level ground; no hills or sprints.

Week 3–4

Introduce heavy-slow resistance (HSR) or eccentric-biased calf training under guidance; begin light cycling or pool work if wounds healed.
Progressive calf stretching with knee straight and bent; continue heel lifts if insertional tenderness persists.

Week 5–8

Build load tolerance: double- to single-leg calf raises progressing to decline board eccentrics for mid-portion cases.
Jogging reintroduction once pain ≤2/10 during/after brisk walk test and tendon soreness normalizes within 24 hours.

Week 9–12

Gradual return to running with 48-hour spacing initially; agility and plyometrics as tolerated.
Sport-specific drills resume as pain and stiffness allow; maintain 2–3 calf-strength sessions/week.
Note: Insertional cases may avoid deep dorsiflexion, decline board, and aggressive stretching early on. Mid-portion cases tolerate progressively deeper range work sooner.

Recovery after infant heel cord tenotomy

Cast care: A final cast holds the corrected position for about 2–3 weeks.
Bracing: Boots-and-bar bracing begins immediately after cast removal—full-time for 3 months, then during sleep up to 4–5 years to prevent relapse.
Follow-up: Regular checks to ensure brace fit and adherence; physiotherapy supports normal milestones.

Alternatives to consider before or alongside tenotomy

Exercise therapy: Eccentric or heavy-slow resistance loading remains first-line for tendinopathy.
Activity and training load changes: Stepwise progression, avoid rapid spikes, adjust hill work and surfaces.
Footwear and orthoses: Heeled, rocker-bottom shoes or heel lifts to reduce insertional compression; supportive shoes for pronation control.
Adjuncts: Shockwave therapy (ESWT), topical NSAIDs, short-term heel wedges; careful use of tendon-friendly taping.
Injection options: PRP or high-volume injectate in selected cases; avoid intratendinous corticosteroid for Achilles due to rupture risk.
For insertional disease with bony impingement: Address footwear counters and consider Haglund management strategies. Explore our detailed primer on insertional Achilles tendinitis and conservative-to-surgical pathways here: Insertional Achilles Tendinitis: Causes, Symptoms, and Cure.

Who should not have an Achilles tenotomy?

Active infection near the site.
Uncontrolled diabetes or vascular disease that compromises healing.
Inability to follow post-procedure restrictions or rehab.
For adult microtenotomy: Expectation of immediate return to maximal sport loads—tenotomy initiates a healing phase that requires measured progression.

How to prepare for the day of your procedure

Discuss all medications and supplements; clarify anticoagulant plans.
Arrange transport; avoid driving immediately after procedures under sedation.
Wear loose clothing and supportive footwear for the trip home.
Understand your wound care instructions and stocking/bandage plan.
Book your early follow-ups. To make scheduling easy, see our Appointment & Booking Information page.

What results look like in the real world

Pain relief often emerges progressively over 6–12 weeks as collagen remodels with your loading program.
Runners typically reintroduce run-walk intervals between weeks 6–10, returning to steady mileage by 12–16 weeks, depending on baseline severity and adherence to rehab.
Manual workers may return earlier with role modification and a staged plan.
For insertional disease after open debridement, timelines can be longer; your plan will be customized.

How Sports Orthopedics Institute supports your journey

Ultrasound-guided precision: Target only the diseased tendon—preserve the healthy fibers that deliver push-off power.
Integrated physio: We sync your rehab to the biology triggered by tenotomy (isometrics early, HSR next, then plyometrics and sport).
Footwear and gait support: On-site guidance for shoes, heel lifts, and orthoses to control compressive and tensile loads.
Want to explore related ankle issues and how we manage them? Read our ankle injury insights on the Sports Orthopedics blog, and for persistent instability concerns, our ATFL-focused guide offers context on lateral ankle sprains and recovery.

When to call your clinician after tenotomy

Increasing redness, heat, or discharge from the wound.
Calf swelling and pain out of proportion (rule out DVT).
Numbness or tingling that does not improve.
Fever or systemic symptoms.
Pain that is steadily worsening rather than following a typical post-procedure course.

How much does Achilles tenotomy cost?

Costs vary by technique (needle vs. ultrasonic vs. open), facility, imaging, and rehab needs. You’ll receive a transparent, itemized estimate after consultation. For questions or to get personalized advice, reach out via our Contact page.

Frequently asked questions (FAQs)

Is Achilles tendon tenotomy the same as tendon “release”?
Tenotomy refers to cutting or debriding tendon fibers. “Release” is a broader term and may be used for procedures relieving tethered tendons (tenolysis) or muscle-tendon unit tightness. In infants with clubfoot, “heel cord tenotomy” is the specific release for equinus.

What is the difference between microtenotomy and open surgery?
Microtenotomy uses a needle or micro-tip under ultrasound to stimulate healing; open surgery allows direct removal of calcific deposits or controlled lengthening. Recovery and scarring are generally quicker and smaller with percutaneous methods, but indications differ.

Will my Achilles tendon grow back after tenotomy?
In infants, the tendon predictably regenerates while held in the corrected position with casting/bracing. In adults, microtenotomy does not sever the tendon; it triggers a healing response within the tendon, leading to healthier collagen remodeling rather than “regrowth” from a full cut.

Is tenotomy painful?
Local anesthesia during the procedure limits pain. Soreness and swelling for a few days are common. A structured pain-control plan (ice, elevation, analgesics) is provided.

How long until I can walk normally?
Many adults walk comfortably in supportive footwear within days, increasing distances gradually. Full return to running or sport typically takes weeks to a few months, depending on severity and procedure type.

When can I drive after tenotomy?
If the right ankle is treated, wait until you can perform an emergency stop safely and are off sedating medications. Your surgeon will give individualized guidance—often a few days to a week for percutaneous procedures.

What are the chances I’ll need a second procedure?
Most patients do well with one intervention plus diligent rehab. Occasionally, persistent insertional impingement or incomplete relief may prompt additional treatment. In infants, a second tenotomy is rarely needed if equinus recurs.

What are the main risks I should weigh?
Infection, sural nerve irritation, over-lengthening (in lengthening procedures), scar tenderness, and persistent pain if loading errors remain. Ultrasound guidance and careful technique reduce risks.

Will I lose calf strength?
Microtenotomy aims to preserve strength. If a lengthening is performed for equinus, a short-term drop in push-off strength can occur; rehab restores as much function as possible while the gait improves.

Is tenotomy better than shockwave or PRP?
They serve different roles. Many succeed with exercise therapy plus ESWT. Tenotomy is considered when conservative care fails or when imaging shows persistent degenerative zones. Your plan is personalized to your goals, sport, and timeline.

Can a corticosteroid injection help instead?
Corticosteroids around the tendon may reduce bursitis, but intratendinous steroid injections are generally avoided for Achilles due to rupture risk. Your clinician will advise based on your specific pathology.

Do heel lifts or orthoses still matter after tenotomy?
Yes. Managing compressive loads (especially in insertional disease) with heel lifts and shoe changes can be crucial during healing and beyond.

Does Achilles tenotomy help Haglund deformity?
If bony impingement is significant, open debridement of the tendon and prominence (and bursa management) may be more appropriate than microtenotomy alone.

Is the procedure safe for people with diabetes?
With good glycemic control and sterile technique, procedures can be performed safely; however, wound healing risks are higher. Conservative care is preferred first, and meticulous aftercare is essential.

Will I have a scar?
Percutaneous tenotomy leaves a tiny puncture or micro-incision. Open procedures have small incisions; your team will provide scar-care tips to optimize healing.

How can I avoid needing a tenotomy in the future?
Train with progressive load increments, rotate footwear, maintain calf strength and flexibility, prioritize recovery sleep/nutrition, and address early tendon pain promptly.

Take the next step

If you’re in Bangalore and want a specialist review of your case or imaging, our foot & ankle team can help evaluate whether microtenotomy, debridement, or continued conservative care is best for you. Start with a consult via our Contact page.

Key takeaways

Achilles tendon tenotomy is a precise, often minimally invasive option after thorough conservative care fails.
Technique is tailored to the problem: microtenotomy for degenerative tendinopathy, open debridement for insertional calcific disease, and brief percutaneous release in infant clubfoot.
Outcomes are best when the procedure is integrated into a structured, progressive rehabilitation program and biomechanical load management.
A personalized plan—grounded in imaging, your sport, and your goals—matters more than any single technique.

Resources and references

Cleveland Clinic: Tenotomy—Procedure, What It Is & Why It’s Used 
Johns Hopkins: Percutaneous Needle Tenotomy for Tendon Injuries 
PM&R KnowledgeNow: Achilles Tendinopathy 
Systematic Review: Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies (Sports Health, 2020) 
Safety of Ultrasound-Guided Tenotomy & Debridement (Iowa Orthopaedic Journal, 2021) 
NHS patient leaflet: Percutaneous Achilles Tenotomy in Clubfoot—Ponseti Method (Chelsea & Westminster) 
Physiopedia: Achilles Tenotomy 
HSS: The Ponseti Method for Clubfoot Correction 

Disclaimer

This article is for educational purposes and does not replace medical advice. Always consult a qualified orthopedic specialist for personalized recommendations.