What is an Achilles Tenotomy?
An Achilles tenotomy is a minor procedure that releases the tight Achilles tendon at the back of the ankle. It's a crucial step in Ponseti treatment for clubfoot, needed by approximately 80-90% of babies to achieve full correction.
The procedure allows the foot to flex upward (dorsiflex) properly, which casting alone often cannot fully achieve due to the tightness of the Achilles tendon.
Why is the Tenotomy Needed?
During clubfoot, the Achilles tendon is abnormally tight and short. While the casting phase successfully corrects most of the foot deformity, the tendon often prevents the final piece of correction - allowing the foot to flex upward past neutral position.
Without adequate dorsiflexion:
- The heel would remain in equinus (pointed down)
- Walking would be affected
- Risk of relapse would be much higher
When is the Tenotomy Performed?
The tenotomy is typically done:
- After all casting is complete (usually 5-7 casts)
- When the foot has been corrected except for the equinus
- Usually when babies are 6-12 weeks old
- Before starting the boots and bar phase
The Procedure Explained
Before the Tenotomy
- Your specialist will explain the procedure and answer questions
- You may be asked to feed your baby normally beforehand
- The procedure is typically done in the clinic, not an operating theatre
- Some centres allow parents to stay; others prefer you to wait nearby
During the Procedure
The tenotomy itself is remarkably quick and simple:
- Local anaesthetic: A small injection numbs the area around the tendon
- Tiny incision: A very small cut (2-3mm) is made through the skin
- Tendon release: The Achilles tendon is cut with a small blade
- No stitches needed: The incision is so small it heals without stitches
Total time: 5-10 minutes
Immediately After
- A final plaster cast is applied with the foot in the corrected position
- The foot is held at about 15 degrees of dorsiflexion
- This cast stays on for 3 weeks while the tendon heals
- You can take your baby home the same day
Pain and Discomfort
Parents often worry about pain, but the procedure is very well tolerated:
- The local anaesthetic prevents pain during the procedure
- Most babies settle quickly and may even sleep through it
- Some fussiness for 24-48 hours after is normal
- Infant paracetamol can help if needed
- Most babies return to their normal selves within a day or two
How the Tendon Heals
The remarkable thing about the Achilles tenotomy is how the tendon regenerates:
- The tendon regrows at the correct, longer length
- New tendon tissue forms within the gap
- The cast holds the foot in position during healing
- By 3 weeks, the tendon is healed and stronger
- The regenerated tendon functions completely normally
The 3-Week Cast Period
What to Expect
- This cast is similar to the previous casting phase
- Same care instructions apply
- Keep the cast dry
- Monitor toe colour, warmth, and movement
Signs the Tendon is Healing Well
- Baby settles into normal routine
- No signs of infection (redness, swelling, discharge)
- Normal feeding and sleeping patterns
When to Seek Help
Contact your clinic if you notice:
- Fever over 38°C
- Redness or swelling around the ankle area
- Discharge or bad smell from the cast
- Unusual distress that doesn't settle
After the Cast Comes Off
When the final cast is removed after 3 weeks: For more details, see our full Ponseti method overview.
- The foot should be fully corrected
- You may see a small scar at the heel (often barely visible)
- The foot can now flex upward properly
- Boots and bar fitting happens immediately
Tenotomy vs. No Tenotomy
A small percentage of babies (10-20%) don't need a tenotomy. This is determined by:
- Whether the foot can dorsiflex past neutral with gentle pressure
- The specialist's assessment of tendon tightness
- The severity of the original clubfoot
If no tenotomy is needed, your baby moves directly to the boots and bar phase after the last cast.
Questions Parents Often Ask
"Will it leave a scar?"
Yes, but it's typically tiny (2-3mm) and often becomes almost invisible over time. Many parents can't find the scar later in childhood.
"Is it really necessary?"
For most babies, yes. Without adequate dorsiflexion, the correction won't be complete and relapse risk is much higher. Trust your specialist's recommendation.
"Why not do it under general anaesthetic?"
Local anaesthetic is safer for young babies and equally effective. The procedure is so quick that general anaesthesia isn't warranted. Some complex cases may be done under sedation. You might also find our casting phase before tenotomy helpful.
"What if my baby needs another tenotomy later?"
Repeat tenotomy is sometimes needed for relapsed clubfoot. This is more common if boots and bar compliance was inconsistent. It remains a safe, effective procedure.
Long-Term Outcomes
Research shows excellent long-term results after tenotomy:
- The Achilles tendon regains full strength
- Children walk, run, and play normally
- No ongoing weakness or problems
- Sports participation is not affected
Preparing Emotionally
It's natural to feel anxious about your baby having a procedure. Remember:
- This is a routine part of Ponseti treatment
- Thousands of tenotomies are performed safely each year
- The benefits far outweigh the brief discomfort
- Your baby won't remember it
- Talk to other parents who've been through it
Support Resources
- STEPS Charity: Connect with families who've been through tenotomy
- Clubfoot support groups: Share experiences and get reassurance
- Your Ponseti clinic: Ask all your questions before the day