Tenotomy is a surgical procedure in which a tendon is deliberately cut, either partially or completely, to relieve tightness, correct a deformity, or reduce pain caused by chronic tendon disease. The word itself comes from the Greek roots for “tendon” and “to cut,” and the procedure has been performed in various forms since the nineteenth century. What makes tenotomy so versatile is that tendons exist throughout the body, so the operation shows up in a surprisingly wide range of specialties, from pediatric orthopedics to ophthalmology. The specifics of how it is done, what it treats, and what to expect afterward depend entirely on which tendon is being addressed and why.
How the Procedure Works
At its most basic, a tenotomy involves dividing tendon fibers so that a tight or damaged tendon can no longer pull a joint into an abnormal position, or so that diseased tissue can be removed to promote healing. The cut can be complete, severing the tendon entirely, or partial, weakening it enough to restore balance without fully disconnecting it. Surgeons can perform tenotomy through an open incision, through a tiny skin nick using a needle or blade (percutaneous), or with image guidance using ultrasound. In a cadaver study testing percutaneous needle tenotomy across multiple body sites, about 72% of tenotomies achieved a complete cut, roughly 25% were partial, and about 3% failed to adequately divide the tendon.1Annals of Physical and Rehabilitation Medicine. Effectiveness and complications of percutaneous needle tenotomy with a large gauge needle for muscle contractures: A cadaver study
The choice between open and percutaneous approaches matters for recovery. Animal research comparing the two methods on the Achilles tendon found that percutaneous tenotomy led to faster early functional recovery, less inflammation in the first week, and earlier restoration of mechanical strength compared with open tenotomy.2PubMed. Comparative analysis of Achilles tendon healing outcomes after open tenotomy versus percutaneous tenotomy: An experimental study in rats That aligns with the general surgical principle that smaller incisions mean less tissue disruption and quicker healing, which is why percutaneous techniques have become increasingly popular across tenotomy’s many applications.
Clubfoot Correction in Infants
The single most well-known use of tenotomy is in the treatment of clubfoot, a congenital condition where a baby’s foot is twisted inward and downward. The standard approach worldwide is the Ponseti method: a series of gentle manipulations and casts gradually coax the foot into a more normal position over several weeks. But even after the casting phase succeeds, many babies still have a tight Achilles tendon pulling the heel up (called equinus deformity). At that point, a small Achilles tenotomy is performed to release the remaining tightness. This step is needed in a large majority of cases, with one study reporting it in about 85% of clubfoot patients.3PubMed Central. A mini-open technique for Achilles tenotomy in infants with clubfoot
The rate can vary depending on casting technique and when the clinician decides the tendon needs to be cut. A study from Lagos, Nigeria, reported a lower tenotomy rate of about 23%, suggesting that some populations or treatment protocols can achieve correction with fewer surgical interventions.4PubMed Central. Experience with Ponseti Protocol and Achilles Tenotomy in the Management of Clubfoot at the Lagos State University Teaching Hospital, Lagos, Nigeria Either way, the procedure itself is quick. In young infants, it is typically done under local anesthesia through a percutaneous approach, though research has shown that general anesthesia with sevoflurane leads to significantly less distress, calmer behavior, and better feeding afterward compared with local anesthesia alone.5Archives of Anesthesia and Critical Care. The Efficacy of General Anesthesia with Sevoflurane for Pain Management in Neonates and Infants with Idiopathic Clubfoot Treated with Ponseti Technique and Percutaneous Achilles Tenotomy
The severed Achilles tendon in an infant regenerates remarkably well. A final cast is applied after the tenotomy, and the tendon typically bridges the gap with new tissue within a few weeks. MRI research has explored the ideal location for the cut, concluding that performing it 10 to 20 millimeters above the top of the heel bone offers the best balance between cutting through adequate tendon width and staying a safe distance from nearby blood vessels and nerves.6PubMed. Ideal location for Achilles tendon tenotomy following the Ponseti method for correction of clubfoot deformity: Results of MRI cohort in children 18 months old or younger
Shoulder Surgery and the Biceps Tendon
The long head of the biceps tendon is a frequent source of shoulder pain, particularly when it is torn, inflamed, or involved in injuries to the labrum (the ring of cartilage around the shoulder socket). A specific type of labral injury called a SLAP lesion often involves the point where the biceps tendon anchors to the labrum. When these injuries occur in older or less physically demanding patients, surgeons may opt for a biceps tenotomy, simply cutting the tendon free from its attachment and letting it retract down the arm. In elderly, lower-demand patients, this approach produces reliable pain relief, is technically straightforward, and allows immediate range of motion.7The Open Orthopaedics Journal. A Treatment-Based Algorithm for the Management of Type-II SLAP Tears – Section: Elderly Patient, Low Demand: Biceps Tenotomy
Clinical evaluations consistently show significant improvements in both pain scores and functional measurements after biceps tenotomy for SLAP lesions.8Kahramanmaraş Sütçü İmam Üniversitesi Tıp Fakültesi Dergisi. Effects of Biceps Tenotomy on The Shoulder Joint in the Treatment of Slap Lesions One study comparing tenotomy directly to surgical repair of isolated SLAP lesions found that both groups improved dramatically, but the tenotomy group actually achieved higher postoperative functional scores.9The journal of Tepecik Education and Research Hospital. Comparison of Treatment Outcomes After Arthroscopic Repair and Biceps Tenotomy in Patients with Isolated Slap Lesions That finding has nudged some surgeons toward recommending tenotomy as a first-line option in appropriate patients, rather than reserving it as a fallback.
Tenotomy Versus Tenodesis in the Shoulder
The main alternative to biceps tenotomy in the shoulder is tenodesis, where the tendon is detached from the labrum but then reanchored to the upper arm bone with sutures or a screw. The trade-off between the two comes down to cosmetics versus simplicity. Tenotomy is faster, technically easier, and allows immediate motion. Tenodesis requires more surgical hardware and a longer recovery. But tenotomy carries a higher risk of a cosmetic side effect called the Popeye sign, a visible bulge in the upper arm caused by the detached biceps muscle belly sliding downward.
The reported rate of Popeye deformity after tenotomy varies widely. One multicenter randomized trial found it in about a third of tenotomy patients versus roughly 10% after tenodesis.10Orthopaedic Journal of Sports Medicine. Effect of Age, Gender, And BMI on the Incidence and Satisfaction of A Popeye Deformity Following Biceps Tenotomy or Tenodesis: Outcomes of A Multicenter Randomized Controlled Trial A larger observational study reported it in about 20% of tenotomy patients compared with 6% after tenodesis, with tenotomy carrying roughly three times the risk.11PubMed Central. The impact of biceps tenotomy/tenodesis on Popeye sign incidence and functional outcome Another study reported a higher overall incidence of about 59% after tenotomy, but found that leaner patients with more defined muscle bulk were more likely to develop a noticeable deformity, while those with a higher body mass index were somewhat protected from it cosmetically.12PubMed. Raised body mass index and reduced muscle bulk reduces the incidence of Popeye’s deformity post tenotomy of long head of biceps brachii
Here is the reassuring part: across studies, the Popeye deformity does not appear to affect how well the shoulder actually works. Functional scores and strength outcomes are comparable whether or not the deformity develops.11PubMed Central. The impact of biceps tenotomy/tenodesis on Popeye sign incidence and functional outcome That said, patients who undergo tenotomy do report more perceived downsides overall. In one study, 59% of tenotomy patients reported at least one downside, compared with 37% after tenodesis.13PubMed Central. Biceps tenotomy versus tenodesis: patient-reported outcomes and satisfaction For older adults with large rotator cuff tears, tenodesis may offer more stable functional recovery, though by the final follow-up the two procedures tend to converge in their outcomes.14PubMed Central. The Clinical Outcomes of Arthroscopic Tenotomy versus Tenodesis with Medium-to-Massive Rotator Cuff Tear in the Elderly: A Retrospective Study Tenotomy also tends to deliver faster early pain relief compared to tenodesis, which takes longer to heal but produces better cosmetic results.15Medicine Science | International Medical Journal. Comparative outcomes of biceps tenotomy and tenodesis in the treatment of long head of biceps tendon lesions The decision between them is genuinely individual, hinging on how much the patient cares about arm appearance versus how quickly they want to return to activity.
Cerebral Palsy and Spasticity
Children with cerebral palsy often develop tight muscles that gradually pull their hip joints out of alignment, a process called hip migration. The inner thigh muscles (adductors) are common culprits. Adductor tenotomy, where these tight tendons are released, is one of the earlier interventions surgeons use to slow or reverse hip displacement. A study following children with cerebral palsy after adductor tenotomy found a success rate of about 51%, with the strongest predictors of failure being how far the hip had already migrated before surgery and whether a psoas (hip flexor) release was performed at the same time. When the hip had migrated less than 30% on X-ray, no failures occurred. But when migration exceeded 50%, the failure rate climbed to about 76%.16PubMed Central. Adductor Tenotomy to Treat Progressive Hip Migration in Children With Cerebral Palsy: Identifying Predictors of Success to Guide Clinical Practice The message is clear: earlier intervention, before the hip has shifted too far, gives this procedure the best chance of working.
Researchers have also emphasized that the benefits of adductor tenotomy in cerebral palsy go beyond hip alignment. Releasing these tight muscles improves walking ability, eases hygiene and positioning for caregivers, and reduces pain. The recommendation from one long-term follow-up study was to perform soft-tissue release as soon as the patient shows less than 30 degrees of hip abduction, regardless of age or walking status.17PubMed Central. Results of Adductors Muscle Tenotomy in Spastic Cerebral Palsy The same type of procedure has been used in adults with spinal cord injury when muscle spasticity becomes unmanageable through other means.18PubMed Central. Adductor tenotomy and selective obturator neurectomy for the treatment of spasticity in a man with paraplegia
Diabetic Foot Ulcers and Claw Toes
People with diabetes are prone to developing claw toe deformities, where the toes curl downward and the tips press painfully against the ground. The constant pressure creates ulcers on the toe tips that are notoriously slow to heal. A percutaneous flexor tenotomy addresses this by cutting the tendon on the underside of the affected toe, allowing it to straighten enough that the pressure point shifts away from the ulcerated area.
The results are striking for such a minor procedure. In one study, over 95% of ulcers healed after tenotomy, with a median healing time of 27 days. The procedure was also effective when performed preventively on at-risk claw toes that had not yet ulcerated.19PubMed. The Effect of Percutaneous Flexor Tenotomy on Healing and Prevention of Foot Ulcers in Patients With Claw Deformity of the Toe An earlier report found that all ulcers healed without significant complications when flexor tenotomy was combined with gentle straightening of the stiff middle toe joint, and the entire procedure could be done in an outpatient clinic rather than an operating room.20PubMed Central. Outpatient percutaneous flexor tenotomies for management of diabetic claw toe deformities with ulcers: a preliminary report For patients with diabetes, who face elevated surgical risks and slow wound healing, having a minimally invasive option that can be done under local anesthesia is a significant advantage.
Eye Alignment and Strabismus
Tenotomy is not limited to the musculoskeletal system. Ophthalmologists use a variation of the technique to correct strabismus, the misalignment of the eyes that causes double vision or a noticeable eye turn. The eyes are moved by small extraocular muscles, and selectively weakening one of these muscles through a tenotomy can bring the eyes into better alignment. A mini-tenotomy technique has been developed for small-angle strabismus, where the misalignment is subtle. It weakens the target muscle without the full surgical sequence of detaching, suturing, and reattaching the muscle to the eye wall, making it less invasive than a standard recession procedure.21PubMed Central. Mini-tenotomy procedure to correct diplopia associated with small-angle strabismus
For more complex patterns of eye misalignment, surgeons may combine horizontal muscle surgery with a Z-tenotomy of the superior oblique tendon, a technique that partially weakens the tendon by cutting it in a Z-shaped pattern rather than fully dividing it.22PubMed. Z-tenotomy of the superior oblique tendon and horizontal rectus muscle surgery for A-pattern horizontal strabismus The Z shape preserves some tendon continuity while reducing its overall pull, allowing finer control over the correction.
Chronic Tendon Pain in the Elbow and Hip
When a tendon develops chronic degeneration rather than acute inflammation, the condition is called tendinosis. The tissue becomes disorganized, thickened, and painful, and it often resists conservative treatments like rest, physical therapy, and injections. Percutaneous tenotomy has emerged as a middle ground between continued conservative care and full open surgery for these cases.
Lateral epicondylosis, commonly called tennis elbow, is one of the most studied applications. A systematic review of percutaneous needle tenotomy for lateral epicondylosis found it to be a viable alternative to open surgical release of the common extensor tendon, though the authors noted that the quality of available evidence was generally low.23PubMed. Percutaneous Needle Tenotomy for the Treatment of Lateral Epicondylitis: A Systematic Review of the Literature More recently, ultrasound-guided percutaneous tenotomy using specialized devices has shown encouraging results. A three-year study reported that 94% of patients with stubborn lateral elbow tendinopathy were successfully treated, with pain scores dropping from an average of about 8 out of 10 before the procedure to under 3 afterward, and 84% of patients reporting satisfaction.24Indian Journal of Orthopaedics Surgery. Ultrasound guided percutaneous tenotomy for lateral epicondylosis For chronic tendinosis at the lateral elbow, ultrasonic percutaneous tenotomy and traditional open surgical tenotomy have been found to produce similar outcomes, with meaningful symptom improvement typically occurring by three to six months.25PubMed. Percutaneous ultrasonic tenotomy with the TX-1 device versus surgical tenotomy for the treatment of common extensor tendinosis
The hip area has become another frontier. Trochanteric pain syndrome, a common cause of pain on the outside of the hip, can be stubbornly resistant to physical therapy and injections. A study of combined percutaneous ultrasound tenotomy targeting both the iliotibial band and gluteus medius tendons showed significant, durable improvements in pain, function, and quality of life at one year in patients who had already failed standard conservative treatment.26Pain Physician Journal. Iliotibial-Band and Gluteus Medius Percutaneous Ultrasound Tenotomy for Refractory Trochanteric Pain Syndrome: A Longitudinal Observational Study with One-Year Durability Results
How Surgeons Decide Who Is a Good Candidate
Tenotomy is rarely the first thing tried. For chronic tendon pain, the typical pathway starts with rest, physical therapy, bracing, and possibly injections. Tenotomy enters the picture when these conservative measures have been given an adequate trial and the patient is still struggling. The selection process relies on matching symptoms to imaging findings. Ultrasound is commonly used to confirm that the tendon shows signs of degeneration (areas that appear darker and disorganized on the scan, sometimes with increased blood flow or small tears) before proceeding.27Indian Journal of Musculoskeletal Radiology. Ultrasound-Guided Percutaneous Needle Tenotomy for Tendinosis – Section: US-Guided PNT A tendon that looks structurally normal on imaging but hurts is less likely to benefit from a tenotomy, because the problem may lie elsewhere.
For conditions like clubfoot, the decision is more standardized. If the foot still points downward after serial casting, the tenotomy is a planned next step rather than a last resort. In cerebral palsy, the trigger is typically clinical: when hip abduction drops below a certain threshold or imaging shows the hip starting to migrate, tenotomy is recommended before the window for soft-tissue surgery closes and the child needs a more invasive bony procedure.
Risks and Complications
Tenotomy is generally considered safe, particularly the percutaneous forms. In the cadaver study mentioned earlier, adjacent structures were inadvertently injured in about 2% of 401 tenotomies. The injuries included damage to nearby tendons or muscles in about 1% of cases, nerve injury in 0.7%, and a vascular injury in one case (0.2%).28PubMed Central. Effectiveness and Complications of Percutaneous Needle Tenotomy with a Large Needle for Muscle Contractures: A Cadaver Study These are low rates, but they underscore that the procedure is not zero-risk, especially around anatomically crowded areas where nerves and blood vessels run close to the target tendon.
Other potential complications depend on the specific procedure. In the shoulder, the Popeye sign is the most talked-about issue. In the foot, infection is a concern, particularly in diabetic patients whose immune systems and blood flow may be compromised. In clubfoot treatment, the tendon is expected to heal and the risk of serious complications is low, though performing the cut in the wrong location raises the theoretical risk of injuring nearby blood vessels. For cerebral palsy hip surgery, the complication rate in one large study was about 4%, and the main long-term risk is that the procedure may not hold if the underlying spasticity continues to drive the hip out of position.16PubMed Central. Adductor Tenotomy to Treat Progressive Hip Migration in Children With Cerebral Palsy: Identifying Predictors of Success to Guide Clinical Practice
What Happens to the Tendon Afterward
One of the counterintuitive aspects of tenotomy is that a deliberately cut tendon can heal. In infants undergoing Achilles tenotomy for clubfoot, the tendon regenerates across the gap within weeks, forming new tissue that bridges the cut ends. The quality and speed of that healing can vary. In older children undergoing a repeat tenotomy, MRI studies have shown that the tendon heals more slowly and less completely than in children having it done for the first time.
In adults, tendon healing after tenotomy follows the general principles of scar-mediated repair. Animal research has shown that whether or not a tendon is sutured back together or left to heal on its own, the repair tissue is scar, not a perfect recreation of the original tendon architecture.29PubMed. Achilles tendons of MRL/MpJ mice show scar-mediated healing after tenotomy Experimental work has also found a trade-off between healing speed and the quality of the tendon’s sliding surface. Tendons that heal without any barrier around them regenerate faster, but lose the smooth gliding layer that allows the tendon to move freely within its sheath.30Journal of the Grodno State Medical University. Comparison of 3-Week Calcaneal Tendon Regenerates After Tenotomy and Suturing in Experiment In Vivo In many clinical applications, though, this is not a problem. When flexor tendons in the hand are lengthened by tenotomy at the point where muscle meets tendon, the technique works well for releasing digital stiffness while preserving active motion.31PubMed. Flexor tendon lengthening by tenotomy at the musculotendinous junction
A Procedure With a Long History and a Broadening Future
Tenotomy has been around for a long time. The introduction of subcutaneous Achilles tenotomy in the nineteenth century fundamentally changed the surgical treatment of clubfoot and eventually expanded to include tenotomies of other tendons around the foot and ankle.32PubMed. History of club-foot treatment; part II: tenotomy in the nineteenth century Early surgeons discovered both the promise and the limits of the technique: while it was highly effective for equinus deformities caused by polio, cerebral palsy, and old injuries, clubfoot required more than just releasing the Achilles tendon. The forefoot deformities had to be corrected first, a lesson that eventually led to the modern Ponseti method’s approach of serial casting before tenotomy.
Today the procedure continues to evolve. Ultrasound-guided devices let surgeons target diseased tendon tissue with precision, breaking it up with ultrasonic energy through a needle-sized incision. These technologies are extending tenotomy’s reach into conditions like chronic patellar tendinopathy and refractory trochanteric pain that previously had limited surgical options short of open reconstruction. For patients stuck in a cycle of failed conservative treatments, percutaneous tenotomy offers a step between injections and major surgery that did not meaningfully exist a generation ago.