The Most Gratifying In-Office Foot Procedure

My favorite thing to see as a doctor is for a patient to get better quickly without hassling with rehab, a long post-op recovery, physical therapy, time lost from work etc. While taking a patient to the OR is often a necessary evil, I believe that it can be avoided much more often. I believe in addressing a patient's main problem and fixing that problem as efficiently as possible.

A perfect example of this is when a patient presents complaining of a painful toe or hammertoe. This pain is usually on the top, tip, or side of the toe and is usually any toe except the great toe. Sometimes there is a callus or a corn. Sometimes there is a little swelling or bursitis around one of the toe joints. As long as the toe can be manually reduced to some degree, I believe a small in-office procedure can significantly reduce or eliminate this pain. The procedure is called a flexor tenotomy. I like to utilize this procedure quite often because it gives immediate results, the dressing is 2-3 bandaids, there are no sutures, no down time or time off from work, minimal chance of complications, it eliminates a trip to the OR and therefore saves thousands of dollars. The thing it is not meant to do is be a cosmetic fix.

The procedure is performed under simple local anesthesia. The sharp beveled edge of a 16g needle is used to pierce the skin on the bottom of the toe beneath the joint where the deformity is. The tendon that keeps the toe contracted down is released with the pinpoint scalpel-like tip of the needle. The toe is then aggressively flexed up and then put through its full range of motion to ensure that the procedure has increased the flexibility in the toe. The toe is dressed and splinted with 2-3 bandaids and the patient is educated on changing these at home for a week and stretching the toe in the opposite direction of the original contracture. The toe that once only touched the ground at the tip of the toe will now be able to lay flatter and the pressure will be placed on the fleshy fat pad of the toe instead of the bony tip. This significantly reduces or eliminates the pain. This has also proven effective for those who have more pain on top of the toe because if the toe is allowed to lay flat then the top of the toe is not fighting with the inside of the shoe. Additionally, if the pain is on the side of the toe from rubbing against the toe next to it, then the increased flexibility in the toe will not so strongly contract it into the adjacent toe and therefore there will be less pressure and less pain.

The flexor tenotomy is not meant to be a cosmetic fix. When not weightbearing, the toe will still appear to be contracted, but when weightbearing it will flatten.

Conversely, the more often performed procedure on these painful toes is to take the patient to the OR, make an incision over the top of the toe, remove a small piece of bone from one or both sides of the most prominent joint, then place a wire down the length of the toe for 4-6 weeks while it heals. Common complications from this are prolonged swelling, pain, and dislocation. Also, since this is an open procedure, the risk of infection is increased.

Conclusion: If you are suffering from any pain in the toes then you should consider the flexor tenotomy in-office procedure.