Clubfoot tenotomy

A release of the Achilles tendon, done through the skin, usually in clinic, usually under local anesthetic. It takes moments. And it almost always means casting is working, not failing.

Written by Heath, who has lived it: casts from birth, a fusion at sixteen, the US Army, and distance running.

The word does most of the damage. For many parents this is the first time anyone has said their baby needs a procedure and not another cast, and the mind goes straight to an operating theater.

So here is the shape of it before anything else: a very small cut, a tendon that is deliberately allowed to heal longer than it was1, and a cast to hold the position while that happens. Most families are home the same morning.

Why the heel cord needs it

Serial casting is very good at the front and middle of the foot. Week by week it unwinds the arch, brings the forefoot out, and rotates the heel. What it cannot reliably do is lengthen a tight Achilles tendon holding the ankle in a toes-down position.

So a foot arrives near the end of casting looking largely corrected from below and still pointing downward from the side. That is the gap a tenotomy closes. Releasing the tendon lets the ankle come up, and the last piece of the correction falls into place.

The earlier casts do everything they can reach. The tenotomy handles the one thing they cannot.

What the appointment is actually like

Numbing

Local anesthetic at the back of the ankle. For most babies this is the part they object to, and the objection is to being held still as much as to the needle.

The release

A tiny opening through the skin and a release of the tendon. It is over in moments, and there is usually little to see afterward beyond a small dressing.

The final cast

Applied straight away with the ankle held in its new position1. This is the longest part of the visit, and the part doing the most work over the following weeks.

Practices differ. Some clinics use sedation or a theater setting, particularly for older or larger babies, and some use a stitch where others use none. If your clinic describes it differently from this, follow them.

The final cast is not just another cast

It is easy to read the last cast as an afterthought (a formality while things settle). It is closer to the opposite. The tendon heals at whatever length it is held at, so the cast is actively setting the result. That is why it typically stays on around three weeks, not the weekly rhythm you have been living with.

When it comes off, bracing starts immediately. There is usually no gap, because a corrected foot with nothing holding it is exactly the situation bracing exists to prevent. The bracing guide covers what that first day looks like.

Where you are

Pick the stage you are at

Choose where you are now to see what is happening, what to ask, and what is worth a call.

Just told a tenotomy is needed

In most cases this means casting has done what it can reach. The front and middle of the foot are corrected, and the tight heel cord is the last piece.

What it isA release of the Achilles tendon through a tiny opening, usually in clinic and usually under local anesthetic.

Worth askingWhere it will be done, whether your clinic uses local anesthetic or sedation, and how long the final cast stays on.

Worth knowingPractices differ. If your clinic describes it differently from this page, follow them.

The day of the tenotomy

Numbing at the back of the ankle, the release itself, which is over in moments, then the final cast. The cast is the longest part of the visit.

What babies object toMostly the numbing, and being held still.

BringA feed. It settles most babies faster than anything else.

Most familiesAre home the same morning.

The final cast, around three weeks

This cast is setting the result. The tendon heals at whatever length it is held at, which is why it stays on longer than the weekly casts did.

Worth a callBleeding through the cast that spreads, a fever, a strong or worsening smell, or swollen toes.

Also a callToes that look dusky or will not pink up when pressed, or a baby who cannot be consoled and will not feed.

Common and fineOrdinary fussiness on the first evening.

The cast comes off

Bracing starts straight away. There is usually no gap, because a corrected foot with nothing holding it is exactly what bracing exists to prevent.

Ask before you leaveWhich brace, how many hours a day, and when the next check is.

NextThe first day in the brace.

Worth a call in the days after

Bleeding through the cast that spreads instead of settles, a fever, a strong or worsening smell, swelling of the toes, toes that look dusky or will not pink up when pressed, or a baby who cannot be consoled and will not feed. Ordinary fussiness on the first evening is common; a baby who is inconsolable is not.

Sources

Where this comes from

1 Diagnosis and Treatment of Idiopathic Congenital ClubfootAmerican Academy of Pediatrics, 2022 2 Clubfoot overview and treatmentAAOS OrthoInfo 3 Scar characteristics of percutaneous Achilles tenotomy in Ponseti Technique-A cross-sectional studyGarg et al. J Clin Orthop Trauma, 2025. PMID 40538446 4 Rangasamy K, et al. Techniques, anaesthesia preferences, and outcomes of Achilles tenotomy during Ponseti method of idiopathic clubfoot correction: a systematic reviewThe Foot, 2022

Tenotomy questions

What is the success rate of a tenotomy?

High, and the failure figure is the useful one. A systematic review of nineteen studies put the pooled failure or relapse rate after Achilles tenotomy at 4.2 percent, and the rate of needing the tenotomy repeated at 2.5 percent when it was done in clinic under local anaesthetic and 0.8 percent when done in theatre under general, a difference that was not statistically significant.4 The same review notes the procedure is needed in 80 to 90 percent of idiopathic clubfeet.4

What are the risks of a tenotomy?

Low, and specific rather than vague. Across that same review the complication rate was 1.6 percent for clinic tenotomies under local anaesthetic and 0.5 percent in theatre under general, again not a statistically significant difference.4 Bleeding is the most common complication and is controlled in most cases by pressure on the spot.4 The authors’ conclusion is worth knowing before anyone worries about where it is done: in clinic under local is safe and cost-effective, with success rates similar to theatre.

Is a tenotomy surgery?

Technically yes, but it is very small. A release of the Achilles through the skin, often in clinic under local anesthetic. It is not comparable to the open surgical releases clubfoot used to require.

Does it mean casting failed?

No. It usually means casting worked. The earlier casts correct the midfoot and forefoot; the tenotomy addresses the one part casting cannot reach. It is a normal step, not a rescue.

Does it hurt the baby?

The area is numbed. Babies often cry at being held still and at the injection and not at the release itself, and are usually settled and feeding shortly afterward. Discomfort in the following days is generally mild.

How long does it take?

The release itself takes moments. Most of the appointment is numbing, positioning and applying the final cast, so expect to be there far longer than the procedure lasts.

What is the final cast doing?

Holding the ankle in its corrected position while the tendon heals at a longer length. It is part of the correction, which is why it usually stays on around three weeks.

Does the tendon grow back?

It heals and reconstitutes at a longer length, which is the point. The Achilles is not removed or permanently shortened, and children who have had a tenotomy go on to walk, run and jump.

What comes after the final cast?

Boots-and-bar bracing, starting as soon as the cast comes off. The focus shifts from achieving the correction to holding it.

Does a tenotomy mean casting failed?

No. It usually means casting worked. The earlier casts correct the midfoot and forefoot, and the tenotomy addresses the one part casting cannot reach. A heel cord that stays tight. It is a normal step, not a rescue.

Does the tenotomy hurt the baby?

The area is numbed. Babies often cry at being held still and at the injection instead of at the release itself, and are usually settled and feeding shortly afterward. Discomfort in the days after is generally mild.

Will my child need a second tenotomy?

Some children do, usually where relapse brings the tightness back. It is not the expected path, and it does not mean the first one failed.

Will the tenotomy leave a scar?

A small one. In a study of 82 tenotomy scars in 50 children, most were close to normal skin by follow-up, none were raised or keloid, and every child walked in normal shoes.

Around this step

Before and after

Casting schedule →The weeks that lead up to this. Bracing guide →What starts the day the final cast comes off. Questions to ask →If you want to arrive with better questions.