Tendon Lengthening for Muscle Contractures

Wise Young, Ph.D., M.D.
W. M. Keck Center for Collaborative Neuroscience
Rutgers, State University of New Jersey, Pisacataway, NJ 08854
Email: wisey@pipeline.com, Updated: 21 June 2006

[This is an article that I originally wrote for CareCure in 2006.  Because people have continued to ask questions about tendon lengthening, I reproduce it here for easier citation]  Several people have written to me about tendon lengthening to relieve spasticity. I thought that it might be useful to describe and comment on the procedure.

Spasticity and Contractures. Spasticity induces and is aggravated by muscle contractures. Muscles contain receptors called spindles that monitor tension and feeds back to the spinal cord to maintain muscle length. Injury to the spinal cord increases excitabilty of neural circuits that control muscle tension. Spastic muscles resist changes of tension by contracting. Prolonged and continuous muscle spasticity may lead to muscle contracture or shortening of muscles. Contractures interfere with standing and walking. While drugs such as baclofen and tizanidine moderates spasticity, they usually cannot moderate muscle contractures.

Treatments of Contractures. Clnicians use three ways to relieve spasticity muscle contractures. One is to inject a toxin called Botox which damages motor nerves and, in high doses, the motoneurons that innervate muscles. The other is to inject phenol, a chemical, that damages both motor and sensory nerves. A third way is to cut the muscle tendon and lengthen the tendon to relieve the tension on the muscle. The first two methods damage motoneurons or axons, sometimes irreversibly, and may cause weakness of muscles. For people who have some muscle function, tendon lengthening is the method of choice.

Tendon Lengthening. The basic tendon lengthening procedure involves cutting the tendon partway at two points and a cut down the middle of the tendon. This allows the two halves of the tendon to be slid along each other and then sewed together, as illustrated in the diagram below. The procedure is simplified for illustrative purposes but it shows how the cuts (left image) can allow two strands of tendon to be slid alongside each other (middle image), and sewed together (right image). Note that there are other ways to cut the tendon, including methods that involving creating four strands and splicing these strands together. Once healed, the tendon is longer and the cut parts will fill out with scar tissues.

Strength of Repaired Tendons. Tendon lengthening procedures have been carried out for many decades. In fact, I use to participate in such surgeries for children with cerebral palsy and idiopathic toe walking (Source). Children who undergo tendon lengthening even of big musles such as the leg flexors (Source) can return to athletic activities. Many athletes of course rupture their tendons, undergo tendon repair, and then return to their previous activity. Repaired tendons have a scar and the strength of the scar depends on how it healed. The tendon should be immobilized for about four weeks the healing to take place (Source). Properly healed tendons are reasonably strong.

Complications. Making the tendons too long or not lengthening the tendon sufficiently can result in weakening of the muscle (Source) or insufficient resolution of the spasticity. Both surgical experience and judgment is required to get the proper lengthening without significantly weaking the muscle. For obvious reasons, it is not good to go in numerous times to repair the tendon. Repeated surgeries and scar tissues will cause stiffening of the tendon and lost of elastic recoil. Muscle weakness due to immobilization and non-use may be a problem and full function may not return to pre-operative levels for as long as 9 months after surgery, even with intensive physical therapy (Source). The change in one muscle group may affect the balance of other muscles, resulting in abnormal gait (Source).

In summary, tendon lengthening surgery has been practiced for many decades. The procedure does reduce spasticity of major muscle groups and well-healed tendons are strong enough to permit renewal of athletic activity. However, the operation requires experience and good surgical judgment. Like all operations of this nature, complications may occur. Immobilization of the tendon is important for proper healing. Overlengthening, repeated operations, and muscle weakness may occur. The advantages of tendon lengthening is that it may correct specific orthopedic problems and spasticity without damaging nerves or motoneurons.

Figure 1.  Schematic diagream of tendon lengthening.  The surgeon cuts the tendon partway at two points and then a longitudinal cut down the midline of the tendon.  The tendon can then be slid along each other and then sewn together at the appropriate place.  Scar tissue will fill in the rest.

See discussion in http://sci.rutgers.edu/forum/showthread.php?t=64704


17 Responses to “Tendon Lengthening for Muscle Contractures”

  1. Jan Says:


    I was wondering how soon a child should be able to start to weight bear and walk after TA lengthening surgery if that was the only surgery done and pain wasn’t too much of an issue? I have a child who was told not to weight bear for at least 2 weeks post surgery.

  2. Patricia Holloway Says:

    My son had suffered a stroke while I was still carrying him, He is 13 years old. He has trouble with his left side, specifically left hand and foot. I took him to a orthopedic surgeon (pediatric) and he is recommending tendon lenghtening? Not sure what to do or expect from this procedure or if I should even do it.

  3. Anita Says:

    Will the lack of weight bearing activity after such a surgery make ambulation difficult in a boy with duchenne muscular dystrophy?

  4. Emily Says:

    I am trying to come up with a price of how much a tendon lengthening surgery may cost for someone who does not have insurance in Michigan. Any idea of an approximate amount? Any help would be greatly appreciated! Hope you have a wonderful New Year :o)

  5. Joyce Says:

    My podiatrist over lengthened my ehl tendon. Now my big toe will not raise. Can this be reversed!

  6. Rajat Gupta Says:

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  7. Narendra Says:

    Good afternoon dr.

    My son is born with minor CP which has effected his left part of his leg and we had carried tendon elongation surgery at the age of 5 year 5 month . Now he is 9 year old and again his situation is as before i.e he limp his leg and walk i.e spasticity on left side of leg.
    Now the same Dr.Gowardhan Ingale who has done surgery is recommending to go for botox injection and plaster of 3 week. Need your suggestion whether this will help my son. Doctor informed his stage of continuing physio-therapy has exceeded, tightness is more go for botox injection.

    We parent are not in a stage to decide whether to go with botox or not.

    Need your recommendation and suggestion to come to conclusion and proceed further. I am from India, Pune.


    • Wise Young Says:

      Narendra, sorry about the long delay. I have not looked at this web site for a while. I cannot give advice regarding a specific case. Botox is frequently used to relieve spasticity of a given muscle. You should keep two things in mind. First, botox weakens the muscle. Second, the effect of botox is usually temporary and must be accompanied by physical therapy to increase the effect. Wise.

  8. Timm Teakle Says:

    Has any one had tendon lengthening off the pelvic bone on the abductor magnus before?. This may be my last resort to relieve pain & to fix the problem,just scared whether it may work or not? can anyone shed some light on this for me please!

    • Wise Young Says:

      Are you sure that you are considering tendon lengthening of the ABDUCTOR magnus? Tendon lengthening surgery is frequently used for the adductor magnus tendon, which pulls the leg inward.

  9. p c muscle Says:

    p c muscle

    Tendon Lengthening for Muscle Contractures | Wise Young @ CareCure

  10. Damo Naiko Vikram Says:

    What is the advisable age to do tendon lengthening for child?

    • Wise Young Says:

      Obviously, the surgery should be done when the child needs the tendon lengthening for specific activities, such as walking. This is not a preemptive type of procedure. It is used only when physical therapy and other attempts to stretch the tendon have failed.

  11. DARON Says:


  12. DARON Says:


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