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  1. #1

    Tendon Lengthening

    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

    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.
    Last edited by Wise Young; 06-22-2006 at 09:59 AM.

  2. #2
    "Tendon lengthening procedures have been carried out for many decades. In fact, I use to participate in such surgeries for children with cerebral palsy."

    I had this done behind the knees back in '73, shot up 6" almost over night!

  3. #3
    Senior Member zillazangel's Avatar
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    VERY helpful information, thank you!!

    Chad has been in bed so much lately that his foot is contracted, pointing down (like a ballerina). When he was in his chair every day, most of the day, the pressure on his feet from his foot plate and from his standing wheelchair, kept his ankles supple and they did not contract. But he has been in bed for so much of the time the last year or so that his ankles, especially his right for some reason, is really tight. Is that surgery appropriate for him? I'd hate to do any surgery on him just because he is so unwell so much of the time.

    I have been trying to diligently do range of motion and REALLY concentrate on the feet/ankles, but I don't feel like I'm making much of a difference frankly.

    Any advice? And even if not, thanks so much for the post.

    Ami
    Wife of Chad (C4/5 since 1988), mom of a great teenager

  4. #4
    Hi Wise,

    thanks for the interesting info

    Just wondering though........I had always thought that the effects of botox were temporary and that also to allow the tendon after surgery to completely heal, that botox was essential to completely iradicate mobility through, say spasm ( which the discomfort of surgery would heighten too ) ?

  5. #5
    Quote Originally Posted by Cherrylips
    Hi Wise,

    thanks for the interesting info

    Just wondering though........I had always thought that the effects of botox were temporary and that also to allow the tendon after surgery to completely heal, that botox was essential to completely iradicate mobility through, say spasm ( which the discomfort of surgery would heighten too ) ?
    cherry, I wrote a lengthy review of botox but unfortunately I dropped my computer and it is being repaired right now. As soon as I get back my computer, I will post the review.

    Wise.

  6. #6
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    Tendon lengthening

    Dr.,


    I'm a c3-4 incomplete quad 6 years out. I have very limited use of my left arm and left thumb for typing, dialing, etc. I get ranged daily

    My problem is tone and muscle contraction are taking over my body.

    I've had a tone problem for a long time, but it's become progressively worse, and now it's at the point where I'm losing my ability to operate my chair, dial my phone, type on the computer, etc. My tendons are shortening. My hands are knarled and my left arm is becoming increasingly difficult to straighten. I've lost my ability to feed myself and brush my teeth. It's also affecting my abs and chest muscles and ability to breath.

    We've done x-rays, CT scans, endless bloodwork, urine samples, Botox, and I have made a trip to Houston TIRR - Dr. Francisco - to consult with a spasticity specialist . I have a Baclofen pump implanted. It does nothing for my torso but helps some with my legs. I take 32mg Zanaflex daily. An MRI ruled out a syrinx.

    I'm not blocked or impacted, no pressure sores, and no Foley problems. My body is so stiff, I can't sit totally upright in my chair, and I sit on my tailbone, which is sore all the time.

    My docs are at a loss. No one has even mentioned tendon shortening or contracted muscles. I've gleaned that by reading this site. I go to Johns Hopkins. Any ideas for another place to get others involved?

  7. #7

    multiple sclerosis and bilateral transfer

    i have m.s.. i am scheduled to have tendon lengthening and bilateral transfer. im wondering if you know any people with this desease who have had success, with this procedure. june 2009

  8. #8
    Junior Member CJ'S-MOM's Avatar
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    Hi, my son CJ who is an incommplete C5/C6 has contractures in both arms. He did not get much range of motion on them when he was in ICU due to them just trying to save him. They have tried two rounds of botox to straighten them and it didn't work. Now they seem to be getting worse even though he is still doing rehab three times a week and getting range of motion. We want to do the tendon release on both arms and I am trying to push his Dr. in Dallas to go that route. Unfortunately he is on Medicaid now because his Private insurance expired in October. The Cobra was only good for 18 months. I don't know if the Dr who can do this surgery will take medicaid. He can move his wrists but not his fingers. He has great bicep control and gains strength in them weekly. Is this surgery something that will help? I read your article that you wrote in 2006 Dr. Young and it sounds like this is his best option. He used to be able to push himself around pretty good in his manual chair but now his arms are not totally reaching the wheels. What can I do to help get this surgery done for him?

  9. #9
    CJ's mom, sounds like CJ had contractures like my friend after 9 months ICU. Wonder if tendon lengthening would help.
    Last edited by med100; 12-27-2009 at 10:18 AM.

  10. #10
    Junior Member CJ'S-MOM's Avatar
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    Tendon Lengthening

    CJ's SCI doctor is trying to get the surgery lined up for him. There is only 2 doctors that do this surgery in the US according to his SCI Dr. One here in the DFW area and one in Houston. The one here said he would do it so we are working on getting it done. I don't know if it's the answer for everyone but we have tried everything else so this is the next step for us! Have your friend talk to his regular SCI doctor about his options. Has he tried Botox injections yet? We tried twice and it did not help, it's just a temporary fix and they have now gotten tighter! I hope this works for him. I will post the results if we can get it done.

    Thanks,
    Elaine- CJ'S-MOM

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