*Tendon Balancing for Diabetic Foot Ulcers, Foot Pain and Charcot Foot DOI: http://dx.doi.org/10.5772/intechopen.105938*

The intention of tendon lengthening is to decrease force on the area of ulceration. The pressure on the first metatarsal head should decrease with peroneus longus lengthening as the pressure on the fifth metatarsal should be decreased with posterior tibial lengthening. Force on the entire plantar forefoot should decrease with GSR. Armstrong et al. demonstrated that Achilles lengthening does in fact decrease pressure on the forefoot and recommended this procedure to help treat and prevent foot ulceration [27].

Multiple authors lengthened the Achilles tendon by Hoke's method of hemisection at 3 levels of the tendon [25, 33, 35]. Holstein warned that Hoke's procedure for diabetic forefoot ulcers caused 7/75 Achilles ruptures and 11/75 heel ulcers in his patients [35]. Achilles tenectomy for distal ulcers after transmetatarsal amputation had 4/32 (13%) plantar heel ulcers [34]. Subcutaneous tenotomy method of Strohmeyer was used by Yospovitch and Sheskin [24, 43]. Vulpius technique of GSR is used by this author [44]. A very low rate of heel ulcers and other complications of GSR has been reported [2, 26, 36, 41].

Takahashi and Shrestha used the Vulpius procedure successfully to correct Achilles tightness in 230 adults after cerebrovascular accident [1]. Ninety-eight were diabetics and the average age was 68 and had no tendon or incision problems.

The results appear to be good whatever technique of lengthening of the gastrocnemius-soleus or Achilles tendon, [41]. Choice of the surgeon can determine the technique of Achilles lengthening for forefoot ulcers.

Tendon lengthening literature shows better results than other treatments for forefoot and midfoot ulcers [41]. Tendon lengthening should be used more often to treat of diabetic ulcers forefoot and midfoot ulcers [2, 24–26, 29, 33–37, 40, 41].
