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Medically Reviewed | Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle, Michigan
Quick Answer:
Quick Answer: Tendon transfer surgery in the foot and ankle involves rerouting a functioning tendon from its normal insertion to a new attachment site to restore lost motor function or rebalance muscular forces across a joint. The core principle: the transferred tendon must be expendable at its original site (synergistic function can compensate) and sufficiently strong (MRC grade 4-5) to perform its new function. Common foot and ankle tendon transfers include: flexor digitorum longus (FDL) to extensor for hammertoe and claw toe correction (Girdlestone-Taylor procedure — flexor-to-extensor tendon transfer, FTFT), where the FDL is released from its plantar attachment and rerouted dorsally to act as an extensor force correcting the clawed position; peroneus longus to peroneus brevis transfer for lateral ankle instability with peroneus brevis rupture; tibialis posterior tendon transfer through the interosseous membrane to the dorsum for drop foot correction (Bridle procedure for footdrop); and extensor hallucis longus transfer to the first metatarsal neck for hallux malleus or claw hallux correction. Recovery involves tendon healing in the new position before active strengthening — typically 6–8 weeks of protected positioning followed by progressive physical therapy.
What Is Tendon Transfer Surgery?
Tendon transfer surgery is a reconstructive procedure where a functioning tendon is detached from its original insertion and reattached to a new location to restore lost motor function, rebalance muscular forces across a joint, or correct a structural deformity. The biological principle: tendons can be rerouted to perform new functions — and with post-operative rehabilitation, the nervous system can learn to activate the transferred tendon in its new role. Successful tendon transfer requires that the donor tendon is strong enough (typically MRC grade 4 or 5) to perform its new function, expendable at its original site (other muscles can compensate), and sufficiently long to reach the new attachment site without excessive tension.
In the foot and ankle, tendon transfers address a range of problems: neuromuscular imbalances from conditions like Charcot-Marie-Tooth disease and stroke-related drop foot, structural deformities like hammertoes and claw toes driven by flexor-extensor tendon imbalance, and reconstructive needs after tendon rupture. Dr. Biernacki performs tendon transfer procedures as part of comprehensive foot deformity correction, often combining tendon transfer with osseous (bone) procedures for complete structural restoration.
Flexor-to-Extensor Tendon Transfer for Hammertoe
The Girdlestone-Taylor flexor-to-extensor tendon transfer (FTFT) is the most common tendon transfer procedure in podiatric surgery — addressing the fundamental muscular imbalance driving hammertoe and claw toe deformity. In a hammertoe, the intrinsic foot muscles are insufficient to counteract the pull of the extrinsic flexors (FDL), causing progressive toe buckling. The FTFT corrects this by releasing the FDL from its plantar insertion on the distal phalanx and rerouting the two slips of the divided tendon dorsally around each side of the proximal phalanx to attach to the extensor hood — converting the deforming flexion force into a corrective extension force. The procedure restores the toe to a straight position and provides active extension strength. Typically performed in combination with proximal interphalangeal (PIP) joint arthroplasty or fusion for complete hammertoe correction.
Tibialis Posterior Transfer for Drop Foot
Foot drop — the inability to lift the foot and toes due to loss of anterior compartment muscle function (tibialis anterior, extensor digitorum, extensor hallucis longus) — is corrected with tibialis posterior transfer through the interosseous membrane. The tibialis posterior tendon is detached from the navicular, passed through a window in the interosseous membrane between the tibia and fibula, and attached to the dorsal midfoot or toe extensors — converting a plantar flexion force into dorsiflexion. The Bridle procedure adds peroneus longus to stabilize the transfer. Post-operative rehabilitation is extensive: 6–8 weeks in boot or cast while the tendon heals in its new position, followed by 3–6 months of retraining the nervous system to activate the transferred muscle in its new role.
Dr. Tom's Product Recommendations
Darco Body Armor Short Walker Boot
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Protected walking boot for tendon transfer post-operative recovery — maintains foot and toe in corrected alignment while transferred tendons heal in their new positions during the critical early recovery period.
Dr. Tom says: “My podiatrist prescribed the walking boot after my tendon transfer surgery — it kept my toe in the corrected position while I healed.”
Post-tendon transfer protected recovery, hammertoe surgical boot, toe position maintenance
Patients cleared for regular footwear — boot is only for the protected early recovery phase
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TheraBand Resistance Bands (Set of 5)
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Progressive resistance bands for post-tendon transfer rehabilitation — used in physical therapy to retrain the transferred tendon’s new function through gentle progressive resistance once the tendon is healed.
Dr. Tom says: “My physical therapist used the TheraBands to retrain my tendon transfer — starting with very light resistance and progressing gradually over months.”
Post-tendon transfer rehabilitation, progressive tendon retraining, physical therapy exercise
Early post-operative phase — resistance training begins only after tendon healing is confirmed (typically 6-8 weeks post-op)
Disclosure: We earn a commission at no extra cost to you.
AFO Drop Foot Brace (Ankle-Foot Orthosis)
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Ankle-foot orthosis for managing drop foot while awaiting tendon transfer surgery or during early post-operative recovery — holds the foot in a functional position to prevent foot slap and tripping during ambulation.
Dr. Tom says: “My podiatrist prescribed the AFO brace for my drop foot while we planned my tendon transfer — it allowed me to walk safely and prevented falls.”
Drop foot management, pre-surgical foot drop support, early post-operative ambulation safety
Post-tendon transfer patients once the transfer is functioning — the brace is discontinued as transferred tendon function develops
Disclosure: We earn a commission at no extra cost to you.
✅ Pros / Benefits
- Flexor-to-extensor tendon transfer (FTFT) provides reliable, permanent hammertoe and claw toe correction
- Tibialis posterior transfer restores meaningful dorsiflexion function in drop foot patients
- Tendon transfers address the underlying muscular imbalance — not just the structural deformity
- Combined osseous and soft tissue procedures achieve comprehensive correction in complex deformities
❌ Cons / Risks
- Tendon transfer requires 6–8 weeks of protected recovery while tendon heals in new position
- Drop foot transfer rehabilitation is a 6–12 month process of tendon retraining — results take time
- Transferred tendon must be MRC grade 4–5 strength at the donor site — weak or paralyzed tendons cannot be transferred
- Tendon transfers are permanent — careful pre-operative planning is essential as revision is complex
Dr. Tom Biernacki’s Recommendation
Tendon transfer surgery is elegant reconstructive work — you’re taking a tendon that’s causing a problem in one location and making it the solution in another. The FTFT for hammertoe is satisfying surgery: the biomechanical logic is clear, the execution is precise, and when it works, the toe is straight and functional. Drop foot tendon transfer is more complex — the rehabilitation is long, and the patient has to relearn how to activate the transferred muscle. But for the right patient with the right surgical plan, the functional improvement is transformative. That’s what makes this work rewarding.
— Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle
Frequently Asked Questions
What is a flexor to extensor tendon transfer for hammertoe?
The Girdlestone-Taylor flexor-to-extensor tendon transfer (FTFT) releases the flexor digitorum longus tendon from its plantar attachment and reroutes it dorsally around the proximal phalanx to attach to the extensor hood — converting the deforming downward pull of the flexor into an upward corrective force. The procedure directly addresses the tendon imbalance causing the hammertoe deformity and is typically combined with PIP joint arthroplasty or fusion for complete correction.
How long is recovery from tendon transfer surgery?
Tendon transfer recovery varies by procedure and location. Hammertoe FTFT: 3–4 weeks in post-surgical shoe, return to regular footwear at 6–8 weeks, full activity at 3–4 months. Drop foot tibialis posterior transfer: 6–8 weeks in boot or cast, 3–6 months of physical therapy for tendon retraining, 9–12 months for full functional recovery. Dr. Biernacki provides a detailed recovery timeline at the surgical consultation.
Who is a candidate for tendon transfer surgery?
Candidates for tendon transfer surgery include patients with flexible hammertoe or claw toe deformity where FTFT can correct the imbalance without osseous resection; patients with neuromuscular foot deformities (Charcot-Marie-Tooth, stroke drop foot) where tendon rebalancing restores functional gait; and patients with tendon rupture where transfer of an adjacent tendon restores lost function. All donor tendons must have sufficient strength for their new role.
Is tendon transfer surgery painful?
Post-operative pain from tendon transfer is managed with regional anesthetic blocks placed intraoperatively that provide 12–24 hours of post-operative pain control, followed by oral analgesics as needed. Most patients find tendon transfer recovery manageable with appropriate pain management. The protected boot or cast during early recovery prevents movement that would stress the healing tendon attachment.
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When should I see a podiatrist?
If symptoms persist past 2 weeks, affect your normal activity, or are accompanied by red-flag symptoms (warmth, redness, swelling, inability to bear weight).
What does treatment cost?
Most diagnostic visits and conservative treatments are covered by Medicare and major insurers. Out-of-pocket costs vary by your specific plan.
How quickly can I get an appointment?
Most non-urgent cases see us within 5 business days. Urgent cases (sudden pain, possible fracture) typically same or next business day.
Frequently Asked Questions
When should I see a podiatrist?
See a podiatrist if: foot or ankle pain has lasted more than 2–4 weeks without improvement, you’re changing your gait to avoid pain, you have an open wound or sore that isn’t healing, you notice nail discoloration or thickening, you have diabetes and any foot concern, or pain is severe enough to wake you at night. Most foot conditions are easier and cheaper to treat early — what starts as a minor issue can become a surgical problem with months of delay.
What is the difference between a podiatrist and an orthopedic surgeon?
Podiatrists (DPM — Doctor of Podiatric Medicine) specialize exclusively in the foot, ankle, and lower leg. Orthopedic surgeons (MD/DO) have broader musculoskeletal training but variable foot/ankle subspecialization. For foot and ankle-specific problems, a podiatrist often has more focused training and experience. For injuries involving the leg above the ankle, complex pediatric cases, or multi-level reconstruction, orthopedic consultation may be appropriate. We frequently co-manage patients with orthopedic colleagues.
How do I know if my foot pain is serious?
Signs that warrant same-day or next-day evaluation: severe pain that appeared suddenly without clear cause, swelling, redness, and warmth that appeared suddenly (possible gout, infection, or Charcot fracture), an open wound that looks infected (redness spreading, pus, warmth), inability to bear weight, or any foot problem in a diabetic patient. Pain that’s been present for weeks and is stable is important but not an emergency — schedule within 1–2 weeks.
Can foot problems cause back and knee pain?
Yes — this is a kinetic chain effect. Abnormal foot mechanics (overpronation, supination, leg length discrepancy) cause compensatory changes in knee, hip, and lumbar alignment. Roughly 30% of patients presenting to our clinic with knee pain have a treatable foot-level biomechanical cause. Correcting foot mechanics with orthotics or appropriate footwear often provides significant knee and back relief. If you have chronic knee or back pain and haven’t had your foot mechanics evaluated, it’s worth a consult.
Are orthotics worth it?
For the right conditions, yes — custom orthotics are among the most cost-effective interventions in podiatry. They’re most effective for: plantar fasciitis, flat feet with secondary knee/back pain, leg length discrepancy, metatarsalgia, posterior tibial tendon dysfunction, and diabetic foot pressure management. Quality OTC orthotics ($35–60) resolve symptoms for 60% of patients with mild-to-moderate conditions. Custom orthotics are appropriate when OTC options have failed or when the biomechanical problem is complex. We cast custom orthotics in-office.
How do I choose the right running shoes?
Start with your foot type (flat, neutral, high arch) and running pattern (overpronator, neutral, supinator). Flat feet and overpronators do best in stability or motion-control shoes. Neutral feet do well in neutral-cushioned shoes. High arches need maximum cushioning with flexible soles. Always buy running shoes at the end of the day (foot swelling peaks then), get properly fitted by a specialist, and replace every 300–500 miles. If you’ve been injured repeatedly, a gait analysis can identify the mechanical flaw driving your injury pattern.
What is the difference between a sprain and a fracture?
A sprain is a ligament injury (the tissue connecting bones); a fracture is a break in the bone itself. Both can occur with the same trauma (ankle roll, fall). The old test — ‘if you can walk, it’s not broken’ — is wrong; many fractures are initially weight-bearable. Key differences: a fracture typically produces localized bone tenderness along the bone itself, while a sprain is tender over the ligament. X-ray is the standard to differentiate. High-grade sprains without proper treatment can be as disabling as fractures.
How do I prevent foot and ankle injuries?
The four most impactful prevention strategies: (1) Supportive, appropriately fitted footwear for your foot type and activity. (2) Gradual activity progression — the 10% rule (never increase weekly mileage or intensity by more than 10%). (3) Regular calf and ankle mobility work. (4) Strengthening the posterior tibial tendon, peroneals, and intrinsic foot muscles. Most overuse injuries are preventable; most acute injuries are not — but ankle sprain recurrence (60–70% without rehab) is prevented by balance and proprioception training.
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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.
- Plantar Fasciitis: Diagnosis and Conservative Management (PubMed)
- Plantar Fasciitis (APMA)
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)
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