The Achilles tendon is the largest tendon in the body and runs just behind the ankle. It is the tendon that connects the heel bone to the calf muscles, supporting the lower body when you walk, jump, or run. The Achilles tendon is vulnerable to injury in athletes of all sports— tendonitis can be an overuse phenomenon. The pain can occur in two primary locations: at the insertion of the tendon or a few centimeters above. It is a common, yet painful injury, that if not treated can sideline athletes for weeks to months.
The primary complaint from patients suffering from Achilles tendonitis is pain and swelling just proximal to the heel. The pain can often be felt just above the area where the tendon attaches at the heel or directly at the attachment site. Pain is often the most intense after a period of sitting or long segments of inactivity while the tissue is not properly warmed up. Pain is also usually present during sporting activities or exercise where running is involved.
Our physicians will perform an extensive physical exam including x-rays of the heel. X-rays allow the identification of calcaneal bone spurs or calcifications within the tendon. X-rays also allow identification of a Haglund’s deformity which can exacerbate Achilles tendon pain. An MRI is sometimes indicated to evaluate for partial tearing of the tendon or stress fractures of the calcaneus (heel bone). Our physicians will complete a through physical exam including evaluation of the Achilles tendon for tightness.
Achilles Tendon Non-Surgical Treatment
Early treatment of Achilles tendonitis depends on whether it is insertional or non-insertional. Insertional tendonitis is an inflammatory condition and is treated with non-steroidal anti-inflammatories, eccentric stretching exercise, and a silicone heel lifts.
Non-insertional Achilles tendonitis occurs in the “watershed” area of the Achilles with limited blood supply. This is usually thought of as damage to the tendon with limited blood supply which would heal the injury. Initial treatment involves stretching exercises and relative rest for the tendon with use of a heel lift.
In cases that present more severe symptoms, we may prescribe a boot, crutches, or complete immobilization of the ankle (cast). Other minimal invasive treatment includes the use of biologic injections into the tendon including PRP or BMCC. Steroids are not recommended as these can weaken the tendon and lead to rupture.
Surgical Treatment of Achilles Tendon Injury
In many cases, surgery will not be necessary in patients who have Achilles tendonitis. If conservative treatment fails to work after weeks to months, our physicians may suggest surgery. Surgery for Achilles tendonitis will depend on the location of the disease and the amount of damage to the tendon.
Achilles Tendon Surgical Procedures:
A surgical stretching or lengthening of the calf muscle is known as gastrocnemius recession may be recommended. Patients with tendonitis typically put additional strain on their calf muscles because the tendons become thick and tight. Patents who have a difficult time stretching or flexing their feet may benefit from this procedure. During this technique, one or two of the muscles that make up the calf are lengthened to allow for this additional flexibility.
For insertional Achilles tendonitis with a Haglund’s deformity, a debridement of the diseased tendon and excess bone is typically recommended. This procedure is done with a direct posterior incision and involves a few weeks of non-weight bearing after surgery to allow the tendon to heal.
Non-insertional Achilles tendonitis is treated surgically with percutaneous or open debridement (removal) of diseased tissue. Percutaneous removal is typically done with ultrasound guidance and the use of a Tenex device. Diseased tissue is removed by the back and forth action of a needle placed into the damaged tissue. This procedure typically allows for immediate weight bearing in a CAM boot.
Open debridement of non-insertional Achilles tendonitis is the other surgical option. This involves a larger incision and direct, open removal of diseased tissue. A transfer of the flexor hallicus longus muscle is occasionally needed to add strength to the Achilles tendon after open debridement.
Post-Operative Care for Achilles Tendon Surgery
Operative intervention can done as an outpatient or inpatient procedure depending on the specific surgery. Surgery is typically done with regional nerve blocks to control postoperative pain. Depending on the surgery the patient will be allowed to immediate weight bear in a CAM boot or may require 3-6 weeks of non-weight bearing to allow the tissue to heal. Most patient require a 6-8 week course of physical therapy after their immobilization.
At a Glance
Dr. Brian Waterman, MD
- Chief & Fellowship Director, Sports Medicine, Wake Forest
- Team Physician, Wake Forest University, Chicago White Sox
- Military affiliation/Decorated military officer and surgeon
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