Chronic Achilles Tendon Problems
Problems involving the Achilles tendon are very common. There are two common sites of trouble: where the Achilles inserts into the heel bone (insertional Achilles tendinopathy) and well above the heel (non insertional tendinopathy).
Insertional Achilles tendinopathy
Where the Achilles tendon inserts into the heel bone is a common site of pain. This area becomes inflamed because of wear and tear. It is more common in runners or in those who have changed their pattern of activity recently. Occasionally it starts in response to poor fitting shoes where the heel counter rubs constantly.
If it does not settle, a bony spur often develops in response to the inflamed tendon and this further irritates and worsens the problem.
Both forms of Achilles tendinosis in early stages may respond to non operative management. This consists of:
- Rest and avoiding certain activities
- Anti-inflammatory medication
- Heel raises
- Stretching exercises of the calf and Achilles
Occasionally a single cortisone injection may be ordered. There is no point repeating it if it wears off or does not work.
If non operative management does not succeed or is inappropriate, then surgical treatment is indicated.
Surgery involves several procedures done at the same time:
- Removal of the bony spur
- Removal of worn out tendon
- Reattaching the tendon to the heel bone
The surgery is performed through a straight incision on the back and in the middle of the heel. The Achilles tendon is peeled off the bone and the spur removed. The damaged and worn out areas of tendon are removed. The tendon is then reattached to bone using bone anchors that are bioabsorbable.
This is significant surgery and recovery is prolonged. You need to be in hospital overnight and on crutches for the first two weeks. A three quarter plaster or backslab is used for the first two weeks with crutches. Usually you will need daily blood thinning medication to reduce the risk of blood clots.
Then a moon boot is applied for six weeks and you can begin weight bearing. The boot can be removed for gentle exercises and showering. The heel remains a little swollen for several months. It can take up to six months to fully recover.
Non insertional Achilles tendinopathy
The other common site of Achilles tendon problems is about 5cm above the heel. This is an area of poor blood supply.
The area becomes tender to touch and increasingly painful with activity. It is not known why this starts, but it is more common in runners.
Eventually a small lump may develop or the whole tendon may become swollen. Stiffness is common particularly after rest or sleep.
Usually chronic pain in this area does not mean the tendon will rupture.
Non operative treatment is the same as that for insertional Achilles tendinopathy (see above).
Surgery is a smaller procedure than for insertional tendinopathy. It means an incision about 6cm long over the tender area in the tendon.
The most damaged part of the tendon is removed and then the tendon repaired. Sometimes a tendon transfer is added to augment the Achilles repair.
This is major surgery and recovery is prolonged. You need to be in hospital overnight and on crutches with a plaster cast for at least two weeks. Usually you will need daily blood thinning medication to reduce the risk of blood clots.
Usually the plaster is removed after two weeks and a removable walking boot or moon boot is applied for another four weeks.
It takes months for swelling in the tendon to subside. Some can take up to twelve months to fully recover.
Complications of Surgery
You should be aware that all surgery has a risk of complications and this surgery is no different.
Medical complications that can occur include:
- heart attack
- drug reaction
- blood clots in the legs or lungs (medication may be given to reduce the risk)
- and even death in very rare circumstances
The chance of one of these happening is very small unless you have serious medical problems.
Surgical complications include:
- Infection: antibiotics are given before and after surgery to reduce the chance of infection but cannot eliminate it.
- Painful scar: can result from the small sensory nerves being caught up in scar tissue.
- Wound healing: problems are rare and tend to happen in diabetics and smokers. If you do smoke you should stop smoking for at least four weeks around the operation.
- Rupture of the tendon: this is an extremely rare problem and can even occur without surgery.
- Failure of the procedure to eliminate pain: approximately 10% of patients need a second operation.
Surgery is very effective in the majority of patients.
However it is possible, although very unlikely, to be made worse by surgery if a complication develops that cannot be easily fixed.
A more detailed discussion of your individual case will be made at the consultation.