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 tendinosis) and well above the heel (non-insertional tendinosis).
Insertional Achilles tendinosis
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.
Treating Insertional Achilles tendinosis
Non-operative treatment
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
If non-operative management fails or is inappropriate, then surgical treatment is indicated.
Surgery
Surgery involves several procedures done at the same time:
- Removal of the bony spur
- Removal of worn out tendon
- Re-attaching 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 arear of tendon are removed. The tendon is then re-attached to bone using a bone anchor that is bioabsorbable.
This is significant surgery and recovery is prolonged.
You need to be in hospital one or two days and on crutches for the first two weeks. A three-quarter plaster or back slab is used for the first two weeks with crutches.
Then the back slab is removed, and a fibreglass cast or moonboot is applied for another six weeks.
The heel remains a little swollen for several months and It can take up to a year to fully recover.
Non-insertional Achilles tenodesis
The other common site of Achilles tendon problems is about 5cm above the heel.
The area becomes tender to touch and increasingly painful with activity. It is not known why this starts but it is common in runners.
Eventually a small lump may develop or the whole tendon may become swollen.
Treating Insertional Achilles tendinosis
Non-operative treatment is the same as that for insertional Achilles tendinosis.
Surgery is a smaller procedure than for insertional tendinosis. It means an incision about 7cm 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 injections of blood thinning medication to reduce the risk of blood clots.
Usually the plaster is removed at this stage and a removable walking boot or a walking fibreglass cast is applied for another four weeks.
It takes months for swelling in the foot and ankle to subside and up to twelve months to fully recover.
Potential surgery risks
You should be aware that all surgery has a risk of complication, and this surgery is no different.
Medical complications that can occur include:
- Heart attack
- Stroke
- Drug reaction
- Blood clots in the legs or lungs (medication may be given to reduce the risk)
- And even death in the 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 the 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 after surgery if a complication develops that cannot be easily fixed.
A more detailed discussion of your individual case will be made at the consultation.
