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Please see foot & ankle anatomy for more information about the Achilles tendon.
Many different names and terms have been used historically to describe problems with the Achilles tendon such as Achilles tendinitis, Achilles tendinosis, Achilles paratendinitis and Achilles paratendinosis. All of these are now out of date, especially as the suffix “itis” suggests inflammation and numerous studies have shown that on the whole the problem is a lack of inflammation and the presence of degeneration instead.
Achilles tendon disorders can be broadly classified into 2 main groups:
1 – Non insertional Achilles tendinopathy 2 – Insertional Achilles tendinopathy
The exact underlying cause (mechanism) is still not clearly understood. What we do know is that multiple factors (multifactorial) are involved. The Achilles tendon is the largest tendon in the body. It is subjected to tremendous loads on a daily basis. The tension across the tendon can be up to eight times the body weight during running and jumping and four times during walking. It is felt that repetitive stresses (microtrauma) results in damage to the tendon. The Achilles tendon does not have a good blood supply, so injuries in this region take longer to heal.
The following factors are associated with the development of Achilles tendinopathy:
It is very important to be sure about the cause of the underlying pain as a number of conditions can cause heel pain, and more than one condition may be attributable.
The following conditions can cause pain around the heel:
An x-ray highlighting the common conditions that cause heel pain
Patients with non insertional Achilles tendinopathy typically complain of the following symptoms:
Patients with insertional Achilles tendinopathy typically complain of the following symptoms:
Clinical picture demonstrating features of insertional Achilles tendinopathy in the left foot with swelling of the distal Achilles tendon and bony enlargement at its insertion into the calcaneum
Investigations are not usually required to make the diagnosis of Achilles tendinopathy. Occasionally investigations will be requested (for example in the presence of atypical symptoms) to confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.
Ultrasound is a quick, painless and non invasive method of visualising the Achilles tendon. It offers excellent real time high definition images of the Achilles tendon. The radiologist will be looking for the presence of the following to confirm the diagnosis of Achilles tendinopathy:
MRI provides excellent high definition static images. It is useful in pre operative planning and to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.
The radiologist and your surgeon Mr Malik, will be looking for the presence of the following to confirm the diagnosis of Achilles tendinopathy:
A – MRI of the Achilles tendon demonstrates this to be a well defined hypointense (dark) structure (arrow) inserting onto the calcaneus, thereafter becoming continuous with the plantar fascia (arrow). B – Abnormal MRI demonstrating thickened Achilles tendon and calcification at the insertion (arrows)
MRI of Achilles tendon demonstrating normal Achilles tendon body with abnormal insertion and island of calcified bone in the tendon (arrow)
MRI of non-insertional Achilles tendinopathy with bone marrow oedema in the calcaneum (blue arrow) and partial tear at the Achilles tendon insertion (yellow arrow)
X-rays are usually not required to confirm the diagnosis of Achilles tendinopathy. However it is a quick and effective way of confirming calcific insertional Achilles tendinopathy in patients with a painful bump at the back of their heel. It is also a useful pre operative test.
Plain radiograph demonstrating calcification in the Achilles tendon at its insertion
CT is rarely used in the diagnosis of Achilles tendinopathy. Very occasionally it may be used for pre operative planning for example in the case of a very large bony calcified Achilles tendon.
A – CT 3D reconstruction demonstrating a large calcified Achilles tendon insertion; B – CT image revealing normal posterior border of heel bone (broken yellow line) and abnormal calcified Achilles tendon insertion behind it
The majority of people with Achilles tendinopathy improve with conservative management. However one third of patients will fail to improve with non operative management and 1 in 20 professional athletes will have to end their career due to symptoms.
Some people with Achilles tendinopathy may go on to develop Achilles tendon rupture. Patients with insertional Achilles tendinopathy often develop progressive calcification (new bone formation) at the tendon insertion into the heel bone (calcaneum). Patients with calcific insertional Achilles tendinopathy may find the bump gets bigger and more symptomatic over time.
An- x-ray of a normal foot, B – Moderate calcification at the Achilles tendon insertion; C – severe calcification at the Achilles tendon insertion
Non-operative management for Achilles tendinopathy aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.
It should always be the first line of treatment. Options include:
A period of rest from sports and exercise that bring on symptoms. New training regime and exercise program.
Avoid footwear and running shoes that aggravate symptoms. Patients with large posterior bumps should wear soft heeled shoes. Patients with tight calf muscles will find that shoes with a slight heel will be more comfortable.
Heel sleeves or pads to cushion the bony prominence from a calcified insertional Achilles tendon.
Custom insoles and orthotics will help correct any underlying lower limb malalignment. Heel raises can ease symptoms in patients with tight calf muscles. Night splints are also available and aim to reduce morning stiffness and pain. Results from studies are inconclusive. Many people find them quite uncomfortable to sleep in.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with early Achilles tendinopathy. Very early in the disease process there is an element of inflammation, but this is short lived and soon the pathology is degeneration with NO inflammation. That is why most people find that NSAID’s do not work, or have stopped working after an initial period of symptomatic relief.
Calf stretches (particularly eccentric) as part of a comprehensive physiotherapy program of at least 3 months, has been shown by studies to alleviate symptoms in approximately 90% of patients.
A tight calf muscle will increase the force going through the Achilles tendon and predispose the tendon to micro-tearing and frank rupture. Reducing tension across a tendon by stretching a tight muscle can help reduce painful symptoms.
The following exercises are recommended as part of any physiotherapy program:
Please read here for more details about the exercises.
Extracorporeal shockwave therapy is a technique that employs the use of a machine that produces shockwaves. It is not entirely understood how it works but it is felt that the shockwaves produce microtears which starts an inflammatory (healing) response. It is also believed that ESWT inhibits pain mechanisms.
Treatment involves 3 sessions spaced 1-2 weeks apart. One session lasts for 15 minutes. It should be noted that this is a painful process. Results are comparable with physiotherapy. Effects will not become apparent for approximately 12 weeks. It is a useful treatment for patients who have failed all other conservative options.
The evidence is not robust, but side effects and complications are minimal. Possible mechanism of action may be that the acupuncture needles cause local microtrauma which results in an inflammatory (healing) response.
There is no one treatment that has a reliably successful, quick and easy cure for Achilles tendinopathy. Therefore researchers and doctors are constantly looking for new and better ways of treating Achilles tendinopathy.
Many treatments have come into fashion and then gone away over the years once results had shown that the initial promise was premature and misplaced.
Current treatment options that have little or conflicting evidence in their favour include:
At The London Foot & Ankle Clinic we do not promote or discourage new treatment options for Achilles tendinopathy. We would however advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. Patients undergo these treatments at their own risk.
There are a number of treatments that involve an injection or series of injections for the treatment of Achilles tendinopathy.
Many patients claim to have had excellent temporary pain relief from steroid injections. However steroids weaken tendon tissue and have adverse effects on tendon healing. Any benefit is short lived and at a considerable risk of tendon rupture, weakened tendon tissue and other complications.
Very few foot and ankle orthopaedic surgeons now inject steroids for Achilles tendinopathy due to these risks and lack of long term benefit. We do not carry out this procedure at The London Foot & Ankle Clinic.
This injection is carried out under ultrasound guidance by a consultant radiologist. High concentration glucose and local anaesthetic is injected alongside (not into the tendon itself) the painful area of the tendon.
The aim is to stimulate inflammation and thereby a healing response. Results are mixed and for that reason this should only be undertaken after conservative measures have failed.
In some patients with Achilles tendinopathy there is evidence on utrasound of new blood vessel formation (neovascularisation) around the damaged tendon. These new blood vessels carry with them pain fibres. The high volume injection aims to damage these new vessels and thereby the accompanying nerve supply which in turn should theoretically reduce pain.
Results are mixed and for that reason this should only be undertaken after conservative measures have failed and in suitable patients.
Platelets are cells in the body that help the blood to clot. They are also felt to have important healing properties. In recent years there has been a lot of interest in injecting concentrated platelets into damage tissue to help promote healing. There is little conclusive evidence to show that PRP injections work. We would only consider this option if a patient accepted that a PRP injection:
The procedure involves drawing some blood, spinning it in a centrifuge and then re-injecting it into the tendon under local anaesthetic. Typically 3 courses of injections spaced 1-2 weeks is necessary. Effects will not become apparent for 8-12 weeks.
Surgical management is reserved for patients who have failed to respond to non operative treatment.
Patients should understand that the decision to undergo surgery should not be taken lightly.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.
This operation involves making a small 2cm incision at the back of the knee and releasing the medial head of the gastrocnemius muscle. It lengthens the calf muscle and relieves the tension across the Achilles tendon. It is very effective in reducing pain and improving in function and has a 85-90% success rate.
The operation is carried out under local anaesthetic and a short sedation. It is a day case procedure so you can expect to go home the same day. As the wound itself is small and the operation involves cutting fascia and not muscle most patients are able to walk out of hospital without crutches and are able to drive within 4 to 5 days. Calf stretching exercises are recommended for 2 weeks post surgery to help maintain the increased length obtained by surgery.
Expect to feel the benefit of the operation 6 to 8 weeks post surgery.
A typical wound following a proximal medal gastrocnemius release
A small incision is made along side the Achilles tendon which is opened in the midline. Damaged and degenerate tendon tissue is removed (debridement). If more than 50% of the cross section of the tendon has had to be removed then the Achilles tendon is augmented with a tendon transfer (from FHL) because of the risk of Achilles tendon rupture.
The Flexor Hallucis Longus (FHL) is a powerful muscle that bends the big toe down, and secondarily helps bend the foot so that it points down. When the Achilles is very damaged (worn and torn from disease) it is advantageous to removed the diseased and damaged portions of the Achilles tendon (which is also a source of pain) and to transfer the FHL tendon to the calcaneum (heel bone). The FHL muscle is normally much smaller than the calf muscles from which the Achilles tendon forms. However as more demand and load is placed across it, so it hypertrophies and gets bigger and stronger, taking over much of the function and load of the calf muscles and by extension the Achilles tendon.
After a year of intensive physiotherapy patients typically report an excellent outcome: pain free heel, normal gait and good strength and power in the leg.
This operation is carried out under general anaesthetic. Almost all cases are done as a daycase. After the operation expect to be in a backslab plaster for at least 2 weeks with high elevation (level of the heart) followed by mobilisation in a boot for roughly 4 weeks. Physiotherapy typically starts around week 3-4 post op and will continue for at least 3 months.
Patients should understand that the decision to undergo surgery should not be taken lightly.
A small midline incision is made and the Achilles tendon exposed. The distal end of the insertion of the Achilles tendon is elevated and the damaged tendon removed (debrided) and excess bone growth (calcified tissue) also excised.
The Achilles tendon is then reinserted into the heel bone (calcaneum). This operation is carried out under general anaesthetic. Almost all cases are done as a daycase. After the operation expect to be in a backslab plaster for at least 2 weeks.
This operation is very successful in removing the bump at the back of the heel and relieving painful symptoms. Advances in technology have enabled this operation to be done safely and effectively.
If more than 50% of the cross section of the tendon has had to be removed then the Achilles tendon is augmented with a tendon transfer (from FHL) because of the risk of Achilles tendon rupture.
This operation tackles the problem of insertional Achilles tendinopathy indirectly. Prior to the introduction of the Speedbridge technique, open surgery was associated with complications such as Achilles tendon reattachment and wound healing problems for example. The Zadek calcaneal osteotomy removes a wedge of bone from the calcaneum (heel bone). The heel bone is then secured with 1 or 2 screws. By removing the wedge of bone, the bump is brought forward and no longer and the Achilles tendon is effectively lengthened and the tension reduced.
This operation is carried out under general anaesthetic. This procedure may be undertaken in suitable patients using a minimally invasive surgical technique. Almost all cases are done as a daycase. After the operation expect to be in a backslab plaster for at least 2 weeks.
A – Zadeks calcaneal osteotomy involves removing a wedge of bone, the yellow dotted line represents the anterior border of the Achilles tendon B – Post Zadeks calcaneal osteotomy the superior calcaneal border is shortened (double blue arrow) and the Achilles tendon (yellow dotted line) is no longer under tension
It should be borne in mind that complications can result from a condition with or without surgery.
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
Almost all surgical procedures for Achilles tendinopathy will be undertaken as a day case.
Following a proximal medial gastrocnemius release –
You will have a small waterproof dressing applied to the back of the knee. It is advised not to remove this until seen at clinic by Mr Malik at the 2 week follow up.
For 2 weeks following surgery it is recommended that you keep the area dry. You may wish to get a Limbo bag which will stop the wound getting wet.
Most patients are able to walk comfortably without any aids after the operation. If both legs have been operated on then crutches maybe necessary. A physiotherapist will guide you before your discharge from hospital. Please ensure someone is able to drive you home after the operation. It is important that you commence calf stretching exercises as soon as possible after the operation. Activities can be gradually increased as pain allows.
In addition following an Achilles tendon debridement, Speedbridge or Zadeks calcaneal osteotomy –
You will have a backslab applied post operatively for two weeks.
A photograph of a backslab
Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.
You will be non weight bearing for 2 weeks post operatively. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.
A picture demonstrating high foot elevation following surgery
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked and if completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. You will require to wear a special walking boot for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 6 to 8 weeks before any driving is advisable.
You may be referred at this stage for physiotherapy for early rehabilitation and Achilles tendon strengthening exercises.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.
You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
X-rays will be requested if a Zadeks calcaneal osteotomy was performed to check that the bone has healed.
Final clinical examination. Discharge if satisfactory.
This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.
The time given below is only a guide to the actual surgical time.
For a proximal medial gastrocnemius release
For an Achilles tendon debridement, Speedbridge or Zadeks calcaneal osteotomy
30 to 60 minutes
Following a proximal medial gastrocnemius release –
Most patients are able to drive within a week or two. Please see guidance below.
Following an Achilles tendon debridement, Speedbridge or Zadeks calcaneal osteotomy –
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
Most patients are able to return to work within 3 to 5 days.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Excellent pain relief and return to sports by 3 to 6 months in approximately 90% of patients.
Excellent pain relief and removal of the obvious “bump” in approximately 80 to 90% of patients. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
Orthopaedic Outpatient Department
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