What is Achilles Tendinopathy?
The Achilles tendon is the biggest tendon in the body. It is subject to lots of stresses in the course of daily life and sports.
Several problems can occur to the Achilles Tendon. The tendon can snap, or the tendon can become damaged by wear and tear within the tendon without snapping. This happens within the substance of the tendon, and it becomes swollen. It can be painful and limit normal activity. There may be stiffness after periods of inactivity or first thing in the morning.
The tendon has a poor area of blood supply about 5cm from where it attaches to the heel bone. This is often where pain and swelling occur. This area is at risk of rupturing if subject to excessive forces. Typically, this can occur during sport especially tennis, badminton, squash and basketball. This is usually a disease of middle age, but it occurs much more in runners, especially when stretching exercises are not performed. The tendon is thought to undergo more strain if the running style includes landing more on the outer side of the heel and then rotating the foot in rapidly as the foot becomes flat to the floor.
Sometimes the pain is due to inflammation of the outer lining of the tendon. This is called peritendonitis. It is a different condition to achilles tendinopathy, where there is typically no inflammatory reaction to damage within the tendon.
The diagnosis can be confirmed by clinical examination, an ultrasound scan or an MRI scan. These can demonstrate the swelling of the tendon, as well as damage within the tendon. Clinical examination is usually enough to diagnose a rupture as shown on the left.
If you have Achilles problems, it is best to see an orthopaedic surgeon who specialises in foot and ankle surgery. You can be advised of the possible ways of treating this problem, including non-surgical and surgical means.
How is the Surgery Performed?
Surgery for the Achilles Tendon may be carried out because the tendon has snapped, or because there is wear and tear within the tendon that has not responded to physiotherapy.
Surgery is performed with the patient anaesthetised and facing downwards to expose the calf and Achilles tendon.
If the tendon has snapped, the ends are put back together through minimally invasive surgery. The repair has to be protected as stretching the tendon – by allowing the foot to bend upwards – will risk tearing apart the repair. A special boot is applied straight after surgery to protect the repair.
If you would like to see what happens during surgery, you can see a presentation that I prepared for teaching others about the minimally invasive technique – however, be warned that it contains images from a surgical procedure, that some might feel uncomfortable with.
f the tendon has wear and tear pain without snapping, then surgery aims to increase the amount of blood going into the tendon. This is achieved by making cuts into the outer border of the tendon, to encourage healing within it.
Surgery is carried out under general anaesthetic, but can be augmented with local anaesthetic injections behind the knee or around the ankle. The injections are normally given while you are asleep for your comfort. They can give good pain relief for the first day after the operation. You can go home the same day in the evening.
Risks of Surgery
Specific risks of Achilles Tendon surgery include re-rupture (5%) and wound breakdown (1%). These are increased in smokers. In Achilles tendinopathy surgery, the specific risks are rupture, continued pain and wound breakdown. Other risks include bleeding, infection, poor bone healing, poor skin healing, injury to tendons, injury to nerves, recurrence, and a need for further surgery.
There is a small risk of blood clots in the legs or lungs (DVT and PE), and there are also risks from anaesthesia – the process of being put to sleep for your operation.
Risks of Anaesthesia
The injection behind your knee is given using an ultrasound machine to guide the needle. There is a less than 1% chance of injury to the nerve. General anaesthetic also carries risks. These risks are proportional to your general health. You will need to be assessed for your fitness for surgery and an Anaesthetist will be able to advise you on your individual risk.
After Achilles Tendon Surgery
You will have had injections to numb your foot so that you are not in pain after the operation. This injection will wear off after 18-24 hours, so you must take regular painkillers so that you are not in severe pain when the injection wears off.
The pain will settle over a few weeks. You may see blood stains on the dressings. This is normal and not a cause for alarm. If blood is dripping from the dressings however, return to hospital.
The foot will be swollen as well as sore. You should keep the foot elevated as much as possible for the first two weeks. Keep walking down to a minimum – going to the toilet or for meals. Letting the leg hang down will cause the foot to become more swollen. Most of the swelling will settle within the first few months, but swelling can continue for up to one year.
If you are resting on your sofa, keep your foot elevated on the back rest or arm rest. If you are resting in bed, then place a few pillows under the foot to keep it elevated.
You will normally be in a plastic boot for a total of six weeks. You will be able to put your heel down to bear weight or balance immediately. The plastic boot has a series of three wedges inside which keep the foot pointing down.
After two weeks, the stitches are removed. Full weight bearing is only allowed in the boot, which is taken off for exercises. Every two weeks, the bottom wedge is removed and discarded until 6 weeks after the operation, when there are no wedges left in the boot.
It is important to keep the Achilles tendon moving while it recovers. However, it is important to avoid stretching the tendon as this could decrease the power of the muscle and even cause a further rupture. The foot points down after surgery in it’s natural position. The exercises consist of pointing the foot down from it’s natural position and then relaxing to allow it back to the natural position. In no way should the foot be forced back to the natural position and pointing the foot upwards risks snapping the tendon again. Six weeks after surgery, you can wean yourself off the boot and start stretching the tendon by pointing the foot upwards again, under the supervision of your physiotherapist.
You will need a heel raise to wear for three months after the boot is removed.
RETURNING TO WORK
You will be in the plastic boot for six weeks. I advise that you do not return to work until you can walk comfortably with crutches and the boot. Remember that not everyone is the same, and some people take a longer time to recover from their surgery. Please request a sick note before you leave hospital, if you need one.