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The Achilles tendon is the largest and strongest tendon in the human
body. It is the “cord” in the back of the leg that inserts into the back of the heel. The Achilles tendon got its name,
according to Greek legend, when the Greek warrior, Achilles, was dipped into the river Styx by Thetis, his mother. This rendered him
invincible with the exception of his unsubmerged heel. Unfortunately, he went on to get mortally wounded during the siege of Troy when
he was struck in that heel by an arrow.
Achilles tendonitis is inflammation and partial tearing of the Achilles
tendon. It can occur with overuse of the tendon such as when starting or increasing the intensity of an exercise program or performing
impact loading activities that include a lot of running and/or jumping.
On presentation, patients often complain of pain in the Achilles
tendon with initial morning activity with an increase of pain during exercise. Early symptoms of Achilles tendonitis may include sharp,
transient pain with or without activity. Over time, less activity will stimulate symptoms. Some patients will even experience pain
at rest.
There are two different types of Achilles tendonitis: insertional
and non-insertional. Insertional Achilles tendonitis occurs within or around the tendon at its insertion into the heel. Non-insertional
Achilles tendonitis occurs above the insertion.
Haglund’s deformity, or “pump bump,” is a swelling
and/or bony bump that occurs in the back of the heel. This can occur alone or with Achilles tendonitis. A Haglund’s deformity
often causes discomfort when tight shoewear with a constricting heel counter is worn.
On examination, routine x-rays are taken which may demonstrate calcification
within the Achilles tendon and a Haglund’s deformity. MRI imaging is not routinely performed but may demonstrate a partial tear,
thickening or degeneration of the tendon or calcification. Ultrasound is not customarily performed.
During the physical exam, the Achilles tendon is palpated to detect
signs of pain, swelling, thickening, warmth and redness. The range of motion of the ankle is also examined to check for tightness of
the Achilles tendon and to determine if the Achilles tendon itself is involved versus the area around the Achilles tendon causing “peritendonitis.” Strength
will also be tested. Sometimes the area just in front of or in back of the Achilles tendon insertion is painful which indicates bursitis,
which is an inflammation of one of the fluid filled sacs that lie in between the heel and the tendon and between the tendon and the
skin. The calf may also be squeezed to make sure that the Achilles tendon is intact and has not torn all the way through. If the Achilles
tendon has ruptured, patients report that they felt or heard a “pop” in the back of the heel or had the sensation that
someone kicked them. With Achilles tendon rupture, surgical repair gives the patient the best chance at getting as much function back
as they had prior to their injury.
Conservative management however, is the treatment of choice for
Achilles tendonitis. Eighty to eighty-five percent of patients improve with conservative care, however it can be time consuming as
it may take 6 to 12 months to recover. One of the most important factors influencing recovery time is the length of time symptoms are
present. If Achilles tendonitis has been endured for six months or more, it is difficult to treat without surgery.
Conservative treatment includes anti-inflammatory medications like
ibuprofen or naproxen, rest, decreased activity, gentle stretching exercises, heel lifts worn inside shoes during the day, night splinting
or bracing the leg at night while sleeping and occasionally immobilization in a cast when the pain is severe. Steroid injections may
occasionally help but are not routinely performed because they increase the risk of rupture. Orthotics, shoe inserts that can be custom
made or purchased over-the-counter, may also be recommended if problems with the arch alignment of the foot is playing a part in Achilles
tendonitis symptoms. When patients are pain-free, they may slowly restart activity keeping in mind to again cease activity if the pain
recurs.
If conservative treatment fails, surgery in indicated. An incision
is made at the back of the leg and heel. If the Achilles tendon is only involved then we meticulously remove diseased tendon and repair
the good tendon. Another tendon may need to be transferred to assist the Achille’s tendon. If a Haglund’s deformity
is present it is removed. If the tendon is diseased at its insertion then detach the Achilles tendon from the heel, cut the bump
off, debride the tendon and then reattach the tendon back to the heel using very strong sutures.
After surgery, the leg is splinted with the foot pointing 20 degrees down to take stress off the repair. Crutches, a walker or
a wheelchair are usually given to assist patients with walking as no weight can be put on the foot for at least one month after surgery.
After four weeks, usually a removable cast is placed on the patient and some weight bearing can be initiated. After eight weeks, patients
may start to wear sneakers during the day but will need to wear the removable cast while sleeping at night so the Achilles tendon continues
to heal at the proper length. Range of motion exercises start at 4 weeks post operatively. Physical therapy is considered at
three months after surgery to help patients regain strength and coordination. Swelling may be present for up to six months after surgery.
Complications can be associated with surgery including risk of infection, incisions that are slow to heal, rupture of the Achilles
tendon if weight is placed on it too soon, swelling or blood clot(s) in the legs. Casting may cause abnormal pressure on the skin leading
to an ulcer.
Although Achilles tendonitis can be disabling, it is a common, but treatable ailment. With diligence and persistence, patients may
again be able to experience their active lifestyle. If you or someone you know is suffering from Achilles tendonitis, seek help today
to start the path to recovery.
Reference: Surgery of the Foot and Ankle, Seventh Edition, Volume Two, edited by Michael J. Coughlin, MD and Roger
A. Mann, MD.
Written by: David J. Pochatko, MD, a fellowship trained Foot and Ankle Orthopedic
Surgeon for Northtowns Orthopedics. We specialize in the surgical and non-surgical treatment of foot and ankle problems, injuries and
deformities. We also see many people who have had a failed previous surgery and need revision of that surgery.
Northtowns Orthopedics – where your first surgery is your best chance to get better.
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