Achilles Tendon Disorders

The Achilles tendon connects the calf muscle to the heel bone. Achilles tendon rupture occurs when the tendon completely tears or fails.

Though the Achilles tendon is the largest in the body, it can rupture during sports or daily activities. Typically it occurs with a traumatic event as opposed to chronic repetitive activity.

Achilles tendon ruptures occur mainly in two subsets of people. The most common group is males age 30-50. They are often playing a sport that involves running, cutting or jumping. The second group is the elderly patient with a lower impact injury with a diseased tendon, sometimes from medicines or other systemic diseases.

Patients usually hear or feel a pop in their Achilles during a rupture. They often describe it as though they were kicked or shot back of their ankle, but usually there is no contact. Some patients are able to walk with difficulty. Most have swelling on the back of the ankle and weakness flexing their ankle.

Most of the time diagnosis is based on history and physical exam. Patients will typically have a gap that is easily palpable by an experience physician. Additionally, the foot will often have a different resting position compared to the normal foot. Also, the foot may not respond normally after squeezing the calf. Rarely, MRI or ultrasound can be used. X-rays may be indicated if tender on the bone.

Treatment of an Achilles tendon can be both surgical and nonsurgical. We always have a long conversation with our patients with an Achilles tendon rupture. We like to go over the risks and benefits to each treatment with the patient. At OrthoArizona, we base our treatment on evidence and patient preference. Sometimes doctors forget to consider patient preference. Shared decision making about treatment options are based on your age, activity level, medical problems, and goals. We review the evidence with our patients and educate them and then the patient and provider make a decision together.

A few of the surgical risks include infection, delayed wound healing or nerve injury. While these are rare, they can happen. We also discuss nonsurgical risks such as the possible increased risk of re-rupture or slightly less strength in some studies. Because both treatments can be successful, we support the patient even if their choice may be different than ours. In general the healthier the patient and the more active they are, the more likely we come to surgical treatment. Many patients with poor overall health who are not active often decide on non-surgical treatment.

Decision for surgery is very important and is easier once you understand your condition.

There are several different surgical techniques for Achilles tendon rupture repair. In reality, there are two main types of surgical repair.

The first surgical type is traditional open surgery. This is where the surgeon makes an incision and locates the rupture. The ends of the tendon are typically cleaned up and then sutured together. There are various ways to suture the tendon ends together. The goal is to restore the normal Achilles tendon length as best as possible because a tendon that heals with too little tension can lead to weaker function. The advantage to open repair is that is easier to protect from nerve injury as the nearby nerve can be identified and protected. Also a very good repair can be obtained. The disadvantage is that there is a longer incision.

Surgery can also be performed percutaneously. Here, the repair is done through several small incisions. The tendon ends are still opposed but not in the traditional fashion. The advantage is that with a smaller incision, there may be a lower risk of wound healing complications, but this is not always the case. Some disadvantages are that the repair may not be as secure and that a nearby nerve can get entrapped in the repair site, as it is not visualized through the small incisions.

We offer both options for Achilles tendon rupture repair at OrthoArizona. However, because most patients that undergo Achilles tendon rupture repair are healthy and low risk for healing complications, we believe that the risk of nerve injury outweighs the risk of healing complications with an open repair.

Recovery for Achilles tendon rupture can be different for each patient based on his or her overall health and goals. It also may be slightly different for surgical vs. non-surgical treatment.

At OrthoArizona, nonsurgical treatment for Achilles tendon rupture consists of splinting or casting with the ankle plantarflexed (toes pointed down) to relax the Achilles tendon and minimize any possible gap where the tendon is rupture. After several weeks, I typically transition my patients to a walking boot with special wedges or a hinge to prevent overstretching the Achilles tendon. Walking is permitted with an assisted device. At around 6 weeks we begin advancing activity and wean out of the boot usually between 9-12 weeks from the injury based on the patient’s progress.

If patients elect for surgical repair of their Achilles tendon rupture, we first make sure they are low-risk for outpatient surgery. Surgery typically takes 45-60 minutes. I typically splint or cast patients for a few weeks to relax the incision. When sutures are removed at about 2-3 weeks after surgery, we begin weight bearing in a walking boot with wedges under the heel. Range of motion also begins at this point. Typically we begin physical therapy 6 weeks after surgery and often begin weaning out of the boot at 8-10 weeks postoperative.

Light activity such as jogging and calf strengthening is permitted at about 3 months after surgery and more explosive sports such as basketball often are not resumed for 6-12 months.

At OrthoArizona, we really try to individualize our recovery recommendations but this is a generalization of our approach.

Achilles tendinitis is actually an acute inflammation of the tissue surrounding the Achilles tendon. The tendon itself does not become inflamed. Achilles tendinosis occurs when the degenerative lesions within the tendon occur.  The tendon itself can become thickened with abnormal tissue. These conditions occur where the tendon inserts on the calcaneus (heel bone) or higher up within the tendon. There is a fluid filled sac near the insertion of the Achilles tendon called a bursa.  This can also get inflamed. When this occurs, it is called bursitis.

• Achilles tendinitis is caused by inflammation of the tissue surrounding the tendon.
• Achilles tendinosis is caused by degenerative changes/injuries to the tendon.

Achilles tendinitis is often diagnosed in patients in the following situations:

• Starting training too quickly after a layoff
• Rapid increase in mileage or speed
• Addition of hills or stairs to program
• Trauma or injury during training
• Overuse
  • Achilles tendinosis is usually seen in OLDER patients and associated with:
    • Obesity
    • High blood pressure
    • Diabetes

• Pain in the Achilles tendon or on the back of the calcaneus (heel bone)
• On the first few steps after sitting or lying down
  • Gradually worsens with activity
  • Swelling in the Achilles tendon or back of the calcaneus (heel bone)
  • Limp
  • TENDINITIS is usually more of a rapid onset of symptoms

• First line treatment MAY include:
  • Rest (sometimes in a boot or cast)
  • Stretching 3-5 times a day of the calf muscles and Achilles tendon
  • Ice for 20-30 minutes at the end of the day
  • Non-steroidal anti-inflammatory medications (Ibuprofen, Alleve, etc.)
  • Heel cups
  • Weight loss in overweight individuals
  • STOP walking barefoot (wear supportive shoes)
• Second line treatment MAY include:
  • Night splints
  • Formal physical therapy
  • Orthotics to correct any foot deformities
  • Occasionally a walking boot or cast may be used

• Experimental treatments
• Surgical treatment