The Achilles’ tendon is a large tendon at the back of the ankle that connects the leg muscles to the foot. There are many pathologic changes that may occur in the Achilles’ tendon. Tendinitis, which may be insertional (where the tendon attaches to the heel bone) or non-insertional, and acute rupture of the tendon are 2 of the more common conditions that may require operative intervention.

INSERTIONAL TENDINITIS

Symptons

Inflammation of the Achilles’ tendon where it inserts into the calcaneus (heel bone) is known as insertional tendinitis. It is often associated with an abnormal bony prominence just deep to the tendon known as Haglund’s deformity or pump bump. This may play a role in rubbing on the deep aspect of the tendon to cause pain and inflammation in the tendon and surrounding soft tissues. If large enough, it can also rub on footwear or even prevent the wearing of certain shoes.

Treament – Non-operative

Initial management of this condition includes:

Rest/Activity Modification

The affected tendon should stop movement or activity that could provoke pain. Bearing a lack of weight on it will also assist.

Ice

An ice pack or crushed ice wrapped in a towel can be applied for 15 minutes every two to four hours to reduce pain and swelling.

Stretching Exercises

  • Stretch the calf muscles – Put the leg you want to stretch behind your other leg. Keep your back heel on the floor and bend your front knee until you feel a stretch in the back leg. Hold the stretch for 15 to 20 seconds.
  • Toe raises – Keep your heel stationed on the ground and raise your toes as high as you can – seated or standing.
  • Stand on the balls of your feet – Stand on the balls of your feet on stairs or a curb with your legs straight. Drop both heels down and hold for 10 seconds.

Medication

Anti-inflammatory medication such as tablets and creams can be prescribed by your doctor to assist in reducing the inflammation in your tendon.  Corticosteroid injections should be avoided due to increased risk of tendon rupture.

Heel Lift Orthosis

Also known as a shoe insert, a heel lift can reduce stress on the Achilles’ tendon during healing and rehabilitation.

Heel Arch

A medial arch support may be of assistance by decreasing over-pronation that may exacerbate symptoms.

Treatment – Surgery

An incision is made over the deformity and tendon. The inflammed tissue, bone bump and spur are removed. Finally, the tendon is repaired to the heel bone with 4 suture anchors.  The suture anchors are absorbable screws that are completely buried in the heel bone and the attached sutures are a broad tape that does not dissolve.

NON-INSERTIONAL TENDINITIS

Symptons

Non-insertional tendinitis is inflammation in and around the Achilles’ tendon higher up the leg from the heel.  It most commonly occurs in association with running and jumping sports where forces in the Achilles’ tendon can increase to 10 times body weight. It can also occur in association with overuse syndromes, postural problems, poor footwear, or an underlying inflammatory condition that may affect multiple joints in the body.

Patients usually experience pain approximately 2-6 cm further up the leg from the heel. This may even occur at rest and/or at night. Over time, the tendon becomes thickened and an abnormal lump may be felt in the same area.

Treatment – Non-operative

Initial management is similar to that of insertional tendinitis (see above). A walking boot or blood injections may also be advised. If symptoms have gone on longer than 6 months, this condition becomes very difficult to manage non-operatively as the tendon will have started to degenerate. Accordingly, when non-operative measures have failed or more than six months has elapsed, operative management is indicated.

Walking Boot

A walking boot is fitted to the leg affected suffering the tendon injury to help immobilise it in order for extensive healing to occur.

Blood Injections

Injecting a patient’s blood into the damaged tendon. Blood contains a number of nutrients and substances which can promote healing

Treatment – Surgery

An incision is made just to the inside of the tendon swelling. The diseased tendon and surrounding tissue is removed and the remaining healthy tendon is refashioned to bridge the defect. The adjacent plantaris tendon (sometimes referred to as the “monkey muscle”) is used to augment the repair. This is essentially a spare tendon at the back of the leg that is not missed in activities of daily living and sports.

ACUTE ACHILLES’ TENDON RUPTURE

Symptons

Rupture of the Achilles’ tendon may follow a prodromal phase of tendinosis (latent tendinitis). The actual inciting event however, is usually mechanical stress with a rapid loading of an already-tensed tendon, e.g. lunging forward from a standing start, unexpected stepping in a hole, or jumping from a height. Whatever the cause, patients often describe a sudden pain likened to being kicked in the back of the ankle/lower leg, which may be accompanied by an audible pop.

Treatment – Non-operative

Knee Cast

Non-operative management involves placing the leg in a below knee cast with the toes pointed. This cast is changed every 2 weeks until the ankle is finally in neutral. This process takes approximately 8 weeks.

Due to the difficulty mobilising, morbidity and associated high re-rupture rate (up to 18%), this technique is usually reserved for patients who are at considerable risk of complications from surgery from either an anaesthetic or surgical point of view.

Treatment – Surgery

An operation involves an incision at the back of the leg, and the 2 tendon ends are sewn back together. Very occasionally a strong direct repair is not possible due to significant damage in the tendon upon rupture. In this situation, part of the calf muscle fascia, or a spare tendon in the back of the leg may be required to augment the repair.

SURGERY – RISKS AND COMPLICATIONS

A good result can be expected in 95% of patients, however no surgery is risk free. The risks and complications will be assessed and discussed with you. There is always a small risk of infection, blood clots and anaesthetic problems with lower limb surgery and measures are taken to reduce these.

Specifically, to the procedures described in this brochure, the re-rupture rate is less than 1% and nerve damage is very uncommon (resulting in numbness of the sole or outer border of the foot. Delayed wound healing also occurs on occasion, but only rarely requires further surgery.

RECOVERY TIMES

Hospital stayDay surgery
Rest and elevation2 weeks
Crutches/frame<1-2 weeks
Walking boot (6-8 weeks total)
– Locked to range of motion
– Plantarflexion
– Wean
2 weeks
4 weeks
2 weeks
Weight bearing 
– As tolerated
– Full
Day of surgery
2+ weeks
Rehabilitation (commence at) 
– Range of motion exercises
– Strength exercises
– Single leg heel raise
– Training/fitness
– Sport
2 weeks
8 weeks
12 weeks
3-4 months
4-5 months
Foot/leg swelling3 months
Time off work
– Seated
– Standing
1-2 weeks
6-8 weeks

Contact

This fact sheet is a brief overview of the Achilles’ tendon, produced by our Foot and Ankle Surgeon Dr James Clayton. To make an appointment or enquiry with Dr Clayton or a member of our foot and ankle team, contact 08 8362 7788 or email ortho@sportsmed.com.au.

Foot and Ankle Team