Surgical Overview
The Achilles tendon is a thick tendon located in the back of the leg. It connects the gastrocnemius and soleus muscles in the calf to an insertion point at the calcaneus (heel bone). It is the strongest tendon in the body and allows people to push off while walking, running and jumping. Problems with the Achilles are some of the most common conditions seen by orthopaedic surgeons. Chronic, long-lasting Achilles tendon disorders can range from overuse injuries to tearing of the tendon. Pain in the heel is often caused by a combination of both acute and chronic problems, including inflammation and tendonitis.
Tendinopathy is chronic inflammation of the tendon that can occur in two distinct locations. Insertional tendinopathy (pictures A & B below) involves inflammation at the point where the Achilles tendon inserts into the heel bone. This is commonly associated with calcium formation or a bone spur formation. This condition can occur along with retrocalcaneal bursitis and a bony enlargement of the heel bone, known as Haglund’s deformity.
Retrocalcaneal bursitis is caused by movement-related irritation of the retrocalcaneal bursa, the fluid-filled cushioning sac between the heel bone and the Achilles tendon. This condition involves pain in front of the Achilles tendon, in the area between the tendon and the heel bone. The bursa can become inflamed or thickened and stick to the tendon.
Midsubstance tendinopathy (pictures C & D below) involves tendon degeneration rather than inflammation. In addition, the tendon may become weakened and lose its structure. Although aging may play a part in this process, repetitive minor trauma, such as playing sports that involve running or jumping, without proper healing can also play a role. Areas of tendinopathy may eventually progress to partial or complete ruptures if they experience high loads, as are seen with physically demanding sports, especially during push-off and landing activities.
Retrocalcaneal bursitis is caused by movement-related irritation of the retrocalcaneal bursa, the fluid-filled cushioning sac between the heel bone and the Achilles tendon. This condition involves pain in front of the Achilles tendon, in the area between the tendon and the heel bone. The bursa can become inflamed or thickened and stick to the tendon.
Other imaging studies, such as an ultrasound or MRI, also assist the surgeon in determining the amount of Achilles tendon degeneration, bone spur formation and retrocalcaneal bursitis present. These are critical studies to determine the correct overall treatment plan for your specific type of tendinopathy.
The main symptoms usually associated with Achilles tendinopathy are pain and swelling. In the early stages of disease, pain is present with movement or activity (walking, running, sports, stairs, prolonged standing). As the tendinopathy progresses, the pain can be present even at rest or with minimal pressure on the area. Other common symptoms of Achilles tendinopathy include; joint stiffness, loss of ankle motion, posterior ankle swelling, and difficulty walking (or walking with a limp).
Treatment for Achilles tendinopathy is focused on controlling pain, limiting motion and activities that cause pain, and assisting in increasing walking tolerance. Non-surgical treatment approaches are usually tried first. Non-surgical treatment options include: medications (nonsteroidal anti-inflammatory medications (NSAIDs)), ankle-foot orthosis (AFO) or other ankle braces to decrease ankle motion, physical therapy with eccentric Achilles stretches, dietary supplements (glucosamine and chondroitin), CBD cream and/or platelet-rich plasma (PRP) injections into or around the tendon.
Once conservative treatment options have been exhausted or the degree of tendinopathy is very severe, surgical intervention is usually necessary. There are three main surgical options to treat Achilles tendinopathy depending on its location:
For midsubstance tendinopathy, the damaged tendon is excised and the healthy tendon is then repaired. The retrocalcaneal bursa is also excised to remove any further source of inflammation.
For insertional tendinopathy, the damaged tendon is excised and the healthy tendon is then repaired and reattached to the heel bone. This also includes removal of any bone spurs present near the Achilles tendon. The retrocalcaneal bursa is also excised to remove any further source of inflammation.
In some cases, a tendon transfer from the foot may be necessary to further strengthen the Achilles tendon. In most cases, regenerative stem cells are obtained from the iliac crest in order to encourage further healing of the Achilles tendon after repair. In nearly all cases, these procedures can be done in a minimally invasive fashion which minimizes wound complications, allows earlier weightbearing and a faster overall recovery.
Achilles Tendinopathy
Your surgery takes place at the New England Baptist Outpatient Center as a day surgery.
The procedure generally takes about 1-1.5 hours.
General anesthesia is usually used, but occasionally a light sedation is possible for some patients. All patients will have a preoperative nerve block performed to the back of the knee immediately before the surgery. This will decrease intra-operative anesthesia requirements as well as post-operative pain medication requirements. It is very effective in greatly reducing pain.
Benefits of these surgeries include decreased pain, improved function and maintenance of ankle joint motion.
Conservativetreatments as discussed above including long-term bracing.
In general, most patients are able to return to their previous level of function including recreational activities.
Like any surgery, complications can develop. Fortunately, they are rare for most patients, but not zero. These include infection, bleeding, numbness, blood clots, delayed wound healing, bone fracture, chronic pain and/or swelling. Appropriate recognition and medical treatment of these complications generally will allow for a satisfactory outcome. Many of the risks are mitigated using the minimally invasive surgical techniques.
You will get a dose of antibiotics just before surgery. All patients are started on one 325 mg aspirin once a day for 4 weeks after the surgery to reduce the risk of blood clots.
Read carefully the What to Expect and How to Prepare for Surgery handouts.
No. Bleeding is minimal with use of a tourniquet during the surgery.
Discuss the surgery with your rheumatologist, but it is generally recommended that immunosuppressive modulator medications (eg. Methotrexate, Enbrel, Humira) are stopped for 2 weeks before and 2 weeks after surgery.
The foot is placed into a soft dressing and a special medical boot that allows for some range of motion. This will be set at the time of your surgery. Recovery occurs in the Post Anesthesia Care Unit or PACU, and then you are discharged home.
Focus for the first 2 weeks post surgery is to rest, get plenty of sleep, eat well and drink plenty of water. Your body will have greater metabolic demands on it to heal. Keep your surgical foot elevated at the level of your heart when you are not moving around the house. You should take the pain medication as directed as necessary. You should take the blood thinning medication for reducing the chance of blood clots as well. Keep the dressing clean and dry. You are able to weight bear as tolerated in the boot once your nerve block has worn off.
Small spots may appear on the bandage. You may reinforce the dressing with an ace wrap obtained from a pharmacy. While highly unlikely, excessive bleeding through the bandage is of concern and you should call the office to be seen.
If the surgery was on the LEFT side, many patients drive by two weeks when they are off the pain medication. If surgery was on the RIGHT side, driving can resume around the six week mark, at which time the boot can be removed to drive and then placed back on when getting out of the car. You will also be given a handicap parking placard as necessary.
That depends on what you do. Sedentary desk workers may return as soon as 2 weeks. On the other end of the spectrum, professions that are a bit more demanding may be out of work for 3 months. You will be provided out of work notes or restricted duty notes as necessary during the recovery phase. Family leave paperwork can also be submitted.
Download the Achilles Tendinopathy Post-Operative Guidelines for full details.
