Achilles Tendinopathy

What is Achilles tendinopathy?

The Achilles tendon is the largest tendon in the body and is found at the back of the ankle. Achilles tendinopathy, also known as Achilles tendinitis or tendinosis, is a condition in which there is wear and tear degeneration of the tendon leading to swelling and pain. It is not known what causes this to develop but it is common in people who run and do other high impact sports, as well as people with tight calf muscles.

Achilles tendinopathy can affect the middle part of the tendon (known as midsubstance tendinopathy) or the area where the tendon attaches to the bone (known as insertional tendinopathy). Find out more about treatment of insertional tendinopathy.

People with Achilles tendinopathy will notice pain and swelling in the middle portion of the Achilles tendon. The swelling can sometimes rub on the back of the shoe making the pain worse. Often it will be worsened by running and other sport but many people will have pain at rest.

How is the diagnosis made?

Most of the time your treating specialist can make the diagnosis without requiring any imaging. Occasionally x-rays are required to look for bone spurs (in particular in insertional tendinopathy). If surgery is planned then either an ultrasound or MRI scan or is performed to confirm the extent and location of the damaged areas of tendon. 

What are the treatments?

The first treatments to try are non-operative. Heel cups or raises can help take the load of the tendon. Physiotherapy is really important – the calf is often too tight and as well as calf stretches there are other exercises that can be useful. It will usually be necessary to greatly reduce the amount of running or other impact sports until the problem settles down. 

Extracorporeal shockwave therapy is an excellent non-invasive treatment that works in 60-80% of people. This involves at least three sessions, each lasting about 5 minutes. The treatment works by breaking down the thickened damaged areas of the tendon and kick-starting the healing process. 

Steroid injections are not recommended due to the risk of causing tendon rupture.

What about surgery?

For some people the simple treatments do not work and surgery is suggested. Surgery is never obligatory for this condition, but if the pain is not settling down or is causing other restrictions then it is worth seriously considering this option. 

Surgery is usually carried out under general anaesthetic, either as a day case or with one night stay. Our surgeons use the latest techniques to minimise the disruption of surgery and to accelerate your recovery.

The type of surgery required will depend on the extent of the damage in the tendon. Where there is only a small area of damage, the worn area can be tidied up (“debrided”) and the diseased areas of the tendon are removed. At the same time the lining of the tendon is stripped away from the damaged part of the tendon to stimulate healing.

If calf tightness is contributing to the problem then the calf muscles can be lengthened to help reduce the strain on the Achilles tendon. 

If the damage to the Achilles tendon is more extensive then a tendon transfer can be performed. This involves taking a tendon at the back of the heel which normally powers the big toe and using it to reinforce the Achilles tendon. 

What happens after surgery?

You will usually be able to get home the same day or the day after. You would usually go home with your ankle in a dressing and a moonboot. There will be some swelling and you will find it helpful to keep your foot elevated on a footstool in the early recovery period. Normally you can walk straight away.

If you have had a tendon transfer, you would wear a cast for the first two weeks then a moonboot up to the six week mark. For the two weeks in cast you would need to use crutches or a knee walker to keep the weight off the foot.  During the following four weeks in the moonboot you would start with wedges under the heel to keep the foot pointing down. One of these is removed each week to allow the foot to come up to the neutral position and you start to bear weight. 

You would be seen in clinic at the two week mark to check the wounds. After coming out of the moonboot you would start physiotherapy. At that stage you can start to return to lower impact sports such as cycling, swimming and cross training. You can usually start to run by six weeks. You will usually need physiotherapy to help with the recovery.

Are there any risks?

This type of surgery is successful in 80-90% of patients. Most people can expect to get back to their normal sports. 

All surgery carries risks, and Achilles tendon surgery is no exception. The risks will be discussed with your treating surgeon and in particular whether you are at higher than normal risk. These include:

  • Recurrence. Occasionally the problem can reoccur.
  • Infection. Minor infections are treated with antibiotics and wound dressings. More serious infections can necessitate hospital admission and surgery.
  • Blood clots in the legs or lungs
  • Ongoing pain
  • Persistent swelling
  • Numbness
  • Nerve related pain

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