ACHILLES TENDINOPATHY
What is Achilles tendinopathy?
The Achilles tendon is a strong tendon, formed from the gastrocnemius and soleus muscles, in the calf that attaches to the calcaneum. With overuse or repetitive strain, the tendon tissue can be injured and even develop a tear. These injuries heal with scar tissue leading to localised swelling of the tendon. This can occur
at either the site of Achilles insertion into the calcaneum (insertional tendinopathy) or within its mid-substance (non-insertional
Achilles tendinopathy).
Symptoms
Typically, there is pain around the injured area with swelling, often worse in the morning before stretching and after activity. There may be thickening seen over the area of inflammation and this can make wearing footwear uncomfortable.
Non-operative management
Initial management includes activity modification, incorporating rest periods, modification of footwear with heel lifts and stretching exercises. Analgesics and non-steroidal anti-inflammatory medication may also be used. Early physiotherapy will be instigated to help with the recovery.
Next steps in management could be an injection of high-volume fluid around the tendon under ultrasound guidance. This helps to free the paratenon sheath from the tendon, which can become inflamed and adherent to each other. An alternative is extracorporeal shock wave therapy (if available) to transmit high frequency shockwave impulses to the area of inflammation. This helps break down the scarring that is often present with inflammation and allows the stretching exercises to be carried out effectively.
Operative management
With persistent pain and swelling surgical intervention can be considered. For the non-insertional tendinopathy, the unhealthy tendon is debrided and repaired. However, for insertional tendinopathy the Achilles tendon needs to be lifted from its insertion, debrided and the Haglund’s bump (calcaneal bony prominence) resected prior to reattaching the tendon back to the calcaneum.
Recovery
If an isolated tendon debridement with repair is performed your leg will be heavily bandaged and placed in a walking boot to allow protected weightbearing for 2 weeks. After this 2-week period you can go back into comfortable shoes as tolerated and physiotherapy instigated. Elevation above the heart level, as much as possible, is important.
For insertional tendinopathy your leg will be placed in a below-knee cast for 2 weeks, and at this stage a wound check will be performed and a walking boot with heel wedges applied for a further 4 weeks. A wedge will be removed each week until the foot is flat on the ground, weightbearing is permitted whilst in the boot and crutches will be supplied for support. Elevation, above the heart level, as much as possible, is important.
Return to work can be expected at 4 weeks for Achilles tendon debridement and those undergoing insertional Achilles tendinopathy surgery if the job is sedentary and 8-12 weeks for more manual and labour-intensive type jobs.
Return to driving will not be before 6 weeks and you must be able to perform an emergency stop. It is important to inform your insurance company of the type of procedure that has been undertaken to ensure the cover is valid.
Return to sports that are non-impact can be initiated at 6 weeks (training is allowed), however impact sporting activities are not permitted before 12 weeks
Risks of Surgery
As with any surgery there are potential risks. This will be discussed in more detail during the consultation, however common complications are stiffness, swelling, nerve injury, infection, delayed wound healing, and clots.