Achilles Tendon Disorders

The Achilles tendon is the strongest and perhaps one of the most important tendons in the body. The Greek mythological character Achilles was a remarkable warrior but was vulnerable only in one area: in his heel region where he was ultimately killed by an arrow which penetrated his tendon in this area. Thus the name Achilles was applied to this tendon. Injuries to the Achilles tendon may occur in two main ways: rupture of the Achilles tendon or with Achilles chronic degenerative changes (“scar” tissue in the Achilles tendon). Because of the importance of the Achilles tendon for normal walking and high-level of activity, the function of this tendon must be respected and thorough consideration of all options should be considered with both conservative and surgical treatment individualized as appropriate for each individual.

Achilles tendon rupture
Achilles tendon ruptures can be a severe, debilitating injury. This most commonly occurs in early to middle aged individuals, often described as “weekend warriors.” The injury may occur with sporting activities (basketball, racquet sports, running, etc.) but may also occur with a significant misstep during everyday activities. Patients often experience a sudden “pop” in the back of their ankle and feel as though they were hit in this region although they were not. Significant swelling may occur soon after and although some patients may be able to bear weight, the ability to push off on the ankle is lost. These ruptures are most commonly complete ruptures although on occasion, partial ruptures may occur.

Partial ruptures of the Achilles may be more amenable to conservative treatment as described below. Complete ruptures are commonly treated surgically but conservative treatment is also a viable option for many patients. With surgical treatment, the likelihood of re-rupture of the Achilles tendon is decreased and the length of recovery with casting and time to improvement may be diminished as compared to non-surgical treatment. The non-surgical treatment has the obvious benefits of avoiding potential complications with surgical intervention, most importantly, that of infection. These above concerns as well as a previous history of smoking, desired activity levels, age, and other factors all are important in making the most appropriate decision for each patient.

Surgical treatment involves a single small incision on the back of the ankle directly over the Achilles tendon at the site of the rupture. This incision may be particularly small if a percutaneous technique is utilized (see below). The tendon ends are sewn together and after surgery, once the incisions are healed, ankle motion is begun as soon as possible to maximize function, decreasing scarring, and maximize strength. Weight bearing is allowed in a boot at around 4 to 6 weeks and return to a regular shoe at 10 to 12 weeks. Often, a wedge is utilized in the shoe to help protect the Achilles tendon during the recovery. Continued improvement and gains in strength may be expected for up to a year.
 

Minimally invasive Achilles tendon repair
For many Achilles tendon injuries, a special device that allows for repair of the Achilles tendon through a small one centimeter incision may be utilized. This device allows for opposition and repair of the tendon ends with minimal dissection and may lead to a decreased risk of complications that may be associated with a larger, extensive incision. The tendon is repaired end-to-end and the recovery is otherwise similar to that as described above after surgery. Some tendon rupture patterns are not amenable to minimally-invasive repair techniques and thus a standard open repair technique is utilized. Dr. Vora is particularly interested in treating conditions of the Achilles utilizing minimally invasive techniques and is currently studying the outcomes of treatment for patients treated in this manner.
 

Chronic Achilles tendon disorders (tendonosis, tendonitis)
The Achilles tendon may develop a degenerative condition within the substance of the tendon. This is similar to “scar tissue” that has developed within the substance of the Achilles tendon and can lead to significant pain, swelling, weakness, and difficulty with everyday activities as well as with running and other sporting activities. Often pain exists along the back of the heel along the course of the Achilles, and a painful thickened tendon may be present. Any pressure on this area may reproduce the pain and stiffness commonly experienced. The “scar” may occur within the substance of the tendon above the level of the heel or may occur at the level where the tendon inserts into the heel bone (insertional Achilles tendonitis). The location of the swelling and degenerative change helps define the surgical treatment options and necessary interventions if conservative treatment fails. There is a theoretical increased risk of rupture of the Achilles tendon when pre-existing tendonosis is present within the Achilles.

Conservative treatments involve an eccentric stretching program of the Achilles tendon with or without physical therapy, heel lifts and / or shoewear modifications, icing the Achilles and heel region, open heeled shoes that do not cause irritation of the tendon or the heel bone, occasional immobilization in a boot for severe acute irritation, and other conservative measures. If this treatment fails surgical treatment may be necessary. Not all Achilles tendon problems can undergo the same surgical treatment and thus the location of the abnormality, degree of tendon involvement, and location of involvement define the appropriate treatment options.

The simplest surgical treatment involves a limited debridement and coblation of the Achilles tendon. The procedure involves cleaning out the diseased tendon partially and using thermal energy to create a localized “debridement” of the tendon to stimulate the body to “heal” the tendon. This procedure can often be performed under local anesthesia only and occasionally mild twighlight anesthesia is necessary in addition. A one centimeter incision directly over the diseased tendon is utilized and the tendon is treated. After surgery, the swelling over the tendon may persist but the pain associated with the tendon scarring is often reduced significantly. Recovery involves two weeks of non-weight bearing and immediate motion of the ankle with gradual increased progression of activity. For failure of this type of procedure or with more extensive degenerative change of the Achilles, a more extensive surgical debridement (clean-out) of the Achilles tendon scarring and repair with or without an additional tendon transfer to augment the strength of the Achilles may be necessary. This procedure allows for a more reliable removal of the diseased tendon and likelihood of pain relief but the recovery is more extensive and after complete recovery expectations may not be as promising with regards to elite level sporting activity. Lastly, if the tendon is diseased at the level of insertion into the heel bone (calcaneus) and the back of the heel bone is causing irritation on the tendon as well, it may be necessary to shave down this spike of bone in order remove this irritation on the tendon. The more extensive Achilles tendon surgeries may take up to 8 months to one year to allow for full strength recovery and complete pain relief.

Dr. Vora currently involved in studies evaluating the outcomes of Achilles tendon disorders utilizing tendon transfer techniques and is also particularly interested in the outcomes after surgery for the Achilles tendon utilizing minimally-invasive techniques.