Achilles Tendon Disorders

The Achilles tendon is the largest tendon in the body. It joins the calf abstract writers muscles to the calcaneus (heel bone) and assists in walking, running, raising the heel and jumping. Pathological changes within the tendon may be Insertional – where the tendon attaches to the bone, or  Non insertional – higher up from the attachment.

There are bursae (fluid filled sacks) in front and behind the insertion of the achilles that may become inflamed and painful.

Insertional Tendonitis

  • Video:

    This surgical procedure is used to repair a ruptured achilles tendon, the large tendon that travels down the back of the ankle. This procedure will help the tendon heal properly, restoring function to the foot and ankle.

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  • Cause:

    This is  not completely understood, but thought to be related to repetitive micro trauma.

  • Symptoms:

    Pain is often present with the associated inflammation.
    At the bony insertion site, a bump may develop called a Haglund’s deformity. This may become so large it can cause difficulty with fitting shoe wear, rubbing of the heel and even exquisite tenderness.

  • Imaging:

    Weight-bearing X-rays are required. MRI scan may be required.
    Management is based upon the patient’s age, chronicity of the lesion, skin quality and other medical comorbidities.
    Initially nonoperative measures are commenced. Up to 50% of people can be successfully treated with non-operative measures.

  • Non-operative Treatment:
    • Topical anti-inflammatory creams
    • Pain medications e.g. NSAIDS such as Mobic or Panadol Osteo
    • Shoe wear modification e.g. open back shoes or heel lift
    • Orthotic with medial arch support to help any overpronation of the foot
    • Activity modification: improve fitness and strength via non axial loading exercises e.g. cycling or
      swimming. Avoid axial loading exercises e.g. running. Avoid activities which overstretch the achilles
    • Physiotherapy: eccentric strengthening program. Avoid aggressive stretching programs as these
      often exacerbate symptoms
    • Weight loss management
    • Extracorporeal shockwave therapy may be of benefit but this has not been proven
    • Corticosteroid injections must be avoided – there is a risk of tendon rupture

    Eccentric strengthening:
    stand on the balls of your feet on the edge of a stair with legs straight, gently drop both heels down to below the level of the stair, hold for 10 seconds

  • Surgery:

    Considered if symptoms are progressing and function is decreasing after a trial on non-surgical treatment.

    Depending on the extent and nature of disease, surgical options may include:

    • Open achilles tendon debridement with removal of any calcific tissue and excision of the bony
      Haglunds deformity
    • An augment may be required e.g. FHL tendon
    • Reconstruction of the insertion of the achilles tendon with anchors into the bone

    Please find more information in the post operative protocol section for your specific surgical procedure.

Non-Insertional Achilles Tendonitis

  • Cause:

    This is inflammation of the achilles tendon usually 2-6cm higher up the leg from the insertion point in the main body of the tendon. It is most commonly associated in sports with running and jumping components. There are many contributing factors such as overuse, inadequate footwear, changes in training pattern or environmental factors.
    There may be pain, swelling and tenderness at the site with occasionally a palpable lump.

  • Imaging:

    Weight-bearing X-rays are required. Ultrasound and MRI scans may be required.
    Initial management is non-operative and similar to Insertional Tendonitis.
    Please see above.
    More than 50% of patients respond to non-surgical measures, often combined with a reduction in activities. Despite treatment the clinical outcome is often unpredictable.

  • In addition:

    A walking CAM (controlled ankle motion) boot or moon boot may help reduce the inflammation.
    Occasionally a PRP (platelet rich plasma) injection may be offered. This can help promote reduction in inflammation and healing of the tendon.
    Application of glyceryl trinitrate patch has been shown to be effective.
    If non-surgical management duration is longer than 6 months then surgery may be considered.

    It may consist of:

    • Arthroscopic debridement
    • Open debridement of the unhealthy tendon and augmentation of the main achilles tendon

General info: