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Brian C. Toolan MD
Orthopaedic Foot and Ankle Surgery
The University of Chicago
Section of Orthopaedic Surgery and Rehabilitation Medicine
5841 S. Maryland Ave. MC 3079  Chicago  Illinois 60637
Phone 773.702.6984 Fax 773.702.0076
Achilles Tendonitis Treatment Options
Definition
The Achilles tendon is the largest tendon in the human body and can withstand
forces of 1,000 pounds or more. But it is also the most frequently ruptured tendon, and
both professional and recreational athletes, can suffer from Achilles tendonitis. It is a
common overuse injury. It is a syndrome of irritation of the Achilles tendon. With
overuse, the tendon becomes irritated and inflamed causing pain and noticeable swelling.
In addition, this can lead to small tears within the tendon making it more susceptible to
rupture.
Causes
The two most common causes of Achilles tendonitis are inflexibility of the tendon
and over pronation. Other factors associated with Achilles tendinitis are recent changes
in foot wear and changes in training schedules, like increases in distance running or
addition of hills or stairs to a program; trauma caused by a sudden and/or hard
contraction of the calf muscles when putting out extra effort like in sprinting; or overuse
resulting from natural lack of calf muscle flexibility. Bone spurs or bony prominences on
the calcaneus can rub against the Achilles tendon causing pain swelling and tearing of the
tendon. Age also plays a role. As people age, tendons, like other tissues, become less
flexible, more rigid, and susceptible to injury.
Symptoms
The main complaint associated with Achilles tendonitis is pain over the back of
the heel. This is where the Achilles tendon attaches to the calcaneus (heel bone).
Patients usually experience the most significant pain after periods of inactivity, for
example, when first waking in the morning or when getting up after sitting for long
periods. Pain will also be experienced with activity like running or walking, and the most
severe pain is felt when pushing off or jumping.
Diagnosis
Diagnosis is made by patient history and physical exam. Sometimes the
physician will request and MRI to asses for tears within the tendon or if surgical
treatment is indicated.
Treatment
Treatment is dependent on the degree of injury to the tendon. Usually a period of
rest, which may include limiting activity and/or immobilization for 3-4 weeks, is needed
until the pain is resolved. Anti-inflammatory medications may also help. In addition,
physical therapy and orthotics may benefit after immobilization. These conservative
treatments are usually successful.
If conservative treatment is failed, surgery is an option of last resort. Surgery
would involve removing the torn parts of the tendon and scar tissue, and repairing the
tendon if necessary. Bone spurs may also require removal to reduce the chance of retearing the tendon. It requires four to six weeks of casting non-weight bearing to allow
the tendon to heal followed by physical therapy to regain motion and strength.
Surgical repair of chronic Achilles tendonitis
The procedure generally involves making an upside down figure 7 incision in the
back of your lower leg and repairing the torn tendon. There are the risks of having
surgery which include infection, wound healing problems, and risks associated with
having anesthesia.
The surgery takes approximately 90 minutes and can be performed on an
outpatient basis, meaning you can go home the same day. The degenerated tendon is
removed and repaired. If there is so much degeneration that the tendon cannot be repaired,
sometimes you will have a tendon transfer. A tendon transfer entails taking another tendon
and making it your new Achilles tendon. The tendon that is used is called the FHL tendon
and its function is to bend the very tips of the lesser toes, but this function is not missed.
Post operative management
There are many factors that affect your healing time. The most important is to be
patient, YOUR FOOT MAY NOT TOUCH THE GROUND until your surgeon or
therapist tell you that it’s o.k. This means you must use assistive devices, like crutches, a
walker or roll-a-bout to get around. We do not want you to use a wheel chair because
your entire body gets weak and it will lengthen your recovery time.
Another factor is smoking. YOU MUST NOT SMOKE while you are
recovering. It will delay your healing. This includes second hand smoke. Smoking
decreases the blood flow to your surgical site. This means that oxygen and nutrients
essential for healing are decreased and will lengthen your recovery. It is also possible
that the tendon will not heal, or your wound will not heal and the skin dies. In the event
that you do not heal, you will require additional surgery to get the tendon to heal.
Another factor is swelling. This is something that can be avoided by elevating
your foot above heart level. Swelling can also be controlled with ice therapy. Icing for
20-30 minutes in intervals will significantly decrease your swelling. The best thing to
use for ice therapy is crushed ice or frozen vegetables because they can conform around
your cast or splint. By eliminating swelling, you can reduce or eliminate your pain.
Elevate and ice your foot 20-30 minutes for pain control first. If elevation and ice do not
adequately control the pain, you may then take your pain medication. It is important to
only take your pain medication when you need it. Just because the prescription says
you may take it every 4-6 hours, does not mean that you have to.
Pain management
The first 2-3 days after surgery will be the most uncomfortable. You will have
both swelling and pain. During this time it is very important that you decrease your
activity level, elevate the operated foot above heart level, and use ice therapy. You will
notice when you put your foot down, it will begin to swell immediately and you will
experience a throbbing pain, your toes my turn a dark bluish-purple. To treat this, elevate
and ice and it should go away. Over the next two weeks, you will be able to increase the
amount of time you can have your leg down. It is still important to keep your leg
elevated as much as possible.
After surgery, you will be given a prescription for pain medication. You
should not need any refills. If you are out of pain medication, perhaps you are being too
active and need to decrease your activity level. Before taking a pain pill, we suggest that
you try elevation and ice for 20-30 minutes and if this fails to resolve you pain, you
should take your pain medication.
Casting
Immediately after surgery, you will be placed into a splint. This is to help protect the
surgical repair and allow for skin healing. It is like a cast, made of plaster and is open in
the front to accommodate for swelling.
At two weeks after surgery you will return and have your sutures removed. You may
desire to take some of you pain medication before having your sutures removed. You
will be placed into a lighter-weight fiberglass cast for another 2 weeks. After your month
of immobilization you will be placed into a CAM boot, a removable waking boot, so that
you can start physical therapy.
Physical Therapy
Physical therapy begins at 4 weeks after surgery. The goals of rehabilitation are wound
healing, range of motion with emphasis on neutral dorsiflexion, regaining muscle
strength, normalize gain and return to previous functional level.
All exercises are done within the limits of pain. You will work on range of motion to 710 degrees of dorsiflexion (bending your ankle toward your head) and full plantarflexion
(bending your ankle down toward your toes. We do not want you to move your ankle past
7-10 degrees, so that you do not stretch out the repair and have difficulty with strength
and gait. You may begin strengthening in plantarflexion only.
You will increase weight bearing directed by your therapist. First you will be off the
crutches and then out of the CAM Boot. You will begin working on normalizing your
gait. This process may take approximately 6 weeks to return to shoes, however, you will
still work on strengthening and normalizing your gait for several months after surgery.
Your goal will be to be able to perform a single heel rise.
It is important to remember that you may still have good and bad days after your
treatment is completed. It can take six to nine months to return to your normal level of
activity. Although there will be some bad days, over time you will get progressively
better. We will see you back at the six month anniversary of your surgery. At six
months, the foot should “feel normal”, range of motion is greatly improved, swelling is
decreased and there are no problems with the foot with normal daily activities.
At any time during your treatment, you may call the office at (773) 702-6984 with any
questions or concerns, or call the nurse at 773-834-0355.