Achilles Tendonitis

Achilles Tendonitis

The Achilles tendon is the strongest and largest tendon in the body. It helps with push-off strength during walking, jumping, and running. It connects your calf muscle (gastrocnemius and soleus muscles) to your foot, attaching on the calcaneus (heel bone).

The Achilles tendon can become inflamed and irritated due to a variety of factors, including overuse, tightness, over-training, unsupportive shoes, and repetitive injury. When the tendon becomes inflamed, it is called tendonitis. Fluid and swelling occur around the tendon causing pain. In the early stages, this can be improved with rest, anti-inflammatories, ice, and stretching. When the inflammation persists, chronic changes in the tendon can occur including small tears, thickening, scar tissue development, and an overall change in the tendon’s structure. This leads to chronic changes in the Achilles tendon called tendinosis.

There are two different types of Achilles tendonitis, “insertional” and “non-insertional.”

Insertional Achilles Tendonitis/Tendinosis

Insertional Achilles tendonitis occurs when the attachment site of the Achilles tendon on the heel bone (calcaneus) becomes irritated. When the Achilles tendon becomes inflamed on the calcaneus, the body tries to heal it by producing calcium or a “spur” on the back of the heel. Additionally, there is a prominence on the calcaneus bone called a “Haglund’s deformity,” which decreases blood flow to this area. All of these factors lead to swelling, pain, and a bump on the back of the heel, making shoe wear and activities painful.

Non-insertional Achilles Tendonitis/Tendinosis

Non-insertional Achilles tendonitis/tendinosis occurs in the mid-substance of the Achilles tendon above the insertion site on the calcaneus. The tendon starts to degenerate becoming painful, with scar tissue development, micro-tears, and weakening. This is due to a decrease in blood supply to the tendon leading to poor healing ability by the body. Patients report pain with push-off, athletic activities, and a sensitive area and bump along the Achilles tendon.

Treatment

Non-Surgical Treatment

The first line of treatment for Achilles tendonitis is non-surgical. Dr. Kohring will review these treatment options further with you in the office depending on your specific symptoms, severity, physical exam findings, and goals. The majority of patients will improve with non-operative management. The general treatment plan:

• Initial Treatment
  • Boot immobilization (2 weeks)
  • An anti-inflammatory medication to alleviate pain and swelling (non-steroidal anti-inflammatory drugs (NSAIDs) like Advil®, Motrin®, Ibuprofen®, and Aleve®)
  • Topical treatment like Voltaren gel®
  • Nitroglycerin patches to promote blood flow and healing to the tendon
  • Rest
  • Ice
• Next Phase
  • Formal physical therapy including eccentric Achilles strengthening
  • Aggressive calf stretching
  • Heel lift in shoe
  • NSAIDs (like Advil®, Motrin®, Ibuprofen®, and Aleve®)
  • Topical treatment like Voltaren gel®
  • Nitroglycerin patches to promote blood flow and healing to the tendon
• Final Phase (if needed)
  • Platelet-rich plasma (PRP) injection 

Surgical Treatment

For those patients who do not improve with non-operative management, surgery is based on the type Achilles tendonitis/tendinosis you are experiencing. Dr. Kohring will obtain an MRI prior to surgery to further assess your Achilles tendon.

Insertional Achilles Tendonitis/Tendinosis

Surgery involves making an incision on the back of the calcaneus and splitting the Achilles tendon open on either side. This allows access to remove the calcium deposit and Haglund’s deformity. The bone is then smoothed to allow for a healthy re-attachment site for the Achilles tendon. If there is tendon degeneration, this will also be removed. The tendon is then repaired back down to the bone. In some patients, a calf lengthening procedure called a gastrocnemius recession is performed to take tension off of the Achilles tendon and to “surgically stretch” the tendon to prevent recurrence.

Non-insertional Achilles Tendonitis/Tendinosis

Surgical treatment of non-insertional Achilles tendonitis/tendinosis is performed by making an incision through the middle of the Achilles tendon and removing scar tissue and unhealthy appearing tendon. If more than 50% of the tendon is removed, a transfer of the tendon that flexes your big toe is performed to support the repair. Through the same incision, the flexor hallucis longus (FHL) tendon is released and transferred to the calcaneus near the location of the insertion of the Achilles tendon. The FHL tendon is sewn into the Achilles tendon to aid in healing, strength, and repair. This is a very effective and pain-relieving procedure. In some patients, a calf lengthening procedure called a gastrocnemius recession is performed to take tension off of the Achilles tendon and to “surgically stretch” the tendon to prevent recurrence.

Recovery

Both types of surgery have the same postoperative treatment plan. Patients are placed into a splint (like a cast) for 2 weeks and are non-weight- bearing after surgery. At 2 weeks, the sutures are typically removed and patients are placed into a boot and allowed to start putting about 50% of their body-weight on their foot in the boot. They also start physical therapy at this time. Patients are able to go into a regular shoe at 6 weeks after surgery.

Dr. Kohring will be happy to discuss your Achilles tendon pain with you and determine an appropriate treatment plan based on your specific issues and life goals.