The Achilles tendon, or heel cord, is the largest tendon in the body. It is very important for normal gait patterns and is the main generator of force for push off strength during walking. Throughout the stance phase of gait, the Achilles tendon and its associated muscles contract both eccentrically (as the muscle lengthens) and concentrically (as the muscle shortens). The tendon experiences forces nearly 4x body weight during walking and 7x body weight during running. Due to these constant forces, and the fact that many of us take over 10,000 steps a day, this tendon is a very common site of pathology.
Occasionally, the Achilles tendon will directly rupture into two halves and nearly all push off strength can be lost. This often happens during sports activities such as tennis or basketball. Many patients describe a popping sound and state they felt like someone kicked them in the back of the leg, only to turn around and see that nobody is behind them (see youtube video of ‘Kobe Bryant Ruptured Achilles’). There are multiple studies supporting both operative and non-operative treatment of acute Achilles tendon ruptures. Generally, in active patients, surgeons in the U.S. recommend surgical repair with the goal of primarily repairing the tendon in an effort to regain push off strength, decrease chances of re-rupture, and rehabilitate faster.
Commonly, the tendon may gradually become swollen or painful proximal to its insertion on the bone, but without an acute event or rupture. This is known as Achilles tendinopathy, and may preclude a rupture. Patients may feel a knot on the back of the calf area. In these instances, conservative treatment may be beneficial. Treatment is often initiated with a period of rest in a cast or a walking boot. This may be accompanied by anti-inflammatory medications, ice, compression, or activity modifications. Eventually, physical therapy modalities and a stretching and strengthening program may be instituted. Most studies indicate that conservative treatment is effective about 50% of the time. If your physician institutes some of these treatment regimens and you experience little relief, then you may benefit from surgery. At the time of the operation, an incision is made on the back of the calf and the tendon is evaluated. Often times, unhealthy tissue is encountered in place of healthy tendon tissue. This diseased tissue is excised to debulk the swollen area and to remove the pain generation. Rarely, if a substantial amount of Achilles tendon has to be removed, a different tendon can be transferred into position to replace the Achilles tendon.
The insertion of the Achilles tendon on the heel bone (calcaneus) can also become painful. This is usually a slow chronic process to develop, and with time, calcifications at the Achilles tendon insertion may develop and large bony heel spurs can be seen on x-ray. Sometimes the spurs become so large and the surrounding soft tissue proliferation becomes so severe, that the heel area swells significantly. It may become painful to simply wear a shoe. Conservative treatment options may be the initial mainstay of treatment. A shoe with a roomy heel counter may relieve pain. Oral and topical anti-inflammatories can be beneficial. Many patients eventually choose to have operative intervention for unrelenting pain. This is generally performed utilizing a small incision on the heel to remove the bone spurs and the degenerative tissue, and to reattach good healthy tendon to the heel bone. This is generally highly effective in eradicating the severe swelling and relieving the pain. Very rarely, if substantial amounts of diseased tissue have to be removed, then another tendon may be transferred into position to replace or reinforce the Achilles tendon.
Achilles tendon surgery is usually performed on an outpatient basis. The recovery often entails a period of casting and non-weight-bearing for a few weeks, followed by a walking boot and physical therapy for a couple of months. Most patients return to standard footwear by 12 weeks.
Copyright Protected. Jesse F. Doty MD. Foot and Ankle Specialist. Orthopaedic Surgery. Chattanooga, Tennessee.