Achilles Tendon

Achilles Tendon

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Overview

The Achilles tendon (thick fibrous cord) is the strongest tendon of the body. It is also the largest tendon which connects the muscles of your calf to the heel bone. Movement of this tendon allows us to run, walk and jump.

What is Achilles tendon?

Despite its strength, the Achilles tendon is quite vulnerable to injury because during high impact activities (participation in sports) the tendon bears the weight of the entire body. Also, the tendon has limited blood supply and this delays the speed of recovery.

What is Achilles tendon repair surgery?

A surgery to repair a tear or rupture of the Achilles tendon is termed as Achilles tendon repair surgery. It is usually performed by an orthopedic surgeon specialized in treating musculoskeletal problems of foot and ankle. The surgery aims at restoring the structure and function of the tendon.

Who are candidates for Achilles tendon repair surgery?

Achilles tendon injury is common among both young and elderly patients. Athletes involved in impact sports such as basketball, football or rugby quite often injure their Achilles tendon. Also, individuals playing recreational sports (cricket, badminton etc.) without proper warm up and sports safety equipment are more prone to Achilles tendon injury. Patients diagnosed with following conditions are ideal candidates for the surgery-

  • Achilles tendon tear: happens when sudden strong force is applied e.g. falling from a height or sudden outward movement of the ankle joint.
  • Achilles tendon rupture: happens during tough physical activity, high intensity impact or direct trauma to the tendon
  • Achilles tendinosis or tendinitis: inflammation of the tendon mostly due to inappropriate running or jumping techniques
  • Achilles tendinopathy: degeneration of the tendon due to overuse or repeated stress resulting in micro trauma
  • Foot deformities: such as Charcot foot (foot losing its shape) or Hagglunds deformity (bony enlargement of the heel where Achilles tendon is inserted)
  • Plantar fasciitis: inflammation of the plantar fascia (thick fibrous band that connects heel to the toes)

What are risk factors for Achilles tendon injury?

  • Age: injury is most common in patients between 30 to 40 years of age
  • Sex: Achilles tendon injury is more common in men than in females
  • Osteoarthritis of ankle joint: degenerative disease of the joint causing wear and tear of the ligaments surrounding the ankle joint
  • Prolonged use of steroid injections: steroid injections into the ankle joint for reducing pain, might cause weakness of the adjacent soft tissue structures. Thus, increasing the risk of Achilles tendon rupture.
  • Certain antibiotics
  • Obesity

What are symptoms of Achilles tendon injury?

  • Hearing a pop sound when injury occurs
  • Pain over calf region
  • Heel pain
  • Swelling near the heel
  • Inability to stand tip toe on the injured leg
  • Leg weakness
  • Difficulty standing or walking

How is Achilles tendon injury diagnosed?

In case you are experiencing any of the above-mentioned symptoms, then you should immediately visit your doctor. He/she will take the following steps before confirming the diagnosis

  • Medical history: your doctor will take an elaborate medical history and ask questions regarding onset of symptoms, severity of symptoms, daily activity engagement and sports participation (if any).
  • Physical examination: Next, your doctor will perform a thorough physical examination and look for any kind of swelling, tenderness or deformity of the ankle joint.
  • Diagnostic tests: your doctor may advise you to undergo ultrasound or MRI (magnetic resonance imaging) of the ankle joint to determine extent of injury. Additional blood tests may also be performed.

How is Achilles tendon injury treated?

Older individuals and those with medical comorbidities such as diabetes, high blood pressure etc usually opt for non-surgical/conservative management for Achilles tendon injury. Although, the recovery takes longer and there are chances of re rupture. Treatment includes-

  • Rest: avoid any activity that causes pain. Stop participating in any sports activities. In general, avoid all activities that require you to stand or walk.
  • Icing: wrap the ice pack in a thin towel and apply it on the affected area. Icing will help in reducing pain and swelling. This should be done for 20 to 30 minutes, 3 to 4 times a day to achieve maximum benefit.
  • Pain relieving medications: taking non-steroidal anti-inflammatory medicines will help in reducing pain and swelling. Take the prescribed dose of medicine for a prescribed period of time. Certain medicines are habit forming and have severe side effects.
  • Ankle brace or cast: your doctor will recommend you to wear an ankle brace or cast for the first few weeks to limit movement of the ankle joint.
  • Physical therapy: you can start with simple stretching and strengthening exercises of the forearm muscles once the pain has resolved. Physiotherapy modalities such as therapeutic ultrasound and electrical muscle stimulation will speed up the recovery process.

Surgical management

In most cases, conservative management will provide effective relief from symptoms. However, few patients who do not benefit from this will be offered surgical treatment. Also, young athletes usually opt for surgery.

What happens before Achilles tendon repair surgery?

You will be asked to completely stop smoking, as smoking delays the healing process. It is very important to inform your doctor about all the medications that you are currently taking, e.g., herbal medicines, nutritional supplements, pain relieving medicines and over the counter (OTC) medicines. Some of these medicines/supplements can increase the risk of complications after tendon repair surgery. You will be asked to fast for several hours before surgery. Do not eat or drink anything at least 8 hours before surgery or as directed by your doctor.

What happens during Achilles tendon repair surgery?

  • The Achilles tendon repair surgery is performed under general anaesthesia and you will sleep through the procedure
  • The surgeon makes a small incision over your leg, directly over the heel where Achilles tendon is normally inserted. A tiny camera with attached light is used during the surgery.
  • Next, an incision is made on the sheath that surrounds the Achilles tendon and the damaged/torn part of the tendon is removed.
  • If required your surgeon may remove a part of another tendon from the foot and use it to replace a part or all of the torn Achilles tendon.
  • The layer of the sheath is then closed followed by muscles and then the skin. Sterile bandage is applied over the site.
  • The surgery is usually performed as an outpatient procedure and you will be discharged home the same day.

What happens after Achilles tendon repair surgery?

Expect some pain and swelling over the ankle joint for the first few weeks after the surgery. But these symptoms will gradually wear off. Your doctor will prescribe anti-inflammatory and pain relieving medicines to help you feel better. An ankle splint/cast will be placed to immobilise the joint and accelerate the healing process. Once you get back home, walking around (mostly for basic activities) should be done with the help of crutches. Avoid putting any weight on the operated joint during the first two weeks after the surgery. After around 10 days, the cast will be replaced with a supportive boot, which you need to wear for the next 6 to 8 weeks.

Most patients will be able to resume their normal activities and sedentary jobs within 3 months following the surgery. Driving can be resumed almost 4 months after the surgery. However, it is recommended that you should consult your doctor before doing so. Once the tendon has healed sufficiently, your doctor will recommend you to begin rehabilitation with a physiotherapist. Initially, simple strengthening exercise for ankle and leg muscles can be performed. Gradually the intensity and frequency of exercises can be increased depending on the patient’s overall wellbeing. Around 6 to 8 months of rehab is required to completely recover. You will be able to return to sports almost 6 months after the surgery. But remember, that your Achilles tendon will take around a year to completely recover and get back to its pre surgical state.

What are complications of Achilles tendon repair surgery?

  • Infection
  • Excess bleeding
  • Blood clots
  • Infection
  • Nerve damage
  • Calf weakness
  • Pain in your foot and ankle
  • Decreased movement of the ankle joint
  • Complications from anaesthesia
  • Re rupture of the Achilles tendon

Tips for prevention

  • Proper warm up before engaging in any sport or exercising
  • Proper stretching of calf muscles (avoid bouncing during a stretch)
  • Avoid activities that put excessive stress on Achilles tendon (jumping)
  • Avoid running on uneven surfaces or slippery floors
  • Wear well-fitted athletic shoes with proper heel cushioning
  • Use an ankle support brace or tape on a previously injured ankle joint.
  • Slowly increase your training intensity, not more than 10% weekly

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