Every year one of every 10,000 to 20,000 adults in the United States will rupture their Achilles tendon, according to data from the American Academy of Orhopaedic Surgeons. This number does not include those who will be treated for Achilles tendonitis and bursitis. Men ages 30 to 40 years of age sustain the majority of Achilles tendon injuries.
Injuries
The Achilles tendon connects the powerful calf muscles to the heel. Rising onto the toes results from the calf muscles contracting to pull the heel off the ground. The Achilles tendon lifts the body off the ground in walking, running, and jumping. Several painful injuries can occur; the Achilles tendon can become irritated, the bursa between the tendon and heel can become inflamed, or the Achilles tendon can tear. Some recent advances have been made in the treatment of Achilles tendon injuries.
Tendonitis
Achilles tendonits is typically caused by overuse. When there is a change in activity the tendon responds by developing areas of inflammation. Exercises to stretch the calf muscles, avoiding activities that irritate the tendon and icing are recommended by the AAOS as initial treatment. Patients are referred to physical therapy for instruction in eccentric stretching. Dr. Martin O’Malley, an orthopaedic surgeon speaking at the 2010 meeting of the American Orthopaedic Foot & Ankle Society, also mentioned glyceryl nitrate patches, and corticosteroid injections as options. The AAOS lists tendon rupture as a complication of corticosteroid injections.
Extracorpeal shockwave therapy is believed to stimulate healing by sound waves directed at the area of tendon inflammation, according to the AAOS. This is an unproven but low-risk treatment of Achilles tendonitis. Injection of platelet-rich plasma, PRP, has shown promising results in Dr. O’Malley’s patients. Plasma cells that have been separated from a patient’s blood by spinning are injected into the irritated portion of the tendon. O’Malley cites laboratory studies showing that the plasma contains an array of growth factors, which cause an increase in tendon cells in laboratory experiments. In a review of his patients who had one or two injections of PRP, 80 percent reported Achilles pain resolved. There was not a control group of patients who did not receive the injection of PRP.
Bursa
Insertional tendonitis or retrocalcaneal bursitis causes pain at the Achilles tendon insertion into the heel. Calcifications in the tendon or spur on the heel can develop. This is more common in high-arched feet. Treatment often involves removal of the bursa between the tendon and heel, bone spurs and the superior portion of heel which rubs on the tendon. The surgery can be done through one incision or endoscopically using two small incisions and a camera. The AAOS mentions that the calf muscles may be lengthened during this procedure.
Acute Tears
In an acute injury, the achilles tendon can tear away from its insertion onto the heel. If a piece a bone remains attached, it is surgically fixed back into place using screws.
The tendon usually tears above the heel in an area where the blood supply is poor. Small tears are difficult to differentiate from tendonitis. When the tear is close to 50 percent, the AAOS lists debridement of the tear and repair as a treatment. Surgical repair of the Achilles tendon is done through an incision. Minimally invasive repair uses a small device to pull the tendon end into the wound. A committee of the AAOS, in March 2010, stated their review of several studies showed that there are acceptable outcomes with nonoperative treatment of complete Achilles tendon tears. There may be less chance of re-tearing the tendon after surgical repair.
Helander Nilsson, a Swedish physician presented his study of 97 patients who had Achilles tendon tears at an AAOS meeting in March 2010. Half of the patients had surgical repair of their tendon. All patients were placed in a cast for two weeks then a brace for six weeks. After six months the group that had surgery was better able to raise up on their toes and hop. By a year there was no difference between the group but the injured leg was worse than the noninjured leg.
Chronic Tears
In some patients, a repair of the Achilles tendon may be done months after the injury. Because the Achilles tendon shortens, tendons from the ankle or foot are used in the repair. Duke University reports these patients are weaker after surgery than those that were treated soon after the injury occurred.
Complications
The most common complications of Achilles tendon surgery are infection and poor wound healing. Nerve damage also can occur. The AAOS recommends sedentary, obese, or over 65 years old patients try to avoid undergoing Achilles tendon surgery. Smokers, diabetics, those with poor circulation, immunocompromised, and those with poor nerve function are more likely to have complications from operation on their Achilles tendon.
References
- American Academy of Orthopaedic Surgeons: Torn Achilles Tendon? New Guidelines Say Early Motion Can Be Beneficial
- American Academy of Orthopaedic Surgeons: PRP Show Potential for treating Achilles Tendinosis
- American Academy of Orthopaedic Surgeons: Your Orthopaedic Connection: Achilles Tendonitis
- Duke University: Wheeless Online Textebook: Achilles Tendon Rupture
- “Foot and Ankle International “: Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis; Ortmann FW, McBryde AM.: 2007
