The Achilles tendon is the strongest tendon in the body and is also the most commonly ruptured. However, rupture is only one of the problems that can occur with the Achilles tendon. For every torn tendon, I see many more cases of tendonitis and tendinopathy.
Achilles ruptures are often associated with a “pop” and an instant feeling of pain. Patients relate that the pain does not last very long and — although there is swelling on the bag of the leg — the pain often subsides. Some patients may not realize they have an Achilles tendon tear for a while, resulting in a chronic tear that may require additional care beyond a primary Achilles repair surgery.
The point of this article is to share my experience with everything Achilles from tendonitis to tendinopathy and acute to chronic rupture repairs.
How is acute Achilles tendinitis treated?
In my experience, acute cases of Achilles flare-up or tendonitis are often due to overuse and a level of increased activity that results in the tendon being strained and painful. Patients usually experience pain to the touch and pain when moving the Achilles tendon. There may be inflammation and/or grinding of the tendon with pressure.
Several common causes of Achilles tendonitis include pronation deformity of the foot, which results in hyperextension of the tendon and strain on the entire foot/ankle. Furthermore, an increased level of acute activity can place strain on the tendon and cause inflammation. Commonly, rest, ice, anti-inflammatory treatments, physical therapy, and protection will result in improvement.
If pronation is causing your tendonitis, insoles or orthotics may help to reduce strain. Achilles strengthening exercises and gentle stretching after a period of rest will also protect and improve the function of the tendon.
What are the challenges of chronic Achilles tendinopathy?
If acute Achilles tendonitis is not treated in a timely fashion, continued strain and damage can occur. Often when treating Achilles tendonitis, I have found microscopic tears in the tendon with scar formation and more chronic damage.
The inflammation process that heals your damaged Achilles tendon may reduce over a period of three to six months. This results in chronic, noninflammatory scar formation and enlargement of the tendon.
My goal during treatment of chronic Achilles tendinopathy is to convert a chronic, noninflammatory condition to a more acute inflammatory condition. Reducing your tendonitis from chronic to acute, better allows your body to heal the damaged area.
In my experience, rest, ice, and anti-inflammatory treatments do not always help a chronic condition as inflammation is not the primary problem present. However, physical therapy can be very helpful, and often includes scar tissue-focused modalities in the form of Astym (augmented soft tissue manipulation) or Graston techniques. Both techniques focus on breaking down restrictive tissues and restoring normal function.
In truly stubborn cases, shockwave therapy, platelet-rich plasma (PRP), or amniotic fluid injections may provide relief.
Treatments for chronic Achilles tendinopathy
I have used extracorporeal shockwave therapy for years, but in the past three years my office began using the OrthoGold 100 (SoftWave) device. Through a combination of ultrasonic sound waves, light waves, and shockwaves, we break the scar tissue apart in the damaged tendon. This activates the body’s stem cell response to help heal the region.
If the Achilles is very bulbous and needs extra treatments or multiple treatments are difficult for the patient, I have found that PRP injection is a good choice. My clinic uses ultrasound guidance during the injection process and uses a “peppering technique” to break up the scar tissue while injecting small amounts of PRP. After treatment, I often give patients a walking boot to rest the tendon and make them more comfortable.
Amniotic fluid injections have become a mainstay in my treatment of Achilles tendinopathy. Amniotic fluid triggers a stem cell response and causes an inflammatory healing response in the region of injection. In general, amniotic fluid injections are less painful for patients than PRP. Again, peppering and ultrasound guidance are preferable but not essential, and using a boot may be a good option. It is not rare to repeat the PRP or amniotic injection a second time four to six weeks after the first injection in stubborn cases.
More advanced Achilles tendinopathy treatment options
In serious cases, where the tendon does not respond to these treatments, debridement is the next step. While I was in residency, we would perform open surgery to debride the damaged tendon area. Nowadays, we are able to perform debridement with percutaneous means (through several small incisions, instead of a large incision).
Three common debridement probes we use are:
Topaz is a radiofrequency coblation (low-temperature) device that stimulates healing in the degenerative tendon, creating a local plasma layer that dissolves molecular bonds of soft tissue scarring.
The Tenex and TenJet probes remove scar tissue in a more mechanical manner. Using ultrasound guidance, we insert the probe, break apart the scar tissue, and remove it with suction. TenJet utilizes a power saline jet system that will break up the scar and debride it, while the Tenex system debrides and aspirates by reducing the target tissue to liquid.
What you should know about acute Achilles tears
Most acute ruptured tendons I see in my practice are from “weekend warriors” who are between their early 20s and late 60s and engage in frequent physical activity. Patients may come in complaining they “sprained their ankle,” but under examination, we find weakness to plantar flexion and a palpable gap in the tendon.
While we can usually assess and diagnose a tear with a simple examination, we often turn to imaging to confirm diagnosis. Magnetic resonance imaging (MRI) is a mainstay of imaging, but I have begun to use in-office ultrasound for my testing and radiographic diagnostics. Ultrasound testing is inexpensive, fast, and easy to perform as well as dynamic. An ultrasound can show if the tendon ends approximate with plantarflexion — which I find helpful in planning the treatment course.
How is the treatment of acute Achilles tendon ruptures performed?
It’s rare for me to consider nonsurgical Achilles casting as an option for acute rupture of the Achilles tendon, but it is sometimes worth considering. Depending on what the ultrasound shows, we may have success casting the ankle in a plantarflexed position. However, nonsurgical treatment does come with higher rate of re-rupture and longer recovery time. Casting can also result in a tendon that is weak or not at optimal length.
In the case of Achilles tear surgery, I have started utilizing a minimally invasive repair system almost exclusively. I now find it rare to have to make a large incision in acute cases for an end-to-end repair. Furthermore, a minimally invasive system places the sutures in the non-ruptured region of the tendon — which is likely stronger and of better quality.
If the tear is distal or there isn’t enough quality tendon to do a direct repair, I’ll anchor the sutures to the heel bone. While this technique is more difficult, the repair is stronger.
Achilles surgery recovery
After torn Achilles surgery, we will put you in a cast for five weeks to allow the tendon to heal. At five weeks, we place you in a tall boot with one inch of lift — at this point, you’ll be cleared for weight-bearing and will start physical therapy to recover range of motion. Over three weeks, we slowly remove portions of the lift during follow-up appointments. At 10 weeks post-surgery, protection can be removed and therapy continues.
Full recovery may take three to six months total. During this time, prescription or over-the-counter pain medicine may be used to manage any pain.
How are chronic Achilles tendon ruptures treated?
Chronic ruptures typically occur in patients who continue to function on an injured foot due to lack of acute pain. As a result, the tendon doesn’t heal or heals incorrectly. My primary Achilles tendon repair method for this condition is to repair the Achilles to a functional length.
In my experience, it is rare that a ruptured Achilles tendon can be primarily repaired when chronically ruptured. If there was a high-grade partial tear and the Achilles repaired itself in a lengthened manner, an end-to-end open repair can be performed by removing a tubular section of scar and tendon and re-repairing under anatomical tension.
Often the Achilles tendon and the calf muscles (gastrocnemius and soleus muscles) are weakened and full strength may not return, therefore a flexor hallucis longus (FHL) tendon transfer to the heel can add strength to the Achilles function. The FHL tendon is harvested from behind the Achilles tendon. The FHL will act in sync with the Achilles tendon to add push-off strength.
Recovery from this procedure is usually similar to acute tendon tear repair and extensive therapy will be needed to strengthen the area.
Worried about an Achilles tendon injury? Talk to University Foot & Ankle Institute
Dr. Bob Baravarian is just one of the expert podiatrists and orthopedic surgeons at the University Foot & Ankle Institute (UFAI). UFAI’s podiatrists are experts in non-invasive and surgical repair procedures as well as sports medicine and physical therapy. Whether you’re experiencing ankle pain or just interested in preventative care, UFAI’s staff are here for you.
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Resources
Chiodo CP, Glazebrook M, Bluman EM, Cohen BE, Femino JE, Giza E, Watters III WC, Goldberg MJ, Keith M, Haralson III RH, Turkelson CM. American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of Achilles tendon rupture. JBJS. 2010 Oct 20;92(14):2466-8.
McCormack R, Bovard J. Early functional rehabilitation or cast immobilization for the postoperative management of acute achilles tendon rupture? A systematic review and meta-analysis of randomized controlled trials. Br J Sports Med. 2015. 49:1329-1335.
Schmitz C, Csaszar NBM, Milz S, et al. Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database. Br Med Bull. 2015;116:115-138.
Dr. Baravarian has been involved in athletics his entire life and played competitive tennis in high school and college. He has an interest in sports medicine, arthritis therapy and trauma/reconstructive surgery of the foot and ankle. He servers as a consultant to the ATP (Association of Tennis Professionals) tour, multiple running organizations and several shoe manufacturers. He is also fluent in five languages (English, French, Spanish, Farsi and Hebrew),
Podiatrist Dr. Bob Baravarian is available for consultation at the Santa Monica, Sherman Oaks and UCLA Westwood offices.
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