The Achilles is a strong tendon that attaches the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). Tendinitis and tendinosis can occur at the insertion of the tendon (insertional) or a few inches above the insertion (noninsertional). The description and general treatment for these conditions are described in the tendonitis/tendinosis section.
Surgery is indicated for those patients who do not improve with nonoperative treatment. Specific to Achilles insertional tendinosis, there can be an associated bone spur/prominence on the calcaneus in front of the tendon which is not in the tendon. This is called a Haglund’s deformity. This spur may irritate the tendon. Surgical excision may decompress the tendon. Often times, there is bursitis or inflammation separate from the tendon which is removed. During the surgery, the front portion of the tendon may be debrided or cleaned to stimulate healing. The Achilles tendon is not detached from its insertion. With more advanced tendinosis, calcification may build up in the tendon which could also cause a spur/prominence. The surgical treatment includes detaching the tendon, excising the degenerative tissue/calcification and reattaching the tendon. If the degeneration is significant, the tendon may benefit from a flexor hallucis longus (FHL) transfer to rebuild a portion of the tendon. This is a much more extensive surgery that has a longer recovery compared to a Haglund’s decision. Both procedures are performed as an outpatient under regional general anesthesia. The Haglund’s surgery may involve approximately two weeks of nonweightbearing followed by physical therapy. A walking boot or brace may be indicated for a few weeks. The more extensive surgery involves approximately 4 to 6 weeks of nonweightbearing in a splint or boot followed walking in the boot and physical therapy. The patient transitions to a brace in about the 8 to 10 week mark as they become stronger with physical therapy.
Achilles tendon ruptures usually occur during sports or secondary to trauma. The patient often feels or hears a pop. They describe the sensation is being kicked in the back of the ankle. The diagnosis can usually be determined by physical examination, but radiographs are obtained to ensure that a piece of bone is not avulsed with tendon insertion. Most ruptures occur approximately 2 to 3 inches from the insertion. A MRI or ultrasound can confirm the diagnosis. Over the past few years, the treatment has evolved from surgical to nonsurgical. This is due to data showing that the patient reliably returns to full activity without surgery. This functional rehabilitation program involves initial mobilization in a boot with heel wedge. The patient is nonweightbearing for approximately 2 to 4 weeks followed by weight-bearing in the boot and commencement of physical therapy at approximately 4 to 6 weeks. The boot is usually worn for 10 to 12 weeks. Return to full sporting activity takes at least six months. Surgical repair of a rupture is indicated for avulsed tendons from the insertion and can be considered in younger patients (40 years old or less) with a high level of athletic activity.