Does an Achilles Tendon Injury Require Surgery?
Early treatment of Achilles tendonitis depends on whether it is insertional or non-insertional. Insertional tendonitis is an inflammatory condition and is treated with non-steroidal anti-inflammatory medication, eccentric stretching exercise, and silicone heel lifts.
Non-insertional Achilles tendonitis occurs in the “watershed” area of the Achilles where the blood supply is limited. The condition may or may not have a degree of inflammation associated with it but always involves some degree of degenerative damage to the tendon within the area of limited blood supply. Initial treatment involves stretching exercises and relative rest for the tendon along with use of a heel lift.
In patients who present with more severe symptoms, we may prescribe a boot, crutches, or complete immobilization of the ankle in a walking cast. Other minimally invasive treatment alternatives include the use of biologic injections into the tendon area, including platelet-rich plasma (PRP) or concentrated bone marrow aspirate (cBMA – stem cells). Steroids are not recommended since they can weaken the tendon and lead to a rupture.
What are the Surgical Treatment Options for an Achilles Tendon Injury?
In many cases, surgery will not be necessary in patients who have Achilles tendonitis. However, if conservative treatment fails to work after weeks to months, our physicians may suggest surgery. Surgery for Achilles tendonitis will depend on the location of the disease and the amount of damage to the tendon.
Achilles Tendon Surgical Procedures:
One alternative is a surgical lengthening of the calf muscle which is known as gastrocnemius recession. This involves cutting the fascia, or the covering over the muscle, which allows the muscle to stretch further. Patents who have a difficult time stretching or flexing their feet may benefit from this procedure. With this technique, the tightness in the Achilles tendon is usually relieved allowing additional flexibility.
For insertional Achilles tendonitis with a prominent posterior bone spur (Haglund’s deformity) or an area of calcification within the tendon, a removal of the diseased or damaged tendon and excess bone is typically recommended when it does not respond to nonoperative treatment measures. This procedure is performed through a direct posterior incision and involves a few weeks of non-weight bearing after surgery to allow the tendon to heal back to the bone. In more severe cases of significant tendon damage or tearing, it may be necessary to reinforce the Achilles tendon with a tendon transfer from the flexor hallucis longus (one of the two tendons that go to the big toe and allows it to flex).
Non-insertional Achilles tendonitis is treated surgically with percutaneous or open debridement (removal) of diseased tissue. Percutaneous removal is typically done with ultrasound guidance and the use of a Tenex device which allows focused removal of the pathological tissue. Diseased tissue is removed by the back and forth action of a small high energy ultrasound probe that is placed into the damaged tissue. This procedure allows for immediate weight bearing in a walking boot.
Open surgery with removal of non-insertional Achilles tendonitis is the other surgical option. This involves a larger incision and direct, open removal of diseased tissue. A transfer of the flexor hallicus longus tendon is occasionally needed to add strength to the Achilles tendon after open debridement.
How long is the recovery after Achilles tendon surgery?
Operative intervention can be performed as an outpatient or inpatient procedure depending on the specific surgery. Surgery is typically done with regional nerve blocks to control postoperative pain. Depending on the surgery, the average patient will have two weeks of non-weightbearing while wearing a boot to protect the healing Achilles. The following two weeks, patients may bear weight and do heel lifts in place, as directed. Most patients require a 6-8 week course of physical therapy after their immobilization.