Operating When ‘Mild’ Achilles Tendinitis Does Not Respond To Conservative Treatment
What do you do with the patient who has Achilles tendon pain that is unresponsive to conservative treatment and diagnostic studies are essentially unremarkable? It is easy to recommend surgery when you have a patient with a case of severe tendinosis with partial tears and gross hypertrophy of the tendon. So, what I want to do is walk you through a case.
A 41-year-old female presented to my office for a second opinion. A previous physician diagnosed her with Achilles tendinitis and told her to rest (stop running), ice the area down and take oral anti-inflammatory medication. She did not get better in a month and returned for follow up. She then had magnetic resonance imaging (MRI) and learned the study was consistent with tendinitis. She was then immobile in a fracture boot for a month. She still did not get better.
This is when she showed up in my office. Her physical exam revealed that she was in good physical shape. Her neurovascular exam was unremarkable. Dermatologic exam revealed normal skin texture, turgor and temperature. Her orthopedic exam was remarkable for gastrocsoleus equinus. Evaluation of her Achilles tendon revealed generalized tenderness in the mid body of the tendon proximal to the attachment on the posterior heel. There was no pain to palpation of the posterior heel or in the retrocalcaneal bursa. No significant hypertrophy of the tendon was present. Her X-rays were negative for any retrocalcaneal pathology. Her MRI was remarkable for mild tendinitis/tendinosis in the main body of the tendon.
At this point, I recommended that she have a course of physical therapy to include eccentrically loading exercises and ASTYM® treatments (Performance Dynamics). She did this for a month and came back with the same amount of pain.
So now you have to make a decision of what to do. Your patient is not getting better and she is getting frustrated. You have tried ample non-operative treatments. Her MRI is relatively benign and with that said, it makes your decision to operate a difficult one.
Pointers On Surgical Procedure
It is not common that mild tendinitis/tendinosis does not respond to non-operative care. What I do is address the equinus with a gastrocnemius recession and perform radiofrequency Coblation along the entire course of the tendon. After exposing the tendon, I will feel for hardness or heterogeneity of the tendon by squeezing the tendon with my thumb and index finger, running it up and down the tendon. If there is any obvious tendinosis, then I will do a wedge resection of that.
Perform the technique by making a linear incision from the level of the gastrocnemius aponeurosis to just proximal to the heel. There is no reason to extend the incision to the heel in this case. If there is a retrocalcaneal spur and/or retrocalcaneal pain, then this is not the ideal procedure. Do the proximal dissection first and perform a standard gastrocnemius recession. I have found that the type of recession really does not matter in the long run so you can do whatever technique you are comfortable with.
Direct your attention to the Achilles tendon. I will perform radiofrequency Coblation along the course of the tendon through the deep fascia and paratenon. I do not do any stripping of these tissues as all of the nutrition and blood supply to the tendon are in this tissue. After performing radiofrequency Coblation, I will run my fingers up and down the tendon and if there is any tendinosis, I will take a #11 blade and do a converging double semi-elliptical incision (wedge resection). Repair the tendon with a non-absorbable suture. You can use nylon or a braided suture such as Fiberwire (Arthrex) or Ethibond (Ethicon).
When I do the wedge resection, I will cut directly through the deep fascia and paratenon (again avoiding stripping of this tissue). After removing the tendon wedge, one can easily drape the deep fascia and paratenon over the tendon and close it over the tendon.
Postoperative care includes early range of motion exercises. Institute non-weightbearing for three weeks (if there was a tendon wedge resection). Following this, allow return to weightbearing in a fracture boot for three weeks and then return the patient to regular shoes. Physical therapy starts at week six. Weightbearing in a fracture boot can be immediate for those who do not have a tendon wedge resection.
Certainly there are other methods of treatment for this condition such as platelet rich plasma (PRP) injections and extracorporeal shockwave treatment. These may be somewhat experimental at this point, and I am generally “old school” in my approach until the evidence is overwhelmingly positive for other newer techniques.
This illustrated technique works well in my hands for chronic tendinitis/tendinosis of the main body of the Achilles tendon. If there is posterior heel pain (attachment site or the retrocalcaneal bursa) then one needs to perform additional surgery.