Achilles tendon disorders are commonplace in a podiatric practice. Achilles tendinopathy encompasses a wide variety of pathologies. When I evaluate patients with Achilles tendon pain, I divide the tendon into three zones.
First, I palpate the proximal extent of the tendon, which I consider the body of the tendon. Any thickening in this area may be an indication of tendinosis. If there is no thickening of the tendon, then it is most likely more of a paratendinitis.
Next, I will specifically palpate the retrocalcaneal bursa. I do this by sliding my thumb and index finger on my left hand distally until I reach the posterior superior aspect of the heel. If the bursa is tender to palpation, then this is more likely a bursitis condition.
Lastly, I will palpate the posterior aspect of the heel at the attachment site of the tendon in addition to palpating the medial lateral sides of the posterior heels where the expansion fibers exist. Pain in this area is consistent with what I call an insertional Achilles tendinitis/tendinosis.
Initial treatment for Achilles tendinopathy will include rest, anti-inflammatory medication and icing. The next step of treatment usually involves immobilization in a fracture boot with a taper dose of prednisone. A formal course of physical therapy including eccentric loading exercises and ASTYM (Performance Dynamics) treatments may be beneficial for tendinosis.
When conservative treatment fails to resolve retrocalcaneal pain, then one may consider surgery. I want to focus on the insertional Achilles tendinitis condition and a simple, initial surgical technique.
There are many surgeries that various surgeons have described for the painful posterior heel. Most people believe that one should remove the posterior heel spur and/or posterior superior prominence of the heel. However, it is debatable as to how much of the problem is directly related to the bone. Certainly, a Haglund's deformity, a long calcaneal body and high pitch of the calcaneus play a role in irritation of the Achilles tendon.
What do you do though when there is insertional Achilles tendinitis and no heel spur or Haglund's deformity? Assuming the patient has failed conservative treatments, what surgical recommendations would you make? Do you detach the Achilles tendon, rough up the bone and reattach? Do you inject the tendon with platelet rich plasma? Do you use extracorporeal shockwave therapy?
These are all acceptable treatment options. I would like to share with you what I do for this condition. I also offer this technique to patients who cannot be non-weightbearing, want a quick return to activity and/or would like to try something simple first.
When discussing surgery options with patients, I tend to give them many options as we all know there is more than one way to skin a cat. The conversation is very similar to the conversation I have with patients who have hallux rigidus or a dorsal bunion. I am sure we all have a similar conversation with our patients. We note that we can try something fairly simple such as a cheilectomy and chances are very good that their pain will resolve. However, if the surgery fails to resolve their pain initially or in the future, we can always proceed to a joint fusion or joint arthroplasty.
When looking at a lateral X-ray in a patient who has insertional Achilles tendinitis, I have learned that it is not necessarily the bony mass, calcaneal step or spur that gives the clinical appearance of a lump on the back of the heel. Certainly, the bone spur may be aggravating the tendon but it is the Achilles tendon itself that is thickened at the insertion point, causing the appearance of the lump. This is obvious when you look at an X-ray of a patient's heel in which one side is symptomatic and the other is not. If you look closely, you will see that more often than not, both heels have spurs and the symptomatic side has more soft tissue between the bone and the skin.
The surgery that I prefer for this condition involves using radiofrequency Coblation. I will typically do an open incision although you can do it through holes created by K-wire in a grid-like fashion. I will make a transverse incision at the level of the tendon attachment in a skin crease. Dissect down through the fat and cauterize the small veins. Try not to undermine the skin from the fat and create more of a flap of skin and fat. I will slightly undermine the fat from the tendon proximally to aid in exposure to more of the tendon. I do not incise into the deep fascia or paratenon of the Achilles tendon. After obtaining good exposure of the tendon, I will perform radiofrequency Coblation. Close the subcutaneous tissues with a 4–0 Vicryl in a running fashion. Close the skin with 4-0 nylon.
I will place patients in a fracture boot and they can walk on it immediately. Remove the sutures in 10 days to two weeks. Typically, patients experience a reduction in pain immediately. It is not uncommon for patients to tell me on the first postoperative visit that they can already tell a difference with improvement. Patients can return to a regular shoe per tolerance. Just like any other foot surgery, I tell patients they can take at least six months to completely recover from the surgery.
If the surgery fails to resolve posterior heel pain, then we have other options such as gastrocnemius recession and various types of calcaneal osteotomies.
For the right patient, this may be a simple and effective approach for chronic insertional Achilles tendinitis/tendinosis. I would avoid this approach when is a large posterior heel spur, concomitant bursitis and/or Achilles tendinosis proximally on the tendon. If these conditions are present, then I am going to do some bone work.