Diseases of the Achilles tendon

The Achilles tendon is the largest and strongest tendon in the human body. It is responsible for transmitting immense forces that move our bodies in changing pace, taking off and landing, and changing direction during activities such as walking, running, and jumping. It is not surprising, therefore, that this tendon and especially the point of its union with the heel, the so-called muscular insertion (enthesis), are subject to significant wear and tear during our lifetime.

When patients experience pain around the Achilles tendon, it is important to distinguish between the various pathologies that affect the area. Tendonitis or Achilles tendinopathy is a condition that causes inflammation, swelling and pain in the tendon mass. It is due to repeated cycles of microtraumas and micro-ruptures with inadequate healing. The reduced blood supply to the region also contributes to pathogenesis, along with genetic predisposition and the use of certain medications, such as certain classes of antibiotics. Diagnosis is based on a combination of medical history, clinical examination, and often ultrasound or MRI. The treatment of tendonitis / tendinopathy in Achilles is largely conservative. This includes modifying activities that exacerbate the problem or limiting repetitive, high-energy activities so that the tendon has a chance to heal. Painkillers and topical anti-inflammatory ointments help, as do some orthotics, such as, gel pads or heel lifts. Physiotherapy is important as often the reduced elasticity of the calf muscles (gastrocnemia) is one of the underlying causes of the condition. Extracorpeal shock wave treatment (ESWT) may provide relief in some persistent cases. In resistant cases, surgery may be considered to treat small ruptures that may be present in the tendon or to remove abnormal calcifications or scar tissue in the tendon. It is generally not recommended to inject corticosteroids into the tendon, as this can lead to Achilles ruptures.

Tendonitis of the Achilles muscular insertion, is a condition that affects the area where the Achilles joins the heel bone, the so-called “muscle insertion” of the tendon. As a result of repeated cycles of micro-injury and inadequate healing, pain and swelling occur in the lower end of the tendon and the back of the heel. Inadequate healing also results in tendon growth, slowly developing calcifications and eventually osteophytes, that contribute to pain and swelling. As with Achilles tendonitis, conservative treatment is initially followed. Surgery is indicated when symptoms persist. It usually involves a cleaning of the tendon growth to remove areas with decalcification or osteophytes. Sometimes, in order to access the lesions, the tendon must be detached from a part of its connection with the heel bone. In this case, the detached tendon will need to be reattached to the heel bone with special sutures or bone anchors.

Haglund’s deformity and Achilles tendon bursitis are also pathological conditions with pain and swelling that develop around the tendon growth. The synovial bursa is a structure that helps the Achilles tendon slide to the back of the heel bone in the area of its insertion. In the case of bursitis, the area of the bursa becomes inflamed and filled with viscous fluid. This contributes to the irritation of the tendon that no longer slides effortlessly over the heel bone. In other cases, there is also an osteophyte-like bone swelling in the heel bone (Haglund deformity). This develops in the area of bursitis due to friction of the tendon and generalized inflammation. Swelling in the heel bone can make the shoe painful, as it can rub against the back of the shoes. Conservative treatment is similar to Achilles tendon bursitis and is always applied first, in the early stages. However, in the case of posterior synovial bursitis, a corticosteroid injection into the area can also be carried out individually. Surgery is intended for cases that have not responded to conservative treatment. As with calcific tendonitis, calcium deposits and scar tissue that develop in the Achilles tendon, are removed. The posterior synovial bursa and Haglund’s deformity (bone swelling) are also removed, in a way that they do not rub against the Achilles tendon. If a significant part of the Achilles tendon insertion needs to be detached to treat these pathologies, then it will need to be reattached to the heel bone, using special sutures and bone anchors.

Postoperatively, patients can be fitted with a plaster splint or use a special boot for discharge. As a rule, they cannot charge the leg for a few weeks. Rehabilitation may depend on whether or not the tendon is detached from its insertion, as well as, on the volume of calcifications and osteophytes removed. Physiotherapy is generally required to help with progressive stretching and subsequent strengthening of the tendon. Your surgeon will continue to monitor you for months after surgery, to ensure that the wounds have healed satisfactorily, until the removal of the plaster or boot and the smooth progress of physiotherapy.