The Achilles tendon is the largest tendon in your body. It connects the upper calf muscles to the back of the heel bone. When the Achilles tendon degenerates and becomes inflamed, it is called Achilles tendinitis or Achilles tendinosis.
If you have these conditions, your tendon can swell and become painful. They are common in athletes, runners, and people who have calf tightness. Achilles tendinosis may occur in the middle of the tendon (known as midsubstance Achilles tendinosis) or at the point where the tendon connects to the heel bone (known as insertional Achilles tendinosis).
For midsubstance Achilles tendinosis, surgery focuses on removing the diseased portion of the tendon. If most of the tendon is damaged, your foot and ankle orthopedic surgeon often will use the tendon that goes to the big toe to support the Achilles tendon after repair. Other procedures may include lengthening the Achilles tendon or calf muscles if they are too tight.
Surgery for insertional Achilles tendinosis is similar. Very often the diseased tissue is removed and the tendon is repaired back down to the heel bone. Surgeons often will shave down the bone spur and smooth it out so that it no longer has the ability to rub the Achilles tendon. Often there is a fluid-filled sac (bursa) that contributes to the pain and inflammation. This bursa frequently is removed during the surgery.
Surgery may be an option for Achilles tendinitis or tendinosis if other treatments, including physical therapy, ultrasound, massage, and shock wave therapy, fail to bring pain relief.
General anesthesia is commonly used. Regional anesthesia that numbs the leg also may be used. The patient is positioned face down on the operating table. Your surgeon will make an incision in the back of the ankle directly over the Achilles tendon. The diseased portion of the tendon is removed with a scalpel. If the problem involves the end of the tendon where it inserts on the heel bone, the tendon may be lifted off of the heel bone. The bump at the back of the bone is removed with a chisel or saw, and the tendon is repaired back down to the remaining bone. Some surgeons also perform a stretching of the calf muscles as part of the procedure. The incisions are sewn together. The leg is bandaged and then protected with a splint or boot brace.
It may take up to a full year for symptoms to resolve completely. Often surgical patients will need several months in a protective boot and crutches before they can walk on their own. Physical therapy often is needed to help restore mobility and strength to the repaired tendon.
Surgery can predictably return patients to activity. Success rates for Achilles tendinosis surgery are 80-90%. Some of the variability depends on the amount of tendon that is diseased at the time of surgery.
Risks and Complications
All surgeries come with possible complications, including the risks associated with anesthesia, wound healing issues, infection, damage to nerves and blood vessels, and bleeding or blood clots.
After this surgery, patients can still have moderate pain. If the tendon is repaired there is still risk of future degeneration of the tendon as the patient ages. However, repeat surgery is rarely required. There is also a risk of Achilles tendon rupture.
If I am treated without surgery for Achilles tendinosis will it come back?
While most patients will achieve lasting relief after treatment for Achilles tendinosis, symptoms may return. The risk decreases if the patient continues to do routine stretching even after the symptoms resolve. However, athletes and runners in particular are at a slightly higher risk for this condition because of the high demands they put on the Achilles. These patients should pay close attention to stretching, and shoe choice to prevent chronic recurrence.
Will I still have pain after surgery?
The majority of patients improve after having surgery. However, up to 20-30% of patients still report some pain after surgical treatment.