Chronic Achilles Tendinosis
What is Achilles Tendinosis?
The Achilles tendon is a strong, thick, and important structure that functions to bring the ankle and foot downwards and propel the body forward in gait. Thousands of fibrous bands of tissue bind together to form the dense Achilles. The calf muscle (gastrocnemius) becomes the Achilles tendon about midway in the lower leg. The tendon travels down the back of the leg, crosses the ankle, and attaches to the top and back of the heel bone (calcaneus). The Achilles tendon acts as a “rubber band” that stretches back and forth with each step.
When there is an acute or new injury to a portion of the tendon and it becomes inflamed, this is called Achilles tendonitis (-itis = inflammation). In this acute state of injury, the swelling of the tendon is not visible.
When conservative treatments for Achilles tendonitis fail or when, all too often, people wait too long before seeking treatment, Achilles tendonitis can transition into a chronic state called Achilles Tendinosis where a thickening and swelling of the tendon can be visible. This can eventually lead to partial tears and an Achilles Tendon Rupture.
What are the Symptoms of Achilles Tendinosis?
Patients will complain of a deep achy pain, and sometimes a sharp knife like pain. The pain is more pronounced with each step when walking and any activities. There can even be some pain at rest. There will be a visible mass of swelling and thickening of the tendon. Any pressure on or squeezing of the tendon mass will be significantly painful. Most patients will complain of substantial pain when taking their first few steps out of bed or after sitting for some time, and then walking. This pain can ease when there is more walking, and then increase again towards the end of the day. Most find that being barefoot, using flat shoes and shoes without support lend to more pain because the tendon is used at its maximum. The pain usually will worsen gradually over time.
What Causes Achilles Tendinosis?
Achilles tendinosis is a chronic injury caused by a recurring repetitive injury to the area over time. Sudden movements from a stationary position or repetitive overuse of the tendon can lead to stress through the tendon. When there is an instance where the tendon is not able to stretch and be elastic during an activity (even walking) the tendon to suffer multiple micro tears before its attachment to the heel. This is the weakest portion of the tendon because it has the least amount of blood flow. As the micro tears increase, there is an onset of inflammation and pain that will be felt within the tendon. Left untreated the tendon will not heal properly and scar tissue will develop within the tears of the tendon. This scar tissue is weaker than the original tendon.
When the foot is at rest or under bed sheets, the foot and ankle are in a downward position; the tendon is in a shortened, relaxed state. As soon as sudden weight is put through the foot, the already damaged tendon is asked to stretch too quickly, and more micro tears are created. This is the reason for the common increased pain in the mornings. As the tendon stretches out with more walking, it will tear less. It is seen in women and men, athletes and non-athletes.
Patients that are born with (toe walkers) or acquire over time, a muscle/tendon complex that is too short (equinus), have a higher chance of developing Achilles tendinosis. Examples of those that risk shortening their tendon are those that wear high heel shoes for extended periods of time and ballet dancers that go onto point.
A partial tear or rupture of the tendon that does not heal properly may develop into an Achilles tendinosis. Left untreated, an Achilles tendinosis can develop become an Achilles tendon rupture.
How is Achilles Tendinosis Diagnosed?
Diagnosis is achieved by the clinical examination, and a diagnostic ultrasound of the patient. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s foot and ankle and an evaluation of their gait. There will be special examination of the Achilles tendon and its muscle to determine any underlying cause and any shortening of the tendon. Digital radiographs (x-rays) of the ankle to may be obtained in the office and reviewed with the patient. The films evaluate the heel bone for any heel spurs (retrocalcaneal exostosis) and the tendon is examined for any calcifications within.
Dr. Soomekh may evaluate the tendon using a state-of-the-art diagnostic ultrasound. This examination will show the thickness and swelling and any amount of damage and tearing of the tendon. It is used as an important tool to examine the degree of injury and the effectiveness of treatment.
An MRI may be ordered to evaluate the tendon directly in 3 dimensions. It may also be needed for those patients with suspected partial or full Achilles rupture.
How is Achilles Tendinosis Treated?
Dr. Soomekh educates that early diagnosis and treatment of Achilles Tendinosis are the keys to successful treatment, faster recovery and painless lifestyle.
Conservative Treatment for Achilles Tendinosis:
Conservative treatments rely on their ability decrease pain, reduce inflammation, stop the micro tearing of the tendon, and stretch the tendon. These treatments have a high chance of failure due to the extent chronic nature of the injury to the tendon. Dr. Soomekh will recommend a strict 2 to 4 week initial therapy protocol. Reduction of the inflammation and pain can be achieved by treating the area with a daily regimen of ice therapy and the use of anti-inflammatory medications (NSAID’s). A period of rest will be needed in order to reduce the constant strain on the tendon while it is trying to heal. In most cases a walking boot to restrict the use of the tendon will be recommended. The patient will be educated on a stretching regimen for the calf and the Achilles tendon. Stretching of the muscle/tendon complex is very important in order to elongate the complex allow the tendon to be more elastic and reduce the occurrence of the micro tears. These stretching exercises will be especially important in the mornings before getting out of bed or after a period of rest. Heel lifts can be placed in the shoes to place some slack on the Achilles. Dr. Soomekh may recommend a course of visits to a Physical Therapist.
Custom Molded Orthotics
Custom molded orthotics (insoles) are an integral part of healing and maintaining the integrity of the Achilles and redirecting the pull of the tendon. The pull of the tendon on the heel bone plays an important role in the support of the arch of the foot. When the tendon is damaged and irritated, the arch and the heel will need to be supported by a custom orthotic to reduce the forces placed on the tendon while walking and increased activity. The orthotics control the amount of motion through the heel during gait, and take off some of the strain the tendon would normally incur.
Cortisone (steroid) Injections:
Dr. Soomekh does NOT recommend cortisone injections for Achilles tendinosis. Steroid injections have many positive applications for treatment of foot and ankle problems. However, the Achilles tendon can weaken when injected with cortisone.
Advanced Treatments for Achilles Tendinosis:
In chronic conditions the body’s healing factors are not trying to heal the area of concern and are busy taking care of the rest of the body. Presumably, there are less inflammatory cells around the tendon to aid in healing. In these cases, Dr. Soomekh offers more advanced treatment methods.
The following treatments aim to convert the chronic Achilles Tendinosis condition into an acute condition. By doing so, the body will recognize the injury as a new injury and respond accordingly with the appropriate inflammatory response. Under this controlled setting the new injury can be treated in order to heal it in a timely manner. These techniques will stimulate the tendon, break up scar tissue, and attempt revascularization of the Achilles tendon by converting the chronic injury into an acute inflammatory one leading to an influx of inflammatory healing cells to the tendon.
Platelet Rich Plasma (PRP) Therapy For Achilles tendinosis:
Platelet-rich-plasma (PRP) can be used as a treatment option for Achilles tendinosis. The introduction of a high concentration of platelets can “jump-start” the tendon to begin healing by increasing blood flow, converting the chronic injury into an acute inflammatory one leading to an influx of inflammatory healing cells to the tendon. It is a relatively non-invasive method using the patient’s own healing potential. Dr. Soomekh offers PRP therapy in the office setting. Click here for our details on PRP therapy.
The patient’s blood will be drawn from their arm. The blood will then be placed in a centrifuge in order to obtain the highest concentration of platelets available. The area of the is anesthetized. Dr. Soomekh will use precision ultrasound guidance to deliver the PRP by injection into the Achilles tendon. The patient can return home with special instructions for a post treatment protocol. A walking boot is used to control the stress on the tendon during the healing period. Some patients may benefit from a second or third PRP therapy depending on their progress.
Percutaneous Topaz Coblation Therapy for Achilles Tendinosis:
Topaz Coblation therapy is a minimally invasive option for the treatment of Achilles tendinosis. It is performed in an operating room. A grid of 12 to 20 tiny holes is made through the skin, over the Achilles on the areas of the most pain and thickened tendon. A special probe is placed through the skin into each hole to the level of the tendon. The probe then “burns” small holes into the tendon, stimulating the tendon. This procedure “injures” the tendon in a controlled setting, produce an inflammatory that will stimulate the body to heal the tendon. Since it only requires small holes, compared to a larger open incision, it can heal faster and with no scarring. The patient will return home with special instructions for a post treatment protocol. A walking boot is used to control the stress on the tendon during the healing period.
Tenex™ Percutaneous Tenotomy for Achilles Tendinosis:
Tenex™ tenotomy is a minimally invasive option for the treatment of Achilles Tendinosis. It is performed in an operating room, often with simple local anesthesia. A small incision is made on the side of the Achilles tendon in the area of damaged and or thickened tendon. Under ultrasound guidance, the probe is under the skin and into the damaged tendon. When activated, the probe removes the damaged tissue, while not interrupting the normal tendon. The patient will return home with special instructions for a post treatment protocol. A walking boot is used to control the stress on the tendon during the healing period.
Surgical treatment for Achilles Tendinosis:
Dr. Soomekh will always recommend and attempt conservative treatment when appropriate. However, when Achilles tendinosis becomes chronically painful and activity is limited, surgical repair may be indicated.
Is Achilles Tendon Surgery Painful?
Considering surgery can be intimidating. Ankle surgery including Achilles tendon surgery is not supposed to be painful during recovery. When the skin and the soft tissues are handled with care and focus, most patients experience little to no pain immediately after surgery and throughout the recovery period. Dr. Soomekh takes great care and focus to minimize the chance of postoperative pain. The goal of Achilles tendon surgery is to remove scar tissue and damaged tendon, repair tendon tissue, stimulate the tendon, alleviate pain, allow a return to normal shoes, and allow a return to all activities. Most procedures allow for immediate partial walking and a return to work while wearing a special boot. Dr. Soomekh performs the procedures in an outpatient setting at state of the art facilities.
Open Repair For Achilles Tendinosis:
An incision is made on the back of the leg along the course of the Achilles tendon over the damaged area. Once the tendon is exposed, an incision is made into the substance of the tendon to remove the portions of damaged tendon, scar tissue, and any extra bulk of the tendon. Any bone fragments or calcifications that may be in the tendon are removed. The Achilles is then stimulated to increase blood flow and healing potential. This can be done by making small stab incisions into the tendon, performing Platelet Rich Plasma (PRP) therapy, or using Topaz Coblation therapy. Using specialized stiches, the opened tendon is then repaired. The skin is then closed using plastic surgery techniques. The procedure will require some time in a special boot and crutches with no weight bearing.
Dr. Soomekh has perfected and reinvented these surgical procedures and techniques and is recognized by his peers as one of the top Achilles tendon specialists and Achilles surgeons in Los Angeles.