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Foot & Ankle

Achilles Tendon- Injuries' 

What is the Achilles Tendon?

The Achilles tendon is a very strong tendon at the back of the ankle that connects the calf muscles (Gastrocnemius and Soleus) to the heel bone. Its purpose is to help in lifting up the heel or pointing your toes downward. The Achilles tendon is the strongest tendon in the body and is subject to high forces when we walk run and jump. The tendon can be subject to up to 12.5 x body weight when running. 

Achilles Tendonitis, Tendinopathy and Rupture?

Even though The Achilles tendon is very strong, it can get injured. If we overload the tendon from too much activity, sport or other recreational tasks we can then suffer from Achilles Tendonitis which is a short period of inflammation and pain. This normally settles down if we rest and stop the irritable activity.

If we continue to irritate and overload the tendon, it becomes what is known as a Tendinopathy, which is a degenerative tendon. Tendinopathy occurs through ongoing micro-tears and the tendon cannot repair thus stays in a state of disrepair. It is most common in the over 30s and may present as pain, swelling and stiffness. In the early stages of tendinopathy, pain may be at the beginning of an activity and then reduce or disappear during the activity itself once warmed up, only to reappear when cooling down and the activity has stopped. Over time the tendon will become painful throughout and not improve with warming up. Unfortunately, an Achilles Tendinopathy can take long periods to recover from due to its makeup and it is not unusual for 6 months to pass to fully recover through a specifically guided rehabilitation plan. 

An Achilles Tendon rupture is most common in the 29-40 years and normally occurs during sporting activity. A sport such as Badminton, Tennis, Basketball where we change direction quickly or jump can cause this injury. However, it can occur in some low-level activities. During this, the tendon splits in two and frays. When this occurs many people say they felt like they had been hit at the back of the leg and felt and heard a snap. If you have ruptured your tendon you will be unable to lift up onto your toes and will struggle to walk. 

What Treatments can I do? will I need Surgery?

If you have Achilles Tendonitis or Tendinopathy these injuries can be treated successfully by a Physiotherapist. This will involve a course of specific rehabilitation for the level of irritation you have on the tendon. In Tendonopathies it is seen that slow heavy resistance training is very beneficial in helping cause some regeneration to the tendon. However, this is a slow process as it can take at least 90 days for the tendon to mature and progress thus it is advised it may be between 3-6 months.

If the tendon has ruptured it is important to be seen as soon as possible by an orthopaedic consultant and/or a Sports Physician. This will ensure a better recovery. Normally a scan is undertaken to confirm the level of tear and then the decision as to either treat with surgery or conservatively is undertaken.

On many occasions, a conservative approach can be as successful as an operation in the research 2 years post-injury (Willitis et al 2010). However, this should be discussed with your surgeon as it is not suitable for all. Regarding conservative approaches, the SMART Programme has had very successful outcomes and can be accessed here

(Hutchison et al 2015).  

An Achilles Tendon rupture is treated by the two frayed ends of the Tendon put as close together as possible as the tendon heals with scar tissue. This is the same if treated conservatively or an operation as the principle is the same. This then prevents any laxity on the tendon once it heals, thus giving back normal power. Any delay of diagnosis can necessitate the requirement of surgery, as the two ends cannot be set in close proximity conservatively. Like an elastic band if there is any laxity then there is reduced power due to a lack of energy and recoil. 

What can I expect after?

 If you have had an operation to repair your Achilles or you have been treated conservatively (No-Op) you will still be treated very carefully. Naturally, you will have some pain early on if you have had surgery thus taking medication prescribed can help. In both protocals, you are initially non-weight bearing and put in a cast for the first few weeks that will cover the foot and up to just below the knee. You will have your foot fixed in a pointed position to help the healing of the tendon in a shortened position. For the next few weeks, you will be offloading the foot and may be using crutches, I walker or a scooter. 

Once the cast is removed, you will be given an air cast boot with wedges in to keep the foot pointing downward and crutches to offload the tendon. This will then become your walking boot. you will start Physiotherapy at this stage. You will then reduce the wedges slowly over the coming weeks bringing your ankle and foot back to a normal /neutral angle. 

Physiotherapy with clear guidance on how to offload and protect the tendon will be started which will also be advised to help keep the strength of all the other leg and hip and back muscles. Of course, each Surgeon/Consultant will have specific guidelines for you that should be adhered to.

How do I recover?

Following your Achilles Tendon surgery or conservative approach and you are discharged, it is important to follow the guidance and post-operative instructions.  Research has shown that a tendon heals best if it is carefully moved in a protected environment and guidelines are followed.

You will have to follow strict rehabilitation guidelines to ensure you do not stress the tendon too early and cause further injury. You will be guided through your mobility, strength and daily activity and advised in all areas from self home care, walking, stairs, and how to progress exercise tolerance. This is also with the guidance of your surgeon. It will take 4-6 months to be functioning well and over a year to heal fully.

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