There are a few problems that can affect the Achilles and this tendon can be very hard to heal and can take a long time to rehabilitate. The reason this tendon is a problem is because it has a very poor blood supply, especially a couple of inches above the insertion on the heel called the “watershed” area. This is where the tendon will often rupture like was the case with Kobe Bryant. People who are very active or obese are prone to injury to this tendon. Patients with very tight tendons known as equinus deformity are also at risk. Often times if present for a while there will be a bine spur associated with this that is coming off the heel bone and causing irritation to the adjacent tendon. Also, there can be a bursitis present as well. This can be seen on x-ray as well as ultrasound. Poor shoe gear can also add to this problem with poor shock absorption.
Treatment - this is geared at reducing the swelling and pain with PT, Icing, and proper shoe gear.
Orthotics can be dispensed when indicated. This is indicated during the gait analysis. Topical pain cream is also prescribed. A Dynasplint brace is also sometimes used in more severe cases. This is a brace that is worn at night and it is covered by insurance. You should not wear any flat shoes at anytime, and don’t walk barefoot. Some shoes will irritate the back of the heel if a spur is present.
Shockwave therapy is also very helpful with this condition. This is the latest technology for the treatment of tendon/ligament problems and can be done in the office setting. Usually we will try 6 weeks of conservative therapy and see how you respond. If no improvement then we move onto more aggressive treatment as surgery is last resort.
Shockwave with PRP (Platelet Rich Plasma) or Amniotic Fluid (Stem cells) injected around the tendon. The radial shockwave will stimulate blood flow to the tendon and cause some analgesia and then allow the injectable (PRP or Stem cells) to find the diseased area and repair it. This is done without any incisions and usually takes 4-6 weeks to get the desires results.
Surgery (when indicated)
- Rupture – this is repaired usually by using a small incision and a special device is placed into the incision and special strong sutures are brought through the device through the skin and the tendon is brought together to heal. This is much different than most other methods. In some cases the procedure must be done open and also may require lengthening of the tendon if it is too short. This is a long recovery up to 8 months.
- Chronic swollen tendon with bone spur- the repair is aimed at removing the diseased Achilles tendon after reflecting it off of the heel bone (calcaneus) to then remove the spur and smooth out the heel. In 90% of the cases we also lengthen the gastrocnemius tendon using endoscopic technique. This increases the success rate by taking the pulling forces off the heel. We then use bone anchors to reattach the tendon to the heel. Recovery is about 2 months before you can begin to walk normally. Usually there is a period of 2-4 weeks of non-weight bearing.