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mahadevan
consultant foot and ankle surgeon
Surgery for Insertional Achilles Tendinopathy
What is Insertional Achilles Tendinopathy?
The Achilles tendon (or heel cord) is the largest tendon in the human body. It connects the calf muscles to the heel (calcaneus). Insertional Achilles tendinopathy is degeneration / inflammation of the fibres of the tendon directly where it attaches (insertion) to the heel bone. It may be associated with inflammation of a fluid-filled sac (bursa) or tendon itself. There may be a bony enlargement on the back of the heel (Haglund's deformity) which can cause mechanical irritation. The soft tissue near the Achilles tendon becomes irritated when the bony enlargement rubs against shoes. This often leads to painful bursitis (inflammation of the bursa). In some patients X-rays may show calcification deposits within the tendon at its insertion into the heel (entesophyte). See X-rays below.
What are the indications for surgery?
In the majority of patients, non-surgical treatment remains effective with the use of non-steroidal anti-inflammatory medication, heel lifts, stretching and shoes that do not provide pressure over this area. Cortisone injections are not recommended for the treatment of these types of problems because they can weaken the tendon and make it easier to rupture. However, if bursitis (inflammation of bursa) is the main pain generator, a one off cortisone injection into the bursa could be considered.
Surgical treatment is indicated if there is failure of several months of nonsurgical treatment. Several different approaches and techniques, including endoscopy, are available.
What type of surgery is suitable for me?
The extent of inflammation and calcification within the tendon decides the type of surgery you would be recommended.
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Resection of Haglund's deformity and bursa - this procedure is undertaken when you have a Haglund's deformity and bursitis (Haglund's syndrome) with minimal / no calcification within the tendon (See X-ray A below).
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Resection of entesophyte/ calcification including partial detachment & reattachment of tendon - this procedure is undertaken when you have significant calcification within the tendon (See X-ray B below). It involves having to detach part of the tendon off the heel bone and reattaching it once the calcification has been removed. If you have a Haglund's deformity, this will also be removed.
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Dorsal closing wedge (Zadek) calcaneal osteotomy - this procedure is performed for insertional Achilles tendinopathy. This realignment of the heel bone reduces abnormal loading and pressure over the Achilles tendon (See X-rays C, D & E below)
The best surgical technique for your Achilles tendon will be determined based on your symptoms and findings.
X-ray A showing Haglund deformity
X-ray B showing calcification within tendon and entesophyte
X-ray C showing angle of inclination (a) of heel bone and entesophyte at Achilles insertion
How is the operation done?
You will be admitted on the day of operation. The operation takes about 45 min to 1 hour and is routinely done under a general anaesthetic. Occasionally a spinal anaesthetic may be considered. Most patients go home the same day.
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Resection of Haglund's deformity and bursa
The removal of the Haglund's deformity and bursa can be done endoscopically (‘keyhole’ operation) or open, depending on the extent of involvement. In the ‘keyhole’ operation, 2 keyhole incisions are made on either side of the tendon and the bone and bursa are removed using ‘keyhole’ instruments. In the open technique, a small incision (4 – 5 cm) is made on one side of the tendon to allow surgical access for the procedure. Following surgery, a bandage and boot is applied to protect the ankle for 2 - 3 weeks. Most patients would be able to weight-bear immediately following surgery. As the tendon does not need to be detached from the heel bone, recovery is shorter. Click here for further information.
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Resection of entesophyte / calcification including partial detachment & reattachment of tendon
A single incision (5 – 6 cm) centred over the tendon insertion is made. The Achilles tendon is partially detached off the bone. Part of the diseased tendon is removed. The calcification within the tendon and Haglund's deformity is removed using surgical instruments. The tendon is then re-attached to the bone using bone anchors. Following surgery, a plaster is applied. You will be non-weight bearing on the operated leg for at least 2 weeks. After 2 weeks, you will be allowed to increase your weight-bearing on the operated leg over a period of 6 weeks. You will be using a boot / plaster cast during this stage.
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Dorsal closing wedge (Zadek) calcaneal osteotomy
A curved incision is made on the outer-side of the heel bone. A wedge-shaped segment of bone is removed from the heel using surgical instruments to realign the heel (see X-ray D below). Once this is achieved, a metallic screw is used to secure the bone in it's corrected position (see X-ray E below). This procedure avoids the need to detach the Achilles tendon from its insertion. Following surgery, a plaster is applied. After 2 weeks, you will have a boot fitted. You will be non-weight-bearing for 6 weeks after surgery to allow for the bone to heal.
Diagram of re-attached Achilles tendon using bone anchors [Ref: www.arthrex.com/foot-ankle/achilles-speedbridge]
X-ray D demonstrating intra-operative view following removal of bone wedge from heel
X-ray E showing completed osteotomy with screw in position
Aftercare and FAQs
It is important to keep the leg elevated as much as possible especially for the first 2 weeks. You will usually be able to go home when you feel ready. You will need to arrange for someone to drive you home. You should try to have a friend or relative stay with you for the first 24 hours. Your first clinic follow-up is usually 12 to 14 days after surgery.
Wound care – The plaster / dressing should be kept dry. At your first clinic appointment, wound inspection and suture removal will be undertaken.
Work - If you have a sedentary job you should be able to return to work within 2 weeks (if you can arrange safe transport). If your job is physical, you may need to stay off work until the boot / cast is removed.
Driving - You will not be able to drive for 3 or 8 weeks following surgery (depending on the type of operation). However, if you drive an Automatic and it was your LEFT side that was operated on; then you may start short drives 2 weeks following surgery. It is advisable to check the terms of your car insurance to ensure your cover is valid, as some policies state that you must not drive for a specific time period after an operation.
Flying after surgery - It is generally recommended to wait at least four to six weeks to fly after any lower limb surgery. It may be possible to fly on short-haul or domestic flights at an earlier time, but you should always check with your GP or surgeon. Always consult your doctor, your health insurance provider and the airline you are flying with before making your flight reservation.
What are the surgical risks?
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Infection
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Nerve damage – causing numbness and painful scar
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Deep vein thrombosis (DVT) and pulmonary embolism (PE) – blood clots in the vein or lungs – to reduce this risk you may be prescribed heparin injections if you are not weight-bearing (unless contraindicated)
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Tendon rupture
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Non- or delayed union (healing) of bone (if osteotomy performed)
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Prolonged swelling and stiffness
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Prolonged recovery
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Residual pain
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Plantar fasciitis - some patients experience transient heel pain especially after Zadek osteotomy
It is beyond the scope of this document to list rarer risks (less than one in a thousand) but I will be very happy to discuss any worries about specific concerns and also about any family history or your past health problems. If there is anything you do not understand or if you have any questions or concerns, please feel free to discuss them with me.