Beyond Achilles tendonitis: Insights and strategies for recovery

Achilles tendonitis, encompassing both insertional tendonitis and mid-substance tendonitis, is a multifaceted condition that affects people across various activity levels, impacting mobility and quality of life.

Here, Mr David Redfern, renowned consultant orthopaedic surgeon, offers an expert insight into Achilles tendonitis, including causes, symptoms, and treatment.

What is Achilles tendonitis?

The Achilles tendon, situated behind the ankle, is a large tendon that connects the strong calf muscles to the heel bone (calcaneum). Additionally, the Achilles tendon also facilitates downward ankle movement, which is essential for propelling the body forwards during activities such as walking and running.

Issues affecting the Achilles tendon usually occur in either:

• The area where the Achilles tendon attaches to the heel bone (insertional tendonitis).
• The middle area of the Achilles tendon (mid-substance tendonitis).

Before recommending treatment, it’s crucial to determine which of these two areas is involved and which anatomical structures are affected. In addition to a thorough physical examination, imaging modalities such as X-rays, ultrasound and MRI may be helpful in this assessment.

What are the causes and symptoms?

Regardless if it’s insertional or mid-substance tendonitis, patients frequently experience aggravated symptoms upon waking up in the morning or after a period of rest, known as ‘start-up’ pain. Symptoms then typically alleviate as the patient becomes more active.

Insertional tendonitis

Insertional tendonitis presents as pain in the back heel area of the foot. Footwear may often add to this discomfort, especially when the heel counter rubs against the affected area of the Achilles tendon and its connection to the heel bone.

The condition is often observed in runners. Occasionally, certain characteristics of the patient's heel anatomy may be responsible, but there can be several factors contributing to the issue.

Mid-substance tendonitis

Mid-substance tendonitis presents as painful inflammation of the Achilles tendon, typically occurring around 6-8cm from its connection to the heel bone.

The condition is often observed in runners. In some cases, it can also develop after an unfamiliar increase in physical activity. Additionally, it can also develop after a minor injury or, rarely, after taking antibiotics like fluoroquinolones.

What treatment options are available? When is surgery recommended?

In some cases, surgery may be necessary for proper resolution of Achilles tendonitis. The type of surgery chosen will depend on the characteristics of each patient’s Achilles tendon and its underlying mechanics.

Insertional tendonitis

If non-operative treatment proves ineffective, surgery may be considered. This could involve removing the bony prominence on the heel bone and then performing debridement of the Achilles tendon itself.

Alternatively, surgery could involve using minimally invasive keyhole surgery to realign the heel without affecting the Achilles tendon, which is an approach that I have pioneered.

All surgical options will be reviewed and discussed during consultation.

Mid-substance tendonitis

Most cases of mid-substance tendonitis can be resolved using non-operative treatment such as targeted physiotherapy and shockwave therapy.

However, if non-operative treatment proves ineffective, surgery may be considered. This could involve removing a small part of the paratenon (the sheath surrounding the tendon) and then performing debridement of the Achilles tendon itself.

In some cases, it may also be beneficial to perform surgical adjustment of the muscle tension pulling on the Achilles tendon, known as gastrocnemius recession. Occasionally, it may be required to perform a surgical tendon transfer of the flexor hallucis longus, the outcomes of which are usually successful.

I have been at the forefront of developing minimally invasive techniques for this type of surgery, and I will review and recommend the most suitable surgical option for each individual case.

To schedule an appointment with Mr David Redfern, head on over to his Top Doctors profile today.