A patientâ€™s guide
The Foot and Ankle unit at the Royal National Orthopaedic Hospital is made up of a multi-disciplinary team. The team consists of two specialised orthopaedic foot and ankle consultant surgeons (Mr Singh, Mr Cullen and Mr Goldberg), specialist doctors in training, a physicianâ€™s assistant a clinical nurse specialist, orthotists and physiotherapists. All team members are specialised in foot and ankle care and work together to provide and deliver a quality service 1
Achilles tendon The Achilles tendon or ‘Heel Cord’ attaches the powerful calf muscles to the calcaneus (or heel bone). The primary function of the Achilles tendon is to transmit the power of the calf to the foot resulting in the ability to walk, run and jump. The Achilles tendon is made up of fibres called collagen. Achilles tendinosis With age, collagen fibres become less flexible and more susceptible to injury. Achilles tendinosis is caused by small micro-tears of the collagen fibre structure of the tendon. In some long-standing cases, small new blood vessels attach to the deep part of the tendon. Pain is experienced over the heel cord or over the back of the heel bone. Pain may come on suddenly in ‘Acute Achilles tendinosis’ or gradually in ‘Chronic Achilles Tendinosis’. Patients with acute Achilles tendinosis can often describe an injury or single event that initiated the pain. Pain in Achilles tendinosis tends to be made worse by activity especially on pushing off, for example running and jumping. Pain is especially severe when exercising after periods of inactivity e.g. first walking in the morning. In acute Achilles tendinosis athletes may experience sharp pain as they begin exercising - the pain slowly wears off but returns with prolonged activity. There are two main types of Achilles tendinosis: Insertional Achilles Tendinosis: occurs where the tendon inserts into the heel bone; some people have a prominent lump of bone at the back of the heel often called a ‘pump bump’ or ‘Haglund deformity’ which rubs on the tendon causing inflammation and a pocket of fluid called a bursa. Non-insertional Achilles Tendinosis: Occurs a few centimetres above the heel attachment where the blood supply is poor. What are the causes of Achilles tendinosis? Achilles tendinosis is a common overuse injury; it is more common in middle-aged recreational athletes. The most common cause of Achilles tendinosis is inflexibility of the tendon, meaning stress is put on the tendon upon impact. Other contributing factors are: inadequate stretching prior to sports, a tight calf muscle, mechanical problems in 2
the foot, recent changes in footwear or changes in training schedules e.g. increasing mileage.
How is Achilles tendinosis diagnosed? A physical examination is used to determine the location of the problem. Sometimes your surgeon might arrange for you to have an MRI or ultrasound scan to evaluate tears within the tendon. If surgical treatment is planned, scans may be helpful for preoperative evaluation and planning. What is the treatment for Achilles tendinosis? Non-operative Stretching of the Achilles tendon is the single most important measure â€“ see exercises below. These exercises help to make the calf muscle more supple, the tendon less stiff, and help the tendon repair itself. Physiotherapy may be helpful: your physiotherapist will be able to 3
advise you on the best exercises to perform and simple measures for reducing inflammation. Orthoses such as arch supports may be prescribed for you; these are placed inside your shoe to correct mechanical abnormalities such as over-pronation; these insoles help reduce stresses in the Achilles tendon and can be extremely effective. Some patients report that their orthoses feel a little uncomfortable at first, but with patience and gradual introduction you will usually find that they become more comfortable. We prefer to use insoles to reduce overpronation rather than heel raises that are prescribed by many orthopaedic surgeons. A night splint to hold your ankle at a right angle at night is often helpful, especially in patients whose pain is worse in the morning. Anti-inflammatory tablets can be prescribed, these help to reduce pain when there is inflammation. Local ice massage twice a day can also improve pain. Steroid injections are rarely used as these have been shown to increase the risk of a complete rupture of the tendon. Operative In a small number of cases the tendinosis does not improve even after 12 months of appropriate treatment. Surgery is then considered to remove any inflamed or damaged tissue from the tendon - to promote healing. In insertional tendinopathy, the bony heel bump (Haglund deformity) is removed along with the inflamed tissue. Is surgery for Achilles Tendinosis safe? Surgery for Achilles tendinosis is generally very safe; but, as with any surgery, there is a small risk of complications. Wound problems including delayed wound healing, wound breakdown, tethering of the skin to the underlying tendon and localized numbness over the scar are the most frequently encountered problems. Other risks are infection, persistent pain arising from the tendon, scar pain and neuroma formation. It is likely that your leg will be placed in a in a plaster cast, extending from the ball of the foot to below the knee, for 4 â€“ 6 weeks to protect the wound. 4
Exercise protocol for Achilles Tendinosis. The following exercises should be performed 6 times daily for at least 12 weeks. Supervision by a physiotherapist may be useful. Eccentric lowering – Stand on a step; support yourself only on the front of your feet, keeping knees straight. A moderate stretch of the calf muscles should be felt. Hold for 15 seconds. These exercises may worsen your pain initially. However, as you get used to the exercises and the pain settles you should increase the load by adding some weight e.g. hand weights, rucksack. Repeat 6 times 6 times a day. Increasing range of movement by taking heels further below the step. Performing the exercise on one leg at a time.
Stand at arm’s length from a wall, feet together. Lean to the wall keeping your heels on the ground and knees straight. Hold for 15 seconds Repeat 6 times 6 times a day
Stand at arm’s length from a wall with your back knee locked and front knee bent. Keep both heels on the ground and bend straight leg. Hold for 15 seconds repeat with other leg. Repeat 6 times 6 times a day Activity - Jogging and walking is allowed if it can be performed with only mild discomfort and no pain. Initially start at a slow pace, for a 5
short distance and on flat ground. Gradually increase the activity if there is no severe pain in the tendon. No training should be done through disabling pain!
Exercise protocol for Achilles Tendinosis. These exercises have been shown to help Achilles Tendiosis and should be performed for at least 12 weeks1. Eccentric strengthening Stand on your toes on the edge of a step. Keeping your knees straight, push up on to your toes. Slowly lower your heels to the level of the step. Repeat 3 x 15, twice per day. You can make the exercise harder by: - dropping your heels below the level of the step - adding weight (e.g. hand weights/rucksack) - doing the exercise on the bad leg only Stretching (1) Stand in a walking position with the leg to be stretched straight behind you and the other leg bent in front of you. Take support from a wall or a chair. Lean your body forwards until you feel a stretch in the calf muscle of the straight leg. Keep your knee in line with your foot and donâ€™t let your foot roll inwards. Hold approx 15 secs. Repeat 3 times, both legs, 3 times per day. Stretching (2) Stand with one foot a few inches from a wall. Take support from a wall or a chair. Bend the knee forward to try to touch the wall until you feel a stretch in the Achilles tendon. Keep your knee in line with your foot and donâ€™t let your foot roll inwards. Hold approx 15 secs. Repeat 3 times, both legs, 3 times per day.
Please note: these exercises may worsen your pain initially. If you experience severe pain or if pain lasts for several hours afterwards, please discuss with a member of the foot and ankle pain or your GP.
Physical exercise is allowed if it can be performed with minimal discomfort. If pain is severe, rest from jogging but you can try low impact activities such as swimming or cycling. Gradually reintroduce jogging as you feel able, starting at a slow pace, for a short distance and on flat ground. Gradually increase the activity if there is no severe pain in the tendon. 7
For further information and advice, please contact: The Foot & Ankle Team Royal National Orthopaedic Hospital Trust Brockley Hill Stanmore Middlesex HA7 4LP Telephone: 020 8909 5305 Mr Cullen Secretary 02089095695 Mr Singh Secretary 02089095842 This Document was produced by RNOH Foot and Ankle Team Surgeons: Mr Cullen and Mr Singh Clinical Nurse Specialist: Karen Alligan Physiotherapists: Joanna Benfield and Emma Stewart Published March 2010 1. Alfredson H. & Lorentzon. Chronic Achilles Tendinosis: Recommendations for Treatment and Prevention. Sports Med 2000 Feb 29 (2); 135-146