- Achilles Tendon Rupture
- Plantar fasciitis
- Achilles Tendonitis
- Posterior Tibial Tendon Dysfunction
- Tarsal Condition
Achilles Tendon Rupture
Definition: The Achilles tendon connects the calf muscles to the calcaneus (heel bone) and is the largest tendon in the body. A rupture of the tendon is a complete or partial tear caused when the tendon overstretches its capacity. Most ruptures occur in the substance of the tendon 4-6 cm above the heel but can also tear away from the insertion on the heel bone. This can be caused by sudden accelerations (stop and go sports like tennis and basketball), sharp pivoting and high impact jumping. Tripping and falling can also lead to this injury. The injury most commonly occurs as the patient pushes off with their foot.
Symptoms: Patients often report a sensation of being “kicked” in the back of the ankle. Sometimes a “pop” is heard accompanied by acute sharp pain. However, in a small number of cases minimal to no pain is reported.
Diagnosis: The Achilles tendon is palpated for localized tenderness, thickening or a defect in the tendon. A calf squeeze or Thompson test is preformed which will accurately detect a tendon rupture. The patient lies face down on the table with feet resting off the end. The calf muscle belly is squeezed. Normally the ankle should plantar flex (toes point more) but if the tendon is torn there will be weak or no movement when the calf is squeezed.
Non-operative treatment: This usually consists of a period of immobilization in a cast with the foot and ankle flexed downwards. This position helps to bring the two ends of the tendon into close approximation so healing can occur. Immobilization is followed by rehabilitation. The length of recovery is often patient dependent but typically takes 3 to 6 months.
Operative treatment: Most surgeons recommend operative treatment in young or middle aged patient, especially if they wish to continue participating in athletics. Surgical repair restores length and tension to the ruptured tendon by sewing the two ends of the tendon back together. You will be immobilized in a splint and/or walking boot after surgery while the tendon heals and then rehabilitation will occur. Recovery time is similar to non-operative treatment but may be shortened by a few weeks.
FAQs:
How can I prevent an Achilles tendon rupture?
Having a BMI greater than 25 puts you at an increased risk for an Achilles tendon rupture. 77% of Achilles tendon injuries occur in people with a BMI greater than 25. Maintaining a healthy weight can be protective for your Achilles Tendon. In addition, smoking has documented negative effects on tendon health and should be avoided. Cold weather training is also associated with higher rates of tendon injury and therefore an adequate warm up is recommended.
I ruptured my Achilles tendon. What is the likelihood that I will rupture the other side as well?
If you rupture your Achilles tendon there is a 6% risk that you will rupture the opposite side as well.
Plantar Fasciitis
Definition: Plantar fasciitis occurs when the thick, fibrous band of tissue that connects the heel bone to the base of the toes becomes inflamed. It is one of the most common causes of foot pain in adults. Possible risk factors include obesity, flat feet and prolonged standing or jumping on hard surfaces and a short Achilles tendon. It also frequently affects runners and dancers.
Symptoms: Pain is most commonly present on the bottom of the heel. Pain is often worst during the first few steps after getting out of bed in the morning and after sitting for a period of time.
Diagnosis: Diagnosis can be made by listening to a patient’s history and preforming a physical exam. X-ray may be used to help rule out other differential diagnoses.
Conservative Treatment: Conservative treatment consists of daily stretching exercises of the calf muscles and plantar fascia combined with massage. A night splint is worn by the patient to keep the plantar fascia stretched overnight. The use of flat soled shoes and walking barefoot is avoided. Shoe orthotics and a 2-3 week trial of NSAIDs can be tried. If the patient is still experiencing pain after these therapies a steroid injection is given using a needling technique to help break up the tough fibers of the plantar fascia.
Surgical Treatment: A partial plantar fascia release surgery involves cutting part of the plantar fascial band to reduce tension and inflammation on the plantar fascia. If a heel spur is present that will be removed at the same time.
Surgical FAQs
How long will the surgery take? Will I be under general anesthesia?
You will receive a regional nerve block prior to surgery which will make your foot numb and eliminate all pain in the foot for 12-24 hours. You will receive light sedation during surgery but will not need general anesthesia. The surgery is an outpatient procedure and typically takes 15 minutes to complete. You will stay in the recovery room for observation for about 30 minutes after your surgery.
Can I walk after surgery?
You will need to use crutches for the first 12-24 hours after surgery until the nerve block has worn off. After the nerve block has worn off you may weight bear through your toes in a post op sandal to reduce pressure on your incision. You will continue toe weight bearing for two weeks before transitioning to flat foot weight bearing as your pain tolerates.
When will my stitches come out?
You will have a follow up visit 2 weeks post-operatively and your sutures will (likely) be removed at that time. For the first two weeks following your surgery you will need to keep the incisions and soft dressing dry by covering the foot with a sealed plastic bag when you shower.
Achilles Tendonitis
Definition: The Achilles tendon connects the calf muscles to the calcaneus (heel bone) and is the largest tendon in the body. Tendonitis simply put is inflammation in a tendon. Inflammation is the body’s response to disease or injury as a result of repetitive stress to the tendon and usually causes pain and swelling.
Achilles tendonitis can be divided into two categories based on the location of the diseased tendon: Insertional Achilles Tendonitis and Non-insertional Achilles tendonitis. Non-insertional type typically affects younger, active people and occurs in the middle of the tendon. As a result of micro-tears in the tendon fibers there is thickening, tenderness and swelling in the mid portion of the Achilles. Insertional type affects the area where the tendon inserts into the heel bone and usually results from years of overuse. Small calcifications in the tendon can occur and extra bone (Haglund Deformity) may be present.
Symptoms: Patients often experience pain and tightness along the Achilles tendon that is worse in the morning or the day after exercising. Pain can also worsen with activity. Constant swelling around the tendon that increases throughout the day is also common.
Diagnosis: The diagnosis of Achilles tendonitis is made by listening to your history and preforming a physical exam. An x-ray is helpful in showing any calcifications or bone spurs that may be contributing to your pain. If you have not shown improvement after conservative treatment an MRI will be ordered to obtain more information on the quality and degree of disease in the tendon in preparation for possible surgical intervention.
Non-operative treatment: Non operative treatments are effective in reducing pain but depending on how long you have been living with your pain it may take 3 months before you notice these therapies making a difference. We start by resting the tendon by wearing a walking boot for one month with the use of ice, oral anti-inflammatories and stretching. Then physical therapy is started using an eccentric strengthening protocol. Dry needling is a modality that may be offered by your physical therapist in which a needle is inserted at the site of pain to stimulate an inflammatory response, leading to formation of new tissue and eventual tendon healing.
Operative Treatment: The Achilles is surgically debrided to remove damaged, thickened tendon. In the case of insertional Achilles tendonitis, the tendon is detached from the heel bone and the bone spur is removed so it does not cause continued irritation to the Achilles tendon. The Achilles is then reattached to the bone. If greater than 50% of the tendon is diseased the tendon that causes the big toe to curl is moved to the heel to support the damaged Achilles.
To watch an animated video describing the surgical repair please click here:
Recovery after surgery: This is an outpatient procedure. The surgery takes about 40 minutes and you will stay at least 30 minutes after your surgery for observation before you go home. You will be given a prescription for pain medicine and anti-nausea medication. You will be put in posterior lower leg splint after your surgery and will remain non weight bearing on the operative side with the use of crutches or a knee scooter for at least two weeks. If the Achilles was detached from the heel bone you will remain non-weightbearing for a total of 6 weeks while the Achilles regrows to the bone. After 6 weeks you will walk in a boot for 1 month and then begin physical therapy.
Posterior Tibial Tendon Dysfunction
Definition: Tendons attach muscles to bones and allow for joint movement. The posterior tibial tendon (PTT) begins in the calf, travels behind the medial malleolus (inside of the ankle) and attaches to bones in the middle of the foot. (picture) The major role of the PTT is to maintain the arch in the foot and to provide support during the toe push off phase of gait. Damage to this tendon in the form of inflammation, overstretching or tears leads to pain on the inside of the ankle and gradual loss of the arch on the inside of the foot. Overtime this leads to a flat foot.
Symptoms: Posterior tibial tendon dysfunction causes a gradual increase in pain without a specific injury. Pain is most common along the inside of the ankle behind the medial malleolus and swelling may be present along the tendon. As the arch of the foot begins to drop, the middle of the foot turns outwards and the ankle rolls inwards, causing impingement of the lateral ankle structures. This can lead to pain on the outside of the ankle as well.
Diagnosis: Diagnosis of posterior tibial tendon dysfunction is based on history and physical examination. Special attention will be given your foot posture when standing. A specific test for this condition is a single heel raise. While standing on the affected leg only you are asked to raise your heel off the ground with your weight supported on the ball of your foot. Inability to perform this movement indicates a diseased posterior tibial tendon. X-ray and MRI can also be useful in making the diagnosis.
Conservative treatment: Conservative treatment is usually recommended first for symptom relief. In most cases of advanced posterior tibial tendon dysfunction surgery will be needed to correct your foot posture and restore your arch. Conservative treatment begins with oral anti-inflammatory medication and ankle bracing that includes an arch support.
Surgical treatments: Based on the stage of disease of your posterior tibial tendon (PTT) and the amount of collapse of your foot one or more surgical techniques may be used. These include 1) cleaning and removing damaged tissue around the tendon, 2) transferring another tendon (flexor digitorum longus) to assume the function of the damage tendon, 3) making a cut in the heel bone and adjusting the heel alignment to take the strain off of the PTT, 4) Placing a wedge in the outside of the heel bone to lengthen the outside of the foot and help recreate your arch, and 5) fusing one or more bones together to stabilize the hindfoot and stop the progression of the foot deformity.
Tarsal Condition
Definition: A tarsal coalition is an abnormal union between two or more bones in the hindfoot. The unions can be fibrous, cartilaginous or bony and are most commonly found between the calcaneus and navicular bones. Coalitions between the calcaneus and talus and calcaneus and cuboid also occur but are less common. Coalitions usually form during fetal development and often never cause symptoms. When symptoms do present, they usually occur in early adolescence when the coalition mineralizes (ossifies), leading to a stiff, painful flatfoot.
Symptoms: Patients often complain of pain over the subtalar joint of the foot. Increased pain with activity and walking or running on uneven surfaces is common. Because a tarsal coalition limits motion in the foot it may lead to frequent ankle sprains.
Diagnosis: A rigid flat foot, limited painful inversion of the foot and decreased subtalar motion are often noted. The coalition can often be identified on x-ray. A CT or MRI provides more sensitivity and specificity for diagnosing this condition when needed.
Conservative Treatment: Treatment for a painful tarsal coalition begins with rest and possible immobilization in a walking boot or cast for 1 month to alleviate stress on the tarsal bones. Foot orthotics, physical therapy and steroid injection can also be effective in reducing the pain associated with this condition.
Surgical Treatment: Surgical treatment will depend upon the size of your coalition and the presence of joint arthritis. In most cases the coalition can be resected which will allow proper movement between the affected bones and relieve pain. If the coalition is very large or if arthritis has already developed in the joint, fusion of the two involved bones is the best option for pain reduction.
