Achilles Tendon Conditions
Dr. Randale Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV, and today we'll be talking remotely once again with Dr. Erik Nilssen. Dr. Nilssen is an orthopedic foot and ankle surgeon who practices in Gulf Breeze, Florida. Dr. Nilssen did his medical school training at the University of South Florida, and from there orthopedic residency at McGill University, and from there two fellowships – one is Sports Medicine at the American Sports Medicine Institute with James Andrews, and another in foot and ankle surgery under the direction of Angus McBride. Thanks for joining us again today Dr. Nilssen.
Dr. Erik Nilssen: Oh, my pleasure, Randale.
Dr. Randale Sechrest: Well, Dr. Nilssen, today what I thought we would sort, start talking a bit about is Achilles tendon problems. And I think this runs a gamut, a lot of people have heard of ah, achilles ruptures and that sort of stuff, but I think that there's more than just the ruptured achilles tendon that you and I worry about as orthopaedic surgeons. So lets start out uh, by talking a bit about what the Achilles tendon is and what it's function is.
Dr. Erik Nilssen: Sure. Uh, it's a very important structure in the body. Um, as most of you know, it's that real thick, big cord in the back of your leg that runs down your calf and actually inserts in the bottom – the back of your heel. Um, otherwise the bone's called the calcaneus. But ah, what it does, it's an interesting structure. It actually originates, the muscle bellies originate above the knee, called your gastroc muscle. And there's a medial and lateral head, and as it goes distal, it the muscle turns into tendon and then the tendon attaches to the bone, and there's also a muscle underneath it called the soleus muscle, which actually turns into the tendon as well. So it's realy two different muscles that attaches to that cord and it's a really powerful plantar flexor, so pushing on the gas pedal, being able to jump, so, even to walk. So it's a very, very powerful structure uh, that's very needed to carry on activities of daily living.
Dr. Randale Sechrest: And the type of problems that people have with the Achilles tendon, can you sort fo give us a broad overview of the sorts of problems that we're going to be discussing today?
Dr. Erik Nilssen: Sure, I mean um, you know just like I tell my patients, uh, when you talk about tendons, I always try to keep it very simple. And so, I tell everybody tendons can do three things. They can tear, they can get inflamed – which is tendonitis, or they can get diseased – which is tendinopathy. So, those are the three things that we'll kind of touch on. And then on a a, in a sort or another broad view regarding the Achilles tendon, ah, kind of back to the anatomy of a tendon, the Achilles tendon is much like an onion. Okay, you know you buy an onion from the store, there's a covering to that onion, and we call that covering a peritenon, it's just a structure that helps the tendon glide and doesn't get stuck to the skin. So there's a a covering over that tendon called a peritenon, and inside that tendon is like a layer of an onion, it's collagen, and so that collagen is very, very well organized, much like an onion as you go to the layers are very well organized. So I use the onion analogy. Well, much like the onion, the tendon can get something called peritendonitis. An so that sheath can get inflamed, that's one of the major problems. Number two is is, the onion itself can get diseased, and we call that tendinopathy. And then you can get a combination of both. You can get that tendonitis, or tendinopathy together, so the sheath, like the onion sheath's inflamed and also the onion itself is diseased inside. And you can get what's called a bursitis, where it attaches down below the heel. You can also get non-insertional Achilles problems, and insertional problems. Like we talked about with that, you know the tendon comes down, and you can have a problem just above where it inserts or you can actually have it where it inserts. And so anywhere along that tendon can have a problem. But we break it up into insertional, non-insertional, is it an inflammmatory problem, is it a non-inflammatory problem, a disease problem, or a combination of both.
Dr. Randale Sechrest: Well, lets, lets help patients understand this distinction you've just made. Because I think this is key. And that's the different between Achilles tendonitis, for example, we tend to talk about a lot things as tendonitis or some type of itis. And then you've mentioned the term “tendinopathy”. Can you help patients understand the real difference between those two disease processes?
Dr. Erik Nilssen: So, as we understand it today, and this just recently changed a few years ago, but, so tendinitis -someone says your shoulder hurts, you've got rotator cuff tendonitis, or your patella tendon – you've got tendonitis. You know, tendonitis is an inflammatory problem. It means there's inflammation. Okay. When we talk about inflammation we know now that the inflammation that occurs is on the outside of that tendon, that covering, that peritenon. That gets inflamed. Okay, that's an inflammatory process. Now, unlike an inflammatory process, we say tendinopathy, the actual tendon itself, the actual structure - not the outside – but the inside structure. Like I said, it's made of collagen, a very well-organized ah structure. Well, when it gets diseased it gets kind of chaotic, it's almost like, you know when you set up your computer and you've got all these nice cables in the back of your TV and even with your home stereo system, you've got speaker wires, cable wires - all very well aligned in a nice parallel form. Well, imagine that , maybe over the course of a year or two, somehow your kids hooked up a Wii station, the next thing you know you've got wires going everywhere. The sturcture of the tendon itself, that's tendinopathy. It just chaotic, and it gets thickened and uh, doesn't, the structures look the same. And so that's the disease of tendon, that's tendinopathy. So the tendon structure itself is diseased. It loses it's normal anatomy, whereas the tendinitis again is more of the sheath covering gets inflamed, it's an inflammatory process.
Dr. Randale Sechrest: So then now let's talk a little bit about the rupture. And I'm assuming that everybody probably understands what a ruptured Achilles tendon means, but clarify that for us a bit.
Dr. Erik Nilssen: Sure. So if someone says you've ruptured your Achilles, and so, just as we just talked about in this disease process, when it gets disease like that, and we call tendinopathy and it's my belief, and many others, that you're getting microscopic tears in the tendons and the body is trying to heal these microscopic diseased areas, or microscopic tears and it gets thickened and full of just diseased tissue. Now, an acute tear, when someone says oh, you've ruptured your Achilles, that's where the Achilles actually just tears in half. And usually what that is, is it's not you know, it's classically someone eccentrically loads their Achilles tendon so they're playing volleyball and you step back and you abruptly try to push off and fire that Achilles and you feel a big snap. And eveyone tends to think that somebody or something hit them in the backof the leg, really, just above the heel bone. And so oftentimes you know I've had patients that are volleyball players and they think someone kicked them in back of the leg, or someone was stepping out of a pothole and they feel like the pothole cover flipped back and hit him in the heel, but the reality is, it's such a powerful structure, you can audibly hear the snap, and they feel immense pain, and they don't have the push-off strength. That's an acute tear. That's a rupture of an Achilles tendon, same thing in a tear and a rupture, we're talking about the same deal. There's an acute – meaning it just happened, you know within a week or two. And then chronic is when it's been torn and they've kind of neglected it and they come see you weeks to months later.
Dr. Randale Sechrest: You know, are you of the opinion that you can actually rupture a normal Achilles tendon? Is that something you see commonly in athletes? Or do you assume when you see an Achilles tendon rupture that maybe that tendon was a little bit diseased before it ruptured, or both, I guess?
Dr. Erik Nilssen: Ya, I mean it's it's you know populations, it depends on what they do for a living. I mean we have the athletic population, and even the non-athlete. Um, you know obesity is a big problem with Achilles issues. And so generally speaking, the blood supply to the Achilles tendon is such that about 2 to 6 cm above where the Achilles inserts, there's any area where it gets less bood supply – it still gets blood supply, but it's not as good as the other areas. So that's usually the area where we see problems in the Achilles. And so that's usually where it ruptures. And so when someone has an acute rupture, and we go repair those, oftentimes if it's a younger patient, they can have normal tendons, and they just rupture because they had some pretty impressive event. But a lot of times too theres people who have some early disease process. You know for example, you know an NFL player or a college football player, that have been playing football their whole life, putting on this extra wear on this tendon, they can tend to have a little bit of disease process. Before you'll ask them, they'll say well, you know I had some pain prior, or even more than that, they'll have some contractures. They'll actually have a very, very tight Achilles. Uh, and then they're sort of susceptible to tearing that.
Dr. Randale Sechrest: Well, lets move on to talk a little bit about the other symptoms, before the tear. As you mentioned, the tear is pretty easy to spot, you feel like somebody kicked you in the back of the calf, and all of a sudden you can't push off on your toe. But what about the tendinopathy and the tendinitis? What do people present to your office, what type of symptoms do they present with when they come to your office for Achilles tendon problems?
Dr. Erik Nilssen: So, usually when patients come, if they have you know, with say non-insertional Achilles. So that's where the tendon, ah, we're not talking about the insterion site – we're talking about a little bit higher up, maybe 2-6 cm above the insertion site. So when they have a tendinitis and tendinopathy, a lot of the times the symptoms will overlap. And so, but with tendinopathy, over time you tend to see a much thicker Achilles, or you'll see almost like a bump, you know, almost like an hourglass. The Achilles comes down and then it has an hourglass and then comes back down again normal. But they'll complain of pain, they can actually walk, and do things. When they try to do activities, run and jog and push off, um, it starts to escalate, really escalate. Pain is the biggest thing. Ah, they can still function but they've got pain with function, whatever they do, walk, run, jump. And it becomes to get more of a chronic issue and they tend to be be, be taking lots of anti-inflammatories trying to get through this, and they come to you after a year, so. But that's non-insertional. Insertional problems, same deal, where the Achilles inserts in the back of the heel – they can get – people call this thing like a pump bump in the back of the heel. They can actually get a real thickened uh, area in the back of the heel. And have this big protuberance in the back of the heel that is quite sensitive to touch. The back of their shoes won't want to touch the back of their heel. They become very sensitive, so they'll wear backless shoes or shoes that have a little bit of a heel lift in them to take pressure off the back of the heel where the Achilles is. And that's the insertional findings we see versus the non-insertional.
Dr. Randale Sechrest: So, in terms of these types of problems that don't involve a rupture of the Achilles tendon, how are you going to evaluate that when that patient shows up in your office?
Dr. Erik Nilssen: So, classically I'll look at them and look at their, you know again, I completely examine, have them walk, have then do heel lifts, uh, facing away from me and look at their heels. And again, I always compare one to the other, and so you want to see both sides. And you'll see sometimes if it's a non-insertional problem, you'll see sort of a bogginess to that tendon. Usually if you look from the back, you know there's not much padding back there, so the tendons very, very close to the skin and you can see the contour of the Achillles very well. And as you stand there and watch them from behind, you can look at the “normal” side versus the “abnormal” side and see more of a thickened area. You don't see that well defined are. And then exquisitely when you sit down you try to, you know you can just start palpating that Achilles. And if wherever their disease problem, whether it's insertional or non-insertional, they're exquisitely tender to squeeze that tendon. And if the tendon looks normal, normal size, I tend to think it's a tendonitis problem. When it's thickened, then you think this disease process like a tendinopathy. And then the insertional side, it's the same way. You can, you palpate medially, centrally, and laterally and usually they've got this you know horrific pain to palpation, very, very sensitive to touch back there. And so that's typically what I do. And then to be complete, you know, you can, you can place them face down on an exam table and bend their knees and check the resting tensions of their Achilles, and check their hamstrings as well, because oftentimes they'll be very, very tight. Tight hamstrings, tight Achilles. Which I think, it helps lead you to Achilles problems. I also look at foot structure. People that have flat feet or high-arched feet - either way, the flat feet can put excess pressure or tightness on the Achilles tendon as well and can lead to these problems.
Dr. Randale Sechrest: And what about imaging? Do you normally go ahead and get x-rays of the foot and ankle? Do you, do you ever do any type of special tests like an MRI scan?
Dr. Erik Nilssen: Ya, so I classically, for a new patient, it's just standard to get an x-ray. It's cost effective. If there's a insertional problem it's very effective because oftentimes what you're looking for is a, it's nice to see if there's a, if there's a, usually we'll see a heel spur that's going, and really what it is is a traction spur and these tendons actually has grown into the tendon, and you can imagine that this is like a rope that's attached to a wall, and it's just constantly being pulled your whole life, as you walk and run and jump, it's pulling even more, and so those that have this disease process, you'll often find, or see this heel spur in the back. Which it's good to know it's there, or a loose body or some sort of bony spur – if you ever go in to do some surgical intervention. But a plain x-ray, other than that, other modalities are ultrasound – much more cost effective than an MRI, but it's usually dependent to, unless you have a good ultrasonographer around, um and very skilled, they can kind fo tell you if there's swelling around the tendon itself, like the tendonitis, or is it actually the tendon itself that's diseased. But my go-to scan usually is an MRI. The MRI is the best test we have that's non-invasive, that will tell you uh, if there's some signal changes in the tendon and tell you if it's diseased, how thick it is. What it looks like around the tendon. So, it gives you a much more detailed view of what's going on. So x-ray, ultrasound, or MRI these are my – but I don't really do ultrasound - it's an option, but I go with an x-ray, and then even an MRI as well.
Dr. Randale Sechrest: And what about, uh, if you suspect a complete rupture? Is there anything else that you do different to evaluate that patient?
Dr. Erik Nilssen: So a complete rupture um, if it's an acute, complete rupture, my go to test is I'll lay them on their belly and bend their knees and look at the thigh picture, and you will see the resting tension of the intact foot is quite tense and you'll see the foot actually plantar flex, meaning that the resting tension of the foot is actually as if it's pushing down on the gas pedal, whereas if it's completely ruptured, you'll see that foot kind of flopping almost 90 degrees. So, what you can do too is you can actually squeeze the calf – it's called a Thompson, Thompson Sign. You can squeeze the calf but on an intact Achilles, you'll see the foot sort of pop, pop back and forth. When the Achilles is torn, you squeeze the calf and you really get nothing. And so that's you know, observation in a resting position on their belly, and a Thompson Sign. And then classically they're very resilient to put any weight on it, but if you're really are unsure, have them put weight on it and see if they can push off. And also you can just palpate. You usually can palpate this nice, nice contoured Achilles throughout the entire length of it on the normal side. And on the injured side you can palpate and you'll palpate a nice gap where you can actually feel the two ends of the Achilles. And so those are my, that's my physical exam.
Dr. Randale Sechrest: And if you suspect, based on your physical exam that this is a complete rupture, do you go ahead and do an MRI scan? Do you, if you know you're going to do surgey on this, do you go ahead and order an MRI scan to get more detail?
Dr. Erik Nilssen: Ya, so for me, I don't get an MRI. Some people do. I don't, I know it's torn, and in my practice, if it's acute tear, I go ahead an fix it. And I really don't discriminate based on age or anything like that. I mean, if someone's fairly unhealthy, and you know, the risk of surgery is quite high, and they've got some serious cardiac issues, or have had heart surgery before, and they're just very low demand patient, doesn't walk much, I may second guess taking them into surgery. But in fact, we're doing this interview now, I just had last week, I had a very active 76 year old gentleman, very active, tore his Achilles acutely and was going to be treated in a cast, non weight bearing, and I saw him and you know, a very healthy and active guy – and I fixed him. And so, I, we know that uh, an acute tear that's fixed surgically, I just go to sleep better at night that I do get a good repair, I can get those tendons together, whereas non-operatively they have a higher incidence to rerupture if you don't fix them than you fix them, which is quite interesting. But there are some studies out there that say well, maybe long term, they do the same. But right now, I think that most people out there with an acute tear, as long as they can handle surgery, will be fixed. It's about a thirty minute procedure. And the only risk with surgery really is your, is your, there's not much padding back there and you worry about infection is the biggest thing. But we, we, knock on wood, I haven't had any of those.
Dr. Randale Sechrest: Well, lets go back and talk a little bit about the treatment of the non-ruptured types of Achilles tendon problems. So when you're dealing with with tendinopathy and maybe tendonitis, how are you going to start out treating that patient?
Dr. Erik Nilssen: So, It's interesting, I mean we, you know, we talk about the tendonitis aspect of Achilles and then the disease part and we sort of treated these, treat both of these kind of the same in the sense that, uh, so tendonitis you know, it's it's you know a young active person comes in. Obviously number one, you want to get them on, I'd get them on some kind of anti-inflammatory, because it's an inflammatory process, if it's tendonitis. Uh, you know rest, ice, activity modification is the biggest thing. And if they're very, very sore, I will, I will try to maybe get them in a boot or some type of immobilization for a short period of time just to get things calmed down. And then I get them in a, what's like a physical therapy program, or get them with a therapist where they can you know, show them a lot of stretching exercises and do some, some, we call them eccentric, eccentric contractions of the muscle. And really what that is, is it's basically, imagine someone do a biceps curl and somebody, as you're flexed, slowly pulling down on the muscle, so you're muscle is actually elongating, but while you're actually contracting it. So eccentrics we note have a very, very good effect on tendon problems, specifically the Achilles tendon. But for the non-inflammatory, or the diseased aspect of Achilles problems, it's interesting, we still put people on anti-inflammatories, but we just said it's a non-inflammatory problem, so it seems kind of strange why we do that when it's a disease process. But, where there is some pain, there is some pain effectiveness of anti-inflammatories, so I think we do it for that, but either way. But uh much more uh aggressive therapy, much more immobilization, but I warn patients with the non-inflammatory disease they have a nice big tendon that's thick and real sore in their heel. I tell them we're probably fifty fifty, I mean we can do therapy, we do immobilization, and antiinflammatories, we don't inject steroids. Steroids are no no's in tendons, they can rupture. So a cortical steroid injection in the tendon itself ah, will rupture it, so I don't do that. So we do, you know a good 6 to 8 weeks therapy program, if it has any success, I keep encouraging them to keep doing their home exercises, activity modification, all that stuff. And then um, when they get to the point where they just can't handle it, then we move to the next step. Those are my non-operative treatments.
Dr. Randale Sechrest: And, and with the exercises, what are you actually trying accomplish with the tendon, especially with the patient with the tendinopathy, the changes in the tendon? What do you think physical therapy does to that disease process?
Dr. Erik Nilssen: The biggest thing it does is it, you know, a lot of times like I said, these patients are so contracted, and and, all this, and how many people that you even know stretch every day. Most people don't, including myself, so um, I think the biggest thing therapy does is it allows, ah it gives that tendon ah more ah um, um, ah attention if you will, for stretching standpoint. So we're looking for a much looser tendon. If we can get them to stretch that tendon out five or ten degrees, meaning that you can dorsiflex the foot about 5-10 more degrees closer to your face, it's going to take a lot less pressure off that tendon itself. That resting pressure and off the heel. So stretching is one thing, getting more length out of it, and then also contracting that muscle. Um, contracting it under a controlled, like a controlled eccentric way that we talked about, I think you're not really going to shrink the disease, the disease process, a lot of it has to do with, with a with vascular issues – getting blood supply and healing factors to that disease process. And so, in terms of increasing blood flow to that, we don't really have, at least I don't know a good scientific data supporting use of that. But we know that really just getting them at a higher resting strength and increasing the strength in the tracture of their heels does make people better, but that's what we're hoping to achieve.
Dr. Randale Sechrest: What about this new platelet-rich plasma treatment that I think people are probably going to have heard about? Do you see beneift of that to Achilles tendon problems?
Dr. Erik Nilssen: Ya, it's actually an option that we even use today and I use that. I think it's a nice product. We're still trying to figure out the problem with the PRP is is, there's different concentrations, you know the companies that make, you know, it all has to do with the rate at which you spin the blood and the concentation of the platelets, and so it all has to do with that. And there's really no standard, so you've got you know, everybody is treating these problems and using PRP, but we don't have a uh, we're not using the same concentrations, because different companies have different spinners. And so that's a problem. And we don't, a lot of times you don't know what you're using. And 10 percent of the time, you could use PRP and you're not even getting platelet concentration in that. Which is a very interesting study done out of Cornell. So if 1 out of 10 were not even getting platelets, I mean that was mind boggling to me. I found that out a couple months ago. So, when I use it, we take the blood, actually look at it under the slide, make sure we do have platelets in there, and then we also have a cell counter, so we try to get a concentration that we, a known concentration. But it definitely has its place. There was a study that showed it for Achilles they used it, and there was no difference. But there was a tremendous difference in plantar fascia, but again, you gotta look at what concentration they used and what company they used. But we're actually doing some studies now, trying to, trying to have a control versus non-control and actually use and record our concentration that we use, but I definitely think there's a place for PRP. And the problem with it too is all the growth factors that are in the platelets that can help heal. There are so many different growth factors, but isolating those growth factors that actually help uh, form tendon, or help form vessels, pretty soon we can break it down and maybe just isolate those – we're a ways away from that but, um, its, its its ah very promising. But there is a role for that for sure.
Dr. Randale Sechrest: You know, you mentioned the difference between the the problems that involve the tendon itself, just up from where it inserts, and then the insertional type problems. Do you treat the insertional type problems any differently at this point?
Dr. Erik Nilssen: Well, if it's an insertional problem, you know we look at, at least I try to figure out it its, you know all, if it's an insertional problem I'll get an x-ray, looking for that spur. And then potentially, if it's an insertional problem, if we end up getting an MRI, which I'll do, I want to see if the tendon itself looks diseased, on the MRI, where it attaches to the bone. Or this concept of this, we call it a retrocalcaneal bursa, or a bursitis. And so, you know, looking at your heel, you've got skin, you've got a little bursa sac, which helps the skin from rubbing on the tendon, so it's skin, bursa, tendon, then another bursa, and then bone. And those bursas keep the skin from rubbing on the tendon, and then rubbing from the tendon on the bone. So, and sometimes you can get a very inflamed bursa, which hurts back there, and you can palpate on that and people will be fooled and say ah, you have insertional achilles problem, or you know, you have a diseased tendon at your insertion site. Well, and the reality is they just have that inflamed bursa which on that situation you could try to inject just the bursa, under ultrasound guidance and get some numbing medicine – maybe some steroid or something in that bursa to help calm the bursa down, which has no risk at rupturing the tendon at that point. So, I will, I will, I will treat the insertional stuff from that standpoint, a little different. But I want to pinpoint exactly – what are we treating, are we treating a bursa problem? Are we treating an inflamed skin area – just an area that, like a trigger point, that's just sensitive? Are we treating a global area that we have a diseased tendon in? So that, that's, it depends on what it is. So I do treat those a little bit different.
Dr. Randale Sechrest: Now you mentioned in all these problems you'll continue conservative care until it comes, it becomes clear that the problem's just not improving. What are our surgical options at that point? And lets start perhaps with the substance issues, those thickened tendons with the tendinopathy. What are the surgical options to treat that problem?
Dr. Erik Nilssen: So, surgically, for the noninsertional, we're talking about two to six cm. Above the insertion site, so they come in with a real thickened hourglass tendon. For those, what we typically do is we expose that tendon and the textbook answers are if the tendon itself is over 50% diseased, and how we got that number I don't know, but, if the disease, if there's more than 50% of the tendon that's not normal, okay, then typically we go in there and you cut out typically, the diseased segment. You take that diseased stuff out, and then classically you want to augment that with some healthy tendon. And so, you can do tendon transfers, you can borrow you know the tendont hat flexes your big toe, theres two tendons to that toe, we'll take one of those tendons away and use that as a, a graft, an autograft, or augments that tendon. And so we'll take some healthy tendon there, some people use allograft, we'll take cadaver tendons and augment it. Some people will take their own tendon as well, but they'll take from a different tendon. So there's a couple things you can do, but classically it involves you know, debriding some of that dead tendon out of there. So if they just have a pretty healthy looking tendon but it's just realy thick, and it's partially diseased, we'll just try to almost – we call it elipticize, so if it's an hourglass, we'll take, we'll shell out some of the diseased tendons so when we suture back together it looks like a nice, straight tendon. And so, basically that's gist of it and sometimes we'll go up a little higher and take some, you know take some length out of the Achilles or take, add some length so it takes the pressure off that, and use some healthier tendon that's higher up and transfer it down. But for non-insertional, that's the gist of what we do.
Dr. Randale Sechrest: And I'm assuming one of the, one of the results of that operation is actually during the healing process, to get a little more blood flow into that area to sort of create a healing process, is that accurate?
Dr. Erik Nilssen: Yeah, it is. And you're just trying to get rid of the diseased tendon and get some healthy tendon in there, and, and, and in augmenting with another tendon, sometime we, we, we transfer that tendon that actually has the muscle belly attached to that tendon and pull that muscle belly down so you've got nice blood around that muscle belly, around the diseased tendon with the hopes that it'll it'll help remodel that tendon and repair it. But, also to, that's where you can get in some, some PRP that we just talked about. And after you repair this, put in some PRP right where you have everything exposed, with the hopes of adding some healing factors to that. There's also some synthetic grafts, that are, uh, some acellular dermal stuff you can use that can actual aid in some tendon regenerative stuff as well. But yeah, the goal is to get some healthy tissue there and so the body can remodel itself and uh repair it as well.
Dr. Randale Sechrest: And what about the insertional problems? How does that differ in terms of your approach surgically?
Dr. Erik Nilssen: So insertional problems as well, it's a little, and you can get some different opinions on this, and I see it all the time, is it's very daunting when a patient walks into a doctors office and they say well, this is a gold standard, you've got insertional problem, you failed all your conservative treatment, this is what we're going to do. And I hear this all the time, is all the patient hears is is we're going to cut your Achilles off your heel, cut your heel bone and reattach it. And when they hear that, they run. I mean who wants your Achilles cut off? And that's kind of the gold standard now, is you make this incision right down the center, peel everything off, and take the Achilles tendon off, and then they – that heel spur we were talking about, they'll take the heel spur away and they'll cut some of the bone in the back of the calcaneus (the heel bone), to nice bleeding bone and they'll cut out the diseased insertional part of that Achilles tendon. And sometimes you have to cut out a a couple centimeters. Well, you cut that out, and you say well how are you going to pull this tendon back down where it belongs? They'll go up even higher, so we'll make the incision even higher, and then do some fascia lengthening up high to pull the tendon down. And then they attach it, kind of like a rotator cuff repair, classically people now are using anchors, and you'll anchor it back down to the tendon. So, but, what I've been doing lately, and um, we're doing a study now, is, we make an incision down the center and we peel it back, but I peel back very, I peel back just enough to get everything that I want cleaned out. And my belief is that even you know, it's a bulking problem, so you can imagine that you've got a big bone spur that's come in the back, you have an Achilles tendon that's thick, and you've got a bursa that's inflamed, so you've got this big trauma to the back of the heel, and if you touch this in the back it hurts. AndI think these nerves are all being compressed, so, it's a debulking procedure, or thinning it out. So I essentially split everything, take that bone spur away, I cut out half of the diseased thickness-wise, so I debulk all that. I take the bursa sacs out as well, and then I'm left with this extra skin that's easy to close, so I know I've debulked all this. And so I detach part of the Achilles tendon, but I suture it back with sutures, I don't use anchors, and try to avoid foreign bodies in the heel. And putting in these anchors isn't a benign process. I think, you look at MRIs after a year out and you'll see some inflammatory changes in the bone with some of these anchors – specifically with a product called, like made out of peek. So I'm getting away from that a little bit. I think a lot of it is industry driven, so anchors are industry driven, they want you to use it because they're pricey. But I think there's a time and a place to use anchors that I do, but I classically try to stay away from that because I don't think it's normal to cut someone's Achilles off from bone entirely. And patient's hear that and they just run! And so they come in, oh, you're not going to cut my Achilles off...I'm like, well. We're going to detach part of it. But you want to kind of debulk it, is what I think, and I've been doing that now for about 10 months, yeah about 10 months, changing the way we've been doing it and we do quite a bit of these and patient's are doing right now quite ver very well.
Dr. Randale Sechrest: And what's the post op um treatment for those two things? How long do you keep those folks uh, restricted after either one of those surgeries?
Dr. Erik Nilssen: So, you know, again, the biggest concern is infection with these surgeries. So, because you've go no, very little padding, but either one, so when I do it just as a debulking, quick procedure, or we do something insertional-wise, I still, I keep them protected in a, right after surgery , in a half cast, immobilized, non wieght bearing for four weeks total. At the four week mark, and they have a cast change in between, but at the four week mark, if the incision looks great then we put them in a walking boot with their crutches. And I have them start moving their ankles up and down at the four week mark, for two weeks on their own. Just moving their ankle. They can put some protected
weight on it, maybe 25 to 50% weight bearing. We get their ankle moving nice, and then I get them in physical therapy at the 6 week mark. That way they've had 2 weeks to kind of move it around themselves, and then I get the therapists to work with them, they're in their boot still, on crutches. And then over the next four to six weeks from there they start weaning out of this boot, start weaning off the crutches, nice and easy. But it takes a while. It's a, it's a pretty good recovery time. I tell patients, you know on a safe side, you know it could take you six months to a year to fully recover. And they think, oh man, I'm not going to walk for a year – No, you'll be walking, even in a boot, at six weeks, but you know, let me give yourself a good 3-4 months to maybe be comfortably walking in a shoe with some discomfort. I mean, even an NFL athlete tears their Achilles acutely, takes 30 minutes to repair, they don't play football again for 6 months to a year. So, and they're in really, really good shape. So someone who doesn't do that for a living again it takes a while to get back. But that's what I tell them.
Dr. Randale Sechrest: Well, lets talk a little bit about the compelte rupture. How do you tend to approach that surgically? How do you fix that?
Dr. Erik Nilssen: So, acute, you know, acute rupture again I, we tell many surgery. We try to get them done as soon as possible. And so we make an incision a little bit off midline. We don't go right down the middle. We just, because it's not insertional, as far as, it's up higher. We go off a little bit to the side and uh, the biggest thing is, back to that onion deal – the skin, so the peritenon on the covering of the tendon itself, we really want to preserve that as much as possible because it has such a valuable blood supply. So we preserve that, open that up and then just take the two ends and we suture those two ends back together with a special suture and a special way. But we suture those back together, so it's just an end to end primary repair. Um, we do that, and then close up that tendon sheath really well so we have that tendon nice and protected by a good sheath.
In a chronic situation where it wasn't really repaired and then you're left with this scar tissue in between, you cut out the disease part and you try to get an end to end repair and then you can also try to augment with a tendon next door. So you're stealing from Peter to pay Paul. And you can augment with a tendon but the surgical approach is essentially the same.
Dr. Randale Sechrest: And how long do you find that it takes the complete rupture ah, to recover? Is that longer than what you've just described or about the same?
Dr. Erik Nilssen: It's about the same, but again even an acute rupture they're much easier to repair at that point than chronic. But I tell them for sure, I mean hey, you know 4-6 weeks immobilization, and then its nice and easy moving with a heel lift. But they're not gonna, they're not gonna typically be able to, when they can go run and jump, is when you can stand up on both tip toes, come off your, come off your good leg and then slowly lower your heel to the ground. And they typically can't do that for at least 4-6 months. They feel pretty good when you have them do that, they go man, I can't hold myself up. They don't have the calf strength yet. So you know, if you can't do that, then it's hard for you to run. So it's, I protect them you know 4-6 months and I just go slow with them. Because that tendon will stretch out. If that tendon stretches out and it's repaired, they don't have the push off strength. Especially from an elite athlete standpoint it's um, uh, that's a challenge for them, they can't lose anything, so you want to really make sure tht tendon heals. And so there's a ….Dr. Andrew's always tells, “It heals faster with plaster.” So keep them in a plaster splint for a long time just to protect that tendon and let it get contracted, they can always loosen it up later once you start rehabing them.
Dr. Randale Sechrest: Well, I think this has been a wonderful discussion about all sorts of different Achilles tendon problems from the fairly traumatic acute rupture to the, I would say probably more common, just everyday tendinopathy that you and I have probably have seen in our careers just over and over again. That is such a common problem. Anything that you feel like we haven't discussed at this point that patients ought to know about the Achilles tendon and the problems that it causes?
Dr. Erik Nilssen: Uh, I think we've covered most. I would just tell uh tell patients that you know if you're having heel pain, um, don't ignore it. And you know, go see an orthopedic surgeon or primary care doctor and get a work-up done and if you feel like, you know they're not really discuss the things that we talked about today, get a second opinion. Uh, I would encourage you to educate yourself a little bit about biologics. I think the PRP, the platelet-rich plasma even stem cells, these kinds of things are kind of coming down the road here and hopefully will keep patients from having surgery. I think there's some viable options in some situations to use those. But uh, but I think an early treatment problem and, and, I mean early treatment recognition and a good, good, physical therapy with a good therapist, who knows what they're doing and a home exercise stretching program can try to help prevent these things. But especially in your weekend runners, that run a lot and long-distance runners, you know. And then also the obese issue, it's tough to tell patients who are overweight, I hate doing that. But when they come in and they have these bad Achilles problems and they're 300 pounds, that's a lot of load on the heel and that's why they've got the problems. So you know, take care of yourself and get second opinions. And, but I think we pretty good job covering all these.
Dr. Randale Sechrest: Well, I want to thank you for this information, I know patients will appreciate it. And I look forward to talking to you about different foot and ankle problems in the future, so thank you very much.
Dr. Erik Nilssen: Ah, thank you Randale, I enjoyed it.