Achilles Tendon Problems

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today we’ll be talking remotely with Dr. William Seeds. Dr. Seeds is an orthopaedic surgeon who practices in Ashtabula, Ohio. Good afternoon, Dr. Seeds.

Dr. Seeds: Good afternoon, Randy. Thanks for having me.

Dr. Sechrest: Well, I want to thank you for coming back and today what I would like to discuss is again a very common orthopaedic complaint that orthopaedists see a lot of and that is Achilles tendon problems. I think those problems can range from a lot of different types of etiologies. But the one I really want to focus in on today is what you and I would consider Achilles tendinosis. Achilles tendinosis in our parlance is a problem that causes or is caused from degeneration of the Achilles tendon. It usually comes in our middle-aged to late middle-aged patient and it can be very painful and disabling. So start out by describing this condition and what patients normally see when the condition starts.

Dr. Seeds: Well, Randy, most of the patients that I see with Achilles problems will be patients that have had it for a longstanding period of time. They’ll be able to tell you that they’ve been dealing with it for months or for years and they’ve been able to get around and continue their activity really by changing their own, making their own kind of conclusions of changing footwear and shoe wear and ways that they can compensate for this problem. Typically, when it’s something that affects their daily activity, when it becomes a continuing type of pain, when it affects their work, when it affects their after work activities, that’s usually when I see them. And also, when they can actually feel something that’s changed on the outside of that tendon. Some of these tendon changes will have what we feel is a nodule or something associated like that, to that area specifically. When they start to realize, “Hey, there’s something different here compared to my other ankle.”, that’s typically when I’ll see that type of patient.

Dr. Sechrest: Dr. Seeds, we should probably stop for a moment and describe what we’re talking about when we talk about the Achilles tendon. I think most people are probably familiar with the Achilles tendon, but describe what this tendon is and where it is in the body.

Dr. Seeds: Well, this is one of the longer tendons in your body. This is the tendon that attaches, it attaches to the calcaneus, which is the heel bone, and then that tendon attaches to what we call the gastrosoleus complex or the gastroc muscles in your calf – the calf muscles. So basically this tendon is attached to the calf muscles and then attaches to the calcaneus and this is what allows us to walk, to raise our heel off the ground and its involved in this process that we’re describing here, this tendinosis.

Dr. Sechrest: Now let’s talk a little bit about the difference between a tendinosis and a tendinitis. I think a lot of people would lump this problem that we’re discussing, the Achilles tendinosis, into the term Achilles tendinitis. You and I see tendinosis and tendinitis as much different processes. Can you describe the distinction of those two concepts for patients?

Dr. Seeds: Well, I think the best way to describe that is to look mechanically at what. . . is there a structural difference between a tendinosis and a tendinitis? A tendinitis, we commonly may look at a tendon that may be inflamed where there’s inflammation possibly around the tendon, around that tendon sheath. Whereas a tendinosis is there’s actually direct trauma, microtrauma inside the tendon. There may be interstitial changes of that tendon where the structure of that tendon has actually been altered. It may be a small amount but it’s been altered and you could almost look at it like, as a term of micro-tears in that tendon. But there’s actually a structural difference between tendinosis and tendinitis.

Dr. Sechrest: Now when patients present with this problem what do they present to your office with? Is it pain? Is it deformity? Is it lack of function? How do patients present and what are their complaints?

Dr. Seeds: Well, typically, as I’ve alluded to, patients will let this go for a while before they initially present. I rarely see people that have just had this problem for the last month show up in my office. It’s usually been they’ve been living with this for many months or up to many years, and usually this is a pain that presents that it just is a pain that’s gone from a nagging process to maybe a daily process. These patients will sometimes present at the same time with a presentation of a mass that palpable on that nodule, a nodule, that some patients present without it, some patients present with it, but that’s something else that may show up and they may be limited. Because of the pain, there may be limitations to what they can do. They can’t walk as far or they’re having difficulty with stairs or their shoe wear has absolutely been altered because of that nodule formation or because of the pain. So those are the things that we’ll typically see with that presentation.

Dr. Sechrest: Now we mentioned that the tendinosis that’s occurring, the Achilles tendinosis that we’re discussing, really is a degenerative problem. It’s occurred over a period of time. What causes it? Is there anything about these patients that’s different, that may lead to this problem?

Dr. Seeds: Well, there certainly are issues that you have to take into account, the other comorbidities of these patients. Do they have problems with their blood flow? Do they have problems with diabetes? Are there other inflammatory processes that we need to be aware of? We do know that the Achilles tendon does have a very poor blood supply. This is a long stretch of tendon that does not have a significant amount of blood supply that can, say they’ve incurred an injury, or they’ve incurred some strain to that tendon where typically we rely on blood flow to help correct and change problems and help heal them. So the tendon itself is an area where we see problems there because they are compromised with blood flow. Other than that, again, it can be related to a specific type of injury itself. Was there an inciting injury to start this or are there other comorbidities associated with this problem? Or did it start with a certain type of shoe wear? Has there been a problem in the type of shoes that they’ve worn that’s caused an outside type of impingement on that tendon?

Dr. Sechrest: Now when you see this patient in the office how are you going to begin their evaluation? What sort of things are you interested in learning from the patient? And then what sort of critical things on the examination are you looking for?

Dr. Seeds: Well, with all my patients with any joint problem or specific area of pain, we’re always going to have an x-ray of that area that I can look at and correlate. So I’ll have an x-ray of the foot and ankle that I can correlate to that patient’s examination. One of the things that I always look for when a patient complains of heel pain is I’m looking for anything such as a heel spur or something we refer to as a Haglund’s deformity where there may be an excess of bone that is grown from the top of that heel bone, the calcaneus, that’s associated with that Achilles tendon where it may be digging into that tendon or may be part of that pain complex. So an x-ray is very important for me to try to start to get an idea of what may be occurring and associated with that heel pain. Also, you can see some slight soft tissue changes on x-ray that may be helpful for you also. I always depend on what the patient has told me on their history. Was there any trauma associated? What type of pain is this? Is this pain when they first get up in the morning? Is it pain after activity? Is it pain all day long and how long have they had it? And then the physical examination and inspection are just as important. I look at the type of shoe wear they have. How has their shoe been worn? How is the wear of the shoe? It can be helpful just to turn the shoe over and look at the shoe wear pattern on the shoe. Is there one part of the heel that’s worn down more than the other? Are there other aspects of the foot also in relation to the heel that may have contributed to this? So that’s the part of the examination you’re looking at. Then you’re actually palpating, you’re inspecting this tendon to see if you can palpate a defect or any type of mass or area that is different than the other side or has changed since that patient has come in because something has been different over time. So you’re trying to correlate all these things to help you in making a diagnosis of a tendinosis type of problem.

Dr. Sechrest: Now are there any special tests required – an MRI scan or anything else – or do you feel like you can reliably make this diagnosis with just a physical examination, what the patient’s telling you, and maybe some plain x-rays? Do you always get an MRI scan on these patients?

Dr. Seeds: Randy, I would say that for Achilles problems I really do utilize the MRI machines significantly with these complaints. More particularly because I’ve already got a high suspicion that there is a tendinosis type of problem if there is any type of mass that I’m palpating or any bump on the Achilles area. My suspicion has already been risen that, okay, there is a tendon problem here. How much of that tendon is involved? What’s the length of that activity, of that perceived tendinosis? So I believe that the MRI is very important in helping you isolate where this injury is, how significant it is, and other factors that can be related to the amount of is there chronic or acute inflammation associated with it. You can really be surprised sometimes with some of these exams. I’ve had MRIs where I haven’t been able to palpate anything, I’ve just gone on what the patient’s symptoms have been and understood that they’ve had significant difficulty and change the examination and then I’ve been able to see very significant interstitial changes that I would have never – I couldn’t palpate it, I couldn’t feel it – but going on the history and the way the patient’s changed their lifestyle, the MRI, once I saw the MRI, it’s made total sense that, wow, they had a very significant lesion that was actually inside that tendon. So, yes, it’s a very valuable test for me and also in looking at that attachment site of the tendon to the bone. Is there an impending avulsion fracture from the tendon pulling off the bone? Things like that that can be very, very helpful.

Dr. Sechrest: Well, let’s talk a little bit about treatment and once you’ve come to the diagnosis and you’re feeling relatively certain that you understand the pathology or the problem that’s occurring there. How do you start to treat patients? Is this process something that’s amenable to conservative treatment or is this something that you feel like most patients are going to need a surgical intervention?

Dr. Seeds: Well, with Achilles problems I’m very conservative in my acute treatment. Most of them, well, all of my patients even with my MRI findings in trying to get an idea and stage the disease, I’m pretty aggressive with right away immobilizing the stress across that Achilles tendon. I’m a big utilizer of what’s called the cast boot where I’ll put them in a boot where they can still be mobile but it’s taking all that stress off the Achilles, and I tell the patients that it could be anywhere from 4 weeks to 6 weeks to 8 weeks up to 12 weeks of immobilization where I’m trying to quiet down that tendon and give the body its chance to try to heal this. As we’ve discussed with the blood supply, knowing it’s poor, knowing that they’re difficult areas to heal, and knowing that these people have gone with these problems for many months or years. To start with, I always explain that, “Hey, this started as a slow process. The healing is going to be a slow process”, and I believe the immobilization is just very important with this and then getting an idea after you’ve done that, you can do your examination at 4 to 6 to 8 weeks and see how do they feel because a lot of times your palpation and what the patient tells you will help you in guiding what your next steps are. So, say they’ve improved after that 6-8 weeks with no pain at palpation and no pain in the boot – well then you can start progressing to a physical therapy program that may last another 6-8 weeks of stretching and strengthening of that tendon and then you’re giving them information that they need to take home to use for many years to come to keep that tendon in that shape.

Dr. Sechrest: Now, with this combined technique of initial rest, and then followed by some progressive exercises with a physical therapist, what are you trying to achieve in the tendon? Are you trying to get the tendon actually to heal itself? Will that tendon actually reorganize and establish a more normal tendon through this treatment?

Dr. Seeds: Well, I’m not convinced that that tendinosis will completely heal itself. But what I’m trying to do is #1 – calm down that area so there is no further injury. #2 is I’m trying to decrease the amount of inflammation that is there presently that’s causing the pain. #3 – once I’ve taken care of that process of letting it calm down and decrease the inflammatory process, then what I’m trying to do is maybe bring in some initial healing in that area, but also strengthen the tendon around that tear to take over and assist in strengthening the rest of that tendon and stretching that tendon so that patient doesn’t get back to that point they were before. I don’t think we can say there can be a complete healing with some of these tendinosis problems.

Dr. Sechrest: Well, let’s talk a little bit about what to do if it doesn’t work. Is this something that surgery can be used on? What are your feelings in terms of how to have that discussion with the patient? When do you stop conservative care?

Dr. Seeds: Yes, I do think there is a definite role for surgical intervention. I believe that after a patient has gone through that conservative treatment of immobilization and initial therapy process where, if their pain comes back pretty quickly, if they’ve failed that process, then it’s telling me that we need to do more to help and actually trying to do something with that area that is damaged to see if we can help change it, heal it, and improve it. And I will tell you that over the past 5 years or so I think things have changed significantly for us in our approach for Achilles tendon problems like this. In the past, we would do things where we would resect or debride part of that bad tendon and then suture back the good tendon to itself with bigger incisions and so forth, and now we have the availability of things that I’ve been utilizing where we do what we would call more of a ‘micro-debridement’ that is there to encourage blood flow angiogenesis blood growth into that tendon to assist that patient in healing their problems and I’ve had, as many of my colleagues have had, very good results with this in dealing with tendon injuries. So I think that in the future here, we’ve had some great changes in the way we’ve been able to treat these problems in getting people back to some process of a good pain relief and a good functional Achilles tendon.

Dr. Sechrest: Well, explain in a little bit more detail what you’re talking about with this ‘micro-procedure’ or the ‘micro-debridement’. What exactly is done during that procedure?

Dr. Seeds: This is a procedure where you can actually go, you can make a smaller incision just specifically over that isolated area of the tendon, where you don’t really have to strip a lot of tissue around the tendon. You can go directly through an incision down through what we call the peritenon that surrounds the Achilles tendon, and you can go right to where that defect is and it’s like a probe that you penetrate into different depths into that tendon lesion and in a grid-like fashion you’re probing and it has a certain amount of heat that it generates. And it’s almost like a poker where it almost like burns heat into that area and what it’s doing it’s debriding part of the dead tissue and it’s encouraging new growth into that area. I’ve been very fortunate to have some very positive results with any tendon injury that’s related to the body where conservative treatment has failed and in the past we’ve done open debridement procedures where I’ve been able to do things that I feel have really benefited the patient as far as the rehabilitation process and the postoperative pain process, but also in the healing process of that injury.

Dr. Sechrest: Well, I think you’ve mentioned the poor blood supply and I think, orthopaedic surgeons for years at least all through my career, we’ve always been taught that you really operate on the Achilles tendon only if you absolutely have to. It sounds to me like this procedure actually allows the blood supply around the Achilles tendon to stay intact so you can do that debridement without destroying what blood supply is around the tendon and probably speeds up the healing process and probably actually improves it significantly in terms of getting blood flow into that area again very rapidly. Is that accurate?

Dr. Seeds: Yes absolutely, Randy, and I think I could take that one more step to tell you that in the past I was doing things where we would take a blood product from the patient, we’d spin it down to get what we would call the reactants that help heal tissue, and I’d inject that back into the defect to help potentiate healing just like what we described. I had some equivocal results with that that I didn’t feel compared to what I’m doing now with this micro-debridement which is essentially almost as least invasive as that. I mean there is still an incision with this but I believe I’m getting more positive outcomes and better results with that micro-debridement.

Dr. Sechrest: Well, I think we ought to talk a little bit about maybe the rehabilitation after this procedure. Is this something that the patient is going to be immobilized for a period of time? Is this something that you begin physical therapy very quickly? How do you rehabilitation these patients?

Dr. Seeds: Well, Randy, I put them all postoperatively with the micro-debridement, I will put them in a cam-walker where I’m protecting the forces across that tendon because I’ve just traumatized the tendon also so I don’t want them putting any undo stress on it. But I will start therapy immediately with these patients where I want to encourage activity because we believe that all assists with encouraging the healing of the tendon itself and encouraging blood flow. So we’ll work on range-of-motion. We’ll work on stretching. We’ll work on little processes of strengthening, of isolation strengthening, and we’ll do that over a 6-8 week time frame. When I first started the process, I used to immobilize everybody for 4-6 weeks and I wouldn’t do anything for 4-6 weeks and then I’d start the therapy. Well, anecdotally, I started having patients that weren’t listening to me. They told me, “Hey, doc. I already went ahead and did it. I was feeling so good”, and I had enough of those people to convince me that, well, maybe I need to change the way I’m rehabbing these people because they’re doing incredibly well and they’re not listening to what I’m telling them. Kind of almost like what happened to all of us with how we used to treat anterior cruciate ligaments in the past, and what some of our patients taught us over time. But the fact remains is I had these people doing incredibly well not listening to me, and just progressing on their own, so I started backing up, backing up, and in fact with pretty much of all of my surgeries now, I’ll start therapy immediately on these people and my results are as good as what I was doing by waiting that 4-6 weeks.

Dr. Sechrest: Well, how long do you think it takes for this tendon to heal so that patients can actually resume normal activities? When do you allow them to go back to work? When do you allow them to go back to any type of sport that’s going to really stress the tendon?

Dr. Seeds: Yeah, that’s a very good question. I’ll let people get back to work if they’re in a boot or something where they can be mobile, if they’re allowed to, in their workplace. I’ll let them do that immediately because the boot takes that significant stress off the tendon. I’ll let them get out of the boot at about the 6 week mark. So at about 4-6 weeks they’re out of the boot where I feel confident enough the tendon is healed and now it’s ready to start really dealing with the stresses, the normal physiological stresses that your body puts on that area, and that will take another 4-6 weeks in itself, I think, to get that patient back to what I would call close to a normal time frame – and that would be around 3 months. As far as returning for sports activities, I may stretch that out another month or 6 weeks, so between the 3 to 4 ½ month time frame before somebody could be active back in sports. But I think we have to go with the gold standard and know that we can do things to help the tendon but it’s going to take every bit of that 4-6 weeks for that tendon to heal as far as we know that the path of physiology of tendon healing. Then it’s going to take another 4-6 weeks to actually load that tendon back to the normal loading that it undergoes with normal activities like walking and climbing stairs and so forth. So none of that changes, it’s just I think the rehabilitation process though does help us in progressing earlier in getting to that end stage stronger.

Dr. Sechrest: So what are the potential complications of this new technique? And I guess probably extending it to any sort of surgical technique on the Achilles tendon. What do you worry about going wrong as an orthopaedic surgeon with the Achilles tendon surgeries?

Dr. Seeds: Well, I’m always concerned that I’m weakening the tendon when I do this process and we’re protecting that patient and what I don’t want to see is a complete rupture of that Achilles tendon. That’s something that, as you know, changes the ball game and we end up doing more of an extensive process in fixing and repairing that tendon to get that patient back to an active level. So rupture is the #1 thing that I’m trying to prevent, and #2 would be infection – with any incision type of process is infection; and the other would be any type of swelling issues that you may see postsurgical, and that’s what I like about this procedure is with just such a small incision I’m not seeing any of those things that I may have seen with the more aggressive debridements that I might have done in the past; and I’m not aggravating that blood supply as I may have in the past. So I think the two main things are re-rupture and infection.

Dr. Sechrest: Well, I think this new micro-technique is clearly a benefit to patients and an improvement over what we’ve done in the past for this condition, and I can remember doing the debridements that you’ve described where you make a fairly large incision. You’re always worried about the problem with rupture of the tendon in the postoperative period. You’re always worried that you’ve actually created more of a problem by going in and stripping some of that blood supply. So this new technique sure seems to be a huge improvement over what we used to do, and I look forward to seeing your results as these move out into the future. Is there anything as we close this discussion about the Achilles tendon problems that you feel patients should know that we haven’t discussed today?

Dr. Seeds: Yes, I really do believe that I think this type of information is really important to those patients to understand that, boy, the sooner we get to those kind of pain complaints, the better off that patient is going to be. Because, as we’ve discussed, the longer this patient goes with this process, the longer it’s going to be to take care of it, improve it, and get them back to that activity level they’d like to be. I’d like to get to those patients before they get that palpable nodule or the change in the soft tissue. I’d like to get to it earlier because I can make a difference earlier, and I would just say that this kind of information is invaluable. That the sooner these people realize that, “Hey, something isn’t right here. I shouldn’t be having this type of pain. Maybe I need to get it looked at.”

Dr. Sechrest: Well, I think we may want to point out that a lot of what you have just suggested doesn’t involve surgery. If the patient takes care of the problem when it first arises, what I think I hear you saying is that you can effectively take care of that without resorting to any type of surgical procedure – even one of these micro-debridement techniques. So I think, if I hear you correctly, is you’re saying if you feel like you have an Achilles tendon problem, don’t let it go. Don’t let it progress. Get in. See someone. Get some aggressive conservative care maybe to avoid surgery. Is that accurate?

Dr. Seeds: Absolutely, Randy. I can recall a young lady I had who had a problem with her Achilles tendon who actually came in early who felt she was making too big a deal over something and was already second-guessing herself being in the office having me examine her. Where she had no swelling, she had no palpable problem, it was just something that had been nagging her for over the last month. I even went as far as suggesting that we needed the MRI and found that she did have an interstitial tendinosis within the tendon itself, and I put her right in a boot and I tell you what – I think that made a huge difference. She did very well with her follow-up treatment, but that was something that I potentially could have seen many, many months or years down the road where it would have been a more significant problem. Now the patient’s aware of this. She knows what she can do to keep out of trouble with it, and it was that easy to take care of.

Dr. Sechrest: Well, I think that’s good advice. I think we want to make sure that patients understand that the vast majority of these, if they’re captured early, picked up early, can actually be treated without surgery and it’s the uncommon patient that actually gets to the point that they need surgery. But I think that the other piece of this discussion is that the surgical techniques have improved significantly over the last 5-6 years and it’s not quite as horrendous a problem as we, as orthopaedists, used to see Achilles tendon problems. So I thank you for that, and we’ll encourage patients to get in and see about these problems early. Thanks for joining us today.

Dr. Seeds: Thank you, Randy. Thanks for having me.