Insertional Achilles Tendinopathy is progressive degenerative (“wear and Tear”) condition that occurs where the Achilles tendon attaches to the back of the heel bone. There is often a bony lump (bone spur), associated with this, which may be referred to as a Haglund’s deformity.

The condition can affect active, sedentary and overweight persons. It is normally pain, swelling and reduction in function that brings people to see a foot and ankle specialist.

Why would it be done?

Some people can manage the condition by non-surgical means. These may include alterations to footwear, and activity levels. Insoles (orthoses) and Physiotherapy can be useful especially if there is calf muscle tightness. Shockwave therapy can also be a useful adjunct to these treatments. If these treatments don’t work, we may recommend an operation. This can involve removing the prominent bony lump and damaged section of the tendon.

What does it involve?

A surgical incision is made over the back of the heel. The unhealthy piece of tendon may be removed (the degree of which, depends on the amount of damage). A small amount of bone is removed from the back of the heel to create a healthy area to re-attach the tendon. The tendon is re-attached using special bone anchors that allow the tendon to be fixed to the bone. Stitches (sutures) are used to close up the surgical incision. The calf muscle may be released (lengthened) if there is calf muscle tightness. In some cases another tendon may be used (known as a tendon transfer) to help improve the strength of the tendon and assist with healing. You will be advised if any additional surgical work needs to be carried out. This may affect the advice you are given after surgery.

Can it be done as a day case operation?

It is usual to stay one night after the operation to allow adequate pain control. However, if you are otherwise fit and there is someone who can collect you afterwards and stay with you overnight, the operation can be done as a day case. This means that you are admitted to hospital, operated on and discharged home on the same day. You may need to come back to plaster room the day after your operation to have your plaster changed.

Will I have to go to sleep (general anaesthetic)?

The operation is usually performed under general anaesthetic (asleep). Alternatively, an injection in your back can be done to make the ankle numb while you remain awake. Your anaesthetist will advise about the best choice of anaesthetic for you. In addition, local anaesthetic may be injected into your leg or foot while you are asleep to reduce the pain after the operation even if you go to sleep for the surgery. You will also be given painkilling tablets as required.

Will I have a plaster on afterwards?

Yes, you will usually be put in a below the knee cast for about 2-3 weeks. You will then often be instructed to use an Achilles walking boot for about 2 months. You will be shown how to use crutches to assist with walking and balance.

What will happen afterwards?

You can go home when comfortable and safe. You may need a check-up a day or two after surgery, with a plaster change. You must keep the leg elevated (above waist height) most of the time. This helps improve wound healing and reduces infection. You will usually be seen in the clinic 14-17 days after your operation. The plaster will be removed and the wound inspected. If you have had the tendon re-attached you will be placed into a cast or Achilles Walking boot depending on how things are progressing. You will be in the walking boot for around 2 months with differing sized heel wedges. Physiotherapy should start after about 2 weeks. Full recovery from this surgery can take about 12 months.

How soon can I...

Walk on the foot

You will be advised by your surgeon and nurses how much weight you will be able to put through your plaster in the first few weeks after your operation. Normally you would be non-weight bearing for around 2- 3 weeks or until the wound has healed.

Go back to work

If your foot is comfortable, you can keep it up and work with it in a special boot; you can go back to work within 3-4 weeks of surgery. In a manual job with a lot of dirt or dust around and a lot of pressure on your foot, you may need to take anything up to 6 months off work. How long you are away from work will depend on where your job fits between these two extremes.

Drive

Most people do not to drive until the cast or brace is removed. Generally this is when you can wear a shoe and are able to fully weight bear. Drive short distances before long ones. If you cannot safely make an emergency stop your insurance will not cover you in the event of an accident. If only your left foot is operated on and you have an automatic car, you can drive within a few weeks of the operation, when your foot is comfortable enough and you can bear weight through it.

Play sport

You can gradually increase your level of activity under the guidance of your physiotherapist. Once you can walk comfortably you can start running, swimming and cycling, increasing the distance covered gradually. Once you can run comfortably, you can do some turning and jumping. As this recovers you can go back to low impact, noncontact sports and finally to full contact sports. It is common to take 6-8 months to return to high impact sports such as football or rugby.

What are the risks?

As with all surgery, there are risks of complications. Most people (70-80%) are very happy with the outcome of this type of surgery. Complications associated with this surgery may include:

Nerve irritation (Neuritis)

This may result in a burning/shooting pain. This often not permanent

Wound complications

The literature reports about a 3% incidence of wound issues (such as delayed healing and painful scars)

Muscle weakness

This can sometimes occur if the calf muscle has been released.

Swelling/Oedema

This often reduces after a few months. Achilles tendon rupture - these are rare with this surgery. Increased risks for rupture include falls and increasing activity too quick. In these cases revision surgery may be required. Infections – The incidence of infections with this surgery is low. The literature states an incidence of about 2%.

Blood clots

There is a risk for deep vein thrombosis (DVT) and pulmonary embolism (PE) with any large surgery. We take measures (such as blood thinners) to minimise the risk of blood clots.

Wellbeing Advice

Patients that have a healthy diet take regular exercise and refrain from smoking prior to surgery are more likely to experience quicker and better recovery and may also have a more successful outcome from their surgery. If you have any concerns about your general health and wellbeing (diet, exercise, smoking cessation) you are encouraged to discuss this with your GP, who will be able to provide advice on the options available to you.