Achilles Tendon Treatment

What Is the Achilles Tendon and What Are Its Common Problems?

The Achilles tendon is a thick, fibrous connective tissue formed by the union of the calf muscles as they attach to the heel bone. It is strong enough to bear several times our body weight and enables movement by generating propulsive force. Two main groups of problems most commonly occur in this tendon:

1. Achilles Tendinopathy: This is wear of the tendon resulting from overuse or repetitive strain. It is a general term that may include:
   
   • Achilles Tendinitis: Acute (newly onset) inflammation of the tendon. It usually occurs after a sudden increase in activity.
   • Achilles Tendinosis (or Chronic Tendinopathy): A more common condition. Rather than inflammation of the tendon, this is a chronic condition in which the tendon’s structure deteriorates and degenerates over time. It is characterized by thickening, stiffness, and pain in the tendon.
   • Location: Tendinopathy can occur in the mid-portion of the tendon (2-6 cm above the insertion point – mid-portion tendinopathy) or at the point where the tendon attaches to the heel bone (insertional tendinopathy). The insertional type is often accompanied by a bony prominence (similar to a heel spur, or a Haglund deformity) and bursitis (inflammation of the bursa).
2. Achilles Tendon Rupture: A partial or (more commonly) complete tearing of the tendon fibers. It usually occurs during a sudden strain.

Causes and Risk Factors

• Causes/Risk Factors of Achilles Tendinopathy:
  
  • Overuse: Suddenly increasing the frequency or intensity of activities such as running or jumping. Inadequate warm-up.
  • Calf Muscle Tightness/Shortening: Tight calf muscles increase the load placed on the Achilles tendon.
  • Improper Footwear Choice: Inadequate support or heel height issues.
  • Foot Structure Abnormalities: Flat feet (pes planus) or a high arch (pes cavus) can cause abnormal strain on the tendon.
  • Age: With age, the tendon’s flexibility and blood supply decrease, making it more prone to wear (usually over 30 years of age).
  • Certain Medical Conditions: Inflammatory arthritis.
  • Certain Antibiotics: Fluoroquinolone-group antibiotics are known to (rarely) increase the risk of tendon problems.
  • Obesity: Increases the load placed on the tendon.
• Causes/Risk Factors of Achilles Tendon Rupture:
  
  • Sudden, Forceful Strain: Sudden contraction of the calf muscles, particularly when starting a sport or during sudden acceleration/change of direction (e.g., sprinting, jumping to spike a ball).
  • Unexpected Ankle Movement: Excessive stretching of the tendon in situations such as the foot suddenly stepping into a hole or slipping on stairs.
  • Chronic Tendinopathy: Pre-existing wear of the tendon can predispose it to rupture.
  • Age: Most commonly seen in people aged 30-50 who do not exercise regularly but occasionally engage in intense activity (the “weekend warrior”).
  • Previous Cortisone Injections: Cortisone injections given near the tendon can weaken the tendon’s structure and increase the risk of rupture.
  • Fluoroquinolone Use: May rarely increase the risk of rupture.

Symptoms of Achilles Tendon Problems

• Symptoms of Achilles Tendinopathy:
  
  • Pain and stiffness along the tendon or behind the heel. Pain usually increases with activity and decreases with rest.
  • Noticeable stiffness and pain especially first thing in the morning or after sitting for a long time.
  • Pain at the start of activity may ease as the tendon warms up, but can increase again as activity continues.
  • Palpable thickening or a nodule in the tendon.
  • Tenderness when pressing on the tendon.
  • Swelling or redness (more common in tendinitis).
  • In insertional tendinopathy, the pain is lower, behind the heel bone, and there may be complaints of shoe rubbing.
• Symptoms of Achilles Tendon Rupture:
  
  • A sudden, sharp pain is usually felt at the moment of injury. Patients may describe it as feeling “kicked from behind” or “hit by something.”
  • A “pop” or “snap” sound is often heard or felt at the moment of injury.
  • Although the pain is initially severe, it may sometimes decrease afterward.
  • Inability to push the ankle downward, inability to rise onto the toes.
  • Marked difficulty walking, limping, inability to bear weight on the leg.
  • Swelling and bruising between the lower calf and the heel.
  • A palpable gap may be felt in the tendon immediately after the injury (though this gap may become undetectable as swelling increases).
  • Positive Thompson Test: When the calf muscles are squeezed while the patient lies face down or sits in a chair with knees bent, the ankle normally moves downward (plantarflexion). If the Achilles tendon is ruptured, this movement is absent or markedly reduced. This test is highly valuable for diagnosis.

Diagnostic Methods

• Diagnosis of Achilles Tendinopathy:
  
  • The diagnosis is usually made based on the patient’s history and a careful physical examination. The location of tenderness on the tendon, presence of thickening, and painful movements are assessed.
  • Ultrasonography (US): Very useful for showing the tendon’s structure, thickness, degenerative areas within it, small tears, calcifications, and bursitis. It also allows dynamic assessment.
  • Magnetic Resonance Imaging (MRI): Provides more detailed information about the condition of the tendon, the degree of degeneration, and surrounding tissues. It may be ordered especially if surgical treatment is being considered or the diagnosis is unclear.
  • X-ray: Useful for seeing the bony prominence at the heel (Haglund deformity, heel spur) or calcifications, especially in insertional tendinopathy.
• Diagnosis of Achilles Tendon Rupture:
  
  • The diagnosis is usually made by clinical examination. The history of injury, sudden pain, a “pop” sound, difficulty walking, a palpable gap, and a positive Thompson test largely confirm the diagnosis.
  • Ultrasonography (US): A fast and effective method for confirming the rupture, determining whether it is complete or partial, and measuring the gap between the torn ends.
  • Magnetic Resonance Imaging (MRI): Usually not necessary for routine diagnosis. However, it may be ordered if the diagnosis is uncertain, other associated injuries are suspected, or a chronic (delayed) rupture is involved.

Treatment Options

Treatment is planned according to the type of problem (tendinopathy or rupture), its severity, the patient’s age, activity level, and expectations.

Treatment of Achilles Tendinopathy:

In treatment, priority is always given to non-surgical (conservative) methods, which generally require a prolonged effort (3-6 months or more).

• Conservative Treatment (Basic Approach):
  
  • Rest and Activity Modification: Avoiding or reducing activities that increase pain (running, jumping).
  • Ice Application: 15-20 minutes several times a day during painful periods.
  • Medication: NSAIDs for pain and inflammation (useful especially in acute tendinitis; limited effect in chronic tendinosis).
  • Heel Lifts or Orthotics: Soft heel supports or custom insoles placed inside the shoe can reduce the tension placed on the Achilles tendon.
  • Stretching Exercises: Exercises to stretch the calf muscles in particular are important.
  • Eccentric Strengthening Exercises: One of the most effective treatment methods, especially for mid-portion tendinopathy. These are special exercises in which the tendon is lengthened under load in a controlled manner. They must be learned under the guidance of a physiotherapist.
  • Physical Therapy: Methods such as manual therapy and deep friction massage may also be used.
  • Choosing the Right Footwear.
• Other Non-Surgical Methods:
  
  • ESWT (Extracorporeal Shockwave Therapy): A method with proven effectiveness, especially for chronic Achilles tendinopathy and insertional tendinopathy that does not respond to other conservative treatments. It has the potential to stimulate healing and reduce pain.
  • Injections:
    
    • Corticosteroid (Cortisone): Injection into or very close to the Achilles tendon is generally STRONGLY DISCOURAGED, as it weakens the tendon’s structure and increases the risk of rupture. It may very rarely be injected into the tendon sheath or bursa.
    • PRP (Platelet-Rich Plasma): Scientific evidence on its effectiveness is not yet sufficient or consistent, and it is still being researched.
• Surgical Treatment (Rarely Required):
  
  • Considered only in refractory cases where severe pain and loss of function persist despite prolonged (at least 6 months) and well-executed conservative treatment.
  • The surgery is usually performed using an open method. Degenerated (worn) tissue on the tendon is removed (debridement), and small tears within the tendon are repaired. Sometimes support from another tendon (transfer) may be needed to increase the tendon’s strength.
  • In insertional tendinopathy, the bony prominence at the heel (Haglund deformity) is shaved down, the inflamed bursa is removed, and if necessary, the Achilles tendon is detached from the bone and reattached more securely.

Treatment of Achilles Tendon Rupture:

The choice of treatment (surgical or non-surgical) is made based on the patient’s age, activity level, the time elapsed since the tear, associated medical conditions, and patient/surgeon preference. Both methods have advantages and disadvantages.

• Non-Surgical (Conservative) Treatment:
  
  • Who Is It For? Generally preferred for older, less active patients, those with a high surgical risk, or those who do not wish to undergo surgery.
  • How Is It Done? The ankle is usually immobilized first in a downward-flexed (equinus) position, then gradually brought to a neutral position, using special casts or functional braces (boots). The total immobilization period is usually 6 to 12 weeks. The position is adjusted through regular check-ups during this process.
  • Advantages: Surgical risks (infection, wound problems, nerve damage) are avoided.
  • Disadvantages: The risk of re-rupture is higher than with surgery (10-30%). There is a greater risk of the tendon healing in an elongated position, with a resulting decrease in calf muscle strength and push-off power. The immobilization period may sometimes be longer than with surgery.
• Surgical Treatment (Repair):
  
  • Who Is It For? Generally preferred for young, active patients, athletes, or those with high functional expectations. Surgery is also usually required for delayed (chronic) ruptures.
  • How Is It Done? The surgery can be performed using open or minimally invasive (small incisions – percutaneous) methods. The torn tendon ends are located, debrided, and brought together end-to-end and securely sutured using strong suture materials.
  • Advantages: The risk of re-rupture is lower (<5%). There is a higher likelihood of the tendon healing at its original length and tension, which can potentially mean better muscle strength and functional outcome. Rehabilitation can sometimes begin earlier.
  • Disadvantages: There are surgery-related risks: infection and wound healing problems (this risk is significant because the blood supply to the skin in the Achilles region is relatively poor), sural nerve damage (loss of sensation on the outer edge of the foot), adhesions, and anesthesia risks.

Prof. Dr. Murat Bozkurt determines the most appropriate treatment option by evaluating the patient’s individual characteristics in both Achilles tendinopathy and Achilles tendon rupture cases, and performs any necessary surgical interventions (tendon debridement, bone spur excision, Achilles tendon repair) using modern techniques.

Risks, Benefits, and Recovery Process

• Tendinopathy Treatment:
  
  • Conservative treatment is generally safe, but recovery can take a long time and sometimes remain incomplete.
  • Surgical treatment (rarely necessary) can be effective in relieving pain but carries risks such as infection, wound problems, and nerve damage. Even after surgery, several weeks of immobilization and months of physical therapy are required.
• Achilles Rupture Treatment:
  
  • Non-Surgical Treatment: Avoids surgical risks, but the risk of re-rupture is higher and functional outcomes (strength) may be somewhat lower.
  • Surgical Treatment: The risk of re-rupture is lower and it potentially provides better strength and function, but it carries surgical risks (especially wound problems and infection).
  • Recovery (For Both Rupture Treatments): The recovery process is LONG and DEMANDING.
    
    • Immobilization: This varies depending on the treatment method, but the ankle is generally kept immobilized in a cast or special walking boot for a total of 6 to 12 weeks. Weight-bearing on the leg is usually not allowed, or is very limited, during this period.
    • Physical Therapy: Begins after immobilization and continues for months (6-12 months or more). The goals are to regain range of motion, increase calf muscle strength and tendon endurance, improve balance, and return to normal walking/running.
    • Return to Sport: This is generally not expected before 6 months; return to sport at full performance may take 9-12 months.

Treatment of Achilles Tendon Problems in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Achilles tendon problems are common conditions affecting many active individuals and athletes living in Ankara. Prof. Dr. Murat Bozkurt follows these steps in his approach to Achilles tendon problems:

• Accurate Diagnosis: He clarifies the type of problem (tendinopathy or rupture), its degree, and any accompanying pathologies through the patient’s history, a careful physical examination (such as the Thompson test), and the necessary imaging methods (especially ultrasound or MRI).
• Priority on the Conservative Approach in Tendinopathy: For patients diagnosed with Achilles tendinopathy, he first plans a comprehensive non-surgical treatment program (rest, exercise – especially eccentric exercises, physical therapy, options such as ESWT) and ensures it is applied patiently.
• Individualized Treatment Decision in Achilles Rupture: For patients with an Achilles tendon rupture, taking into account factors such as the patient’s age, activity level, expectations, and the condition of the tear, he discusses the advantages and disadvantages of surgical and non-surgical treatment options with the patient in detail and jointly decides on the most appropriate treatment.
• Modern Surgical Techniques: When surgery is required (refractory tendinopathy or rupture), he performs the tendon repair or other necessary procedures using modern and reliable surgical techniques (open or minimally invasive).
• The Importance of Rehabilitation: He emphasizes the critical role of structured, long-term rehabilitation in both conservative treatment and post-surgical recovery, and guides the patient through this process.

Achilles tendon problems are conditions that can lead to pain and loss of function, but that can be managed with accurate diagnosis and appropriate treatment. Treatment selection should be made on an individualized basis, and especially in cases of rupture, the advantages/disadvantages of surgical and non-surgical methods should be carefully evaluated. Full adherence to the rehabilitation process is essential for a successful outcome. You can seek expert help from Prof. Dr. Murat Bozkurt in Ankara for your Achilles tendon problems.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt at 0312 502 70 74.