The Achilles: What You Need to Know

Dr. Brian Fullem practices at Elite Sports Podiatry in Clearwater, FL. He ran 14:25 for 5K while at Bucknell University. This is the continuation in a series of articles by Dr. Fullem, educating us about injury care, injury prevention & other health topics for athletes at all levels of performance.

The Runner’s Guide to Healthy Feet and Ankles:
Simple Steps to Prevent Injury and Run Stronger

by Dr. Brian W. Fullem et al.

Achilles’ tendonosis can be a difficult injury for runners to resolve. A study published in 1995 by Anstrom ( revealed that tendon biopsies performed during surgery for chronic Achilles’ tendon injuries failed to demonstrate inflammatory cells and rather showed degeneration.  This fact alone makes it understandable why this is such a difficult injury to treat and the degeneration has been shown to occur after only two weeks of being injured.

First, an anatomy lesson. One can divide pain in the back of the heel into three parts: mid substance of the tendon, insertional and paratenodosis. Often times the midsubstance tendonosis will have an associated visible lump (see photo below) and is characterized by more pain with initial activity that warms up and feels better during activity in the initial stages before the degeneration progresses to cause pain with each step.  The Achilles is the only tendon in the body covered by it’s own sheeth, the paratenon.  Paratenonitis leads to scarring of the paratenon to the Achilles tendon, which prevents the normal gliding of the tendon. This type of injury leads to more pain with activity. Insertional Achilles issues are often associated with a prominent back of the heel bone or spur, if the top part of the back of the calcaneus is more pronounced this is known as a Haglund’s deformity.

Haglund's and spurring

Insertional spurring back of Rt Heel and X-ray of Rt. Heel with Haglund’s and spurring

Swelling in Rt. Achilles – consistent with tendonosis

Swelling in Rt. Achilles – consistent with tendonosis

Finding the cause of the injury is far more important than anything an MRI or Diagnostic Ultrasound might reveal. A diagnosis is made by utilizing all the information and diagnostic imaging is far from 100% reliable versus the actual pathology seen in surgery. Dr. Nicola Maffulli has extensively published and studied Achilles pathology in athletes. ( Dr Maffuli cautions against basing surgical decisions on pathology found during a Diagnostic Ultrasound as an MRI has been found to much more definitive and sensitive and the MRI correlates better to what is found during surgery. (Schepsis AA, Leach RE. Surgical management of Achilles tendon overuse injuries: a long-term follow-up study. Am J Sports Med 1994;22: 611–19)

Athletes need to understand that surgery is not a quick fix. I would recommend a minimum of 6 months of quality conservative therapy before considering surgical management for most problems. If the surgery has a complication such as an infection it can set the athlete back further.  The medical literature reveals a complication rate of 7-13%. There are some injuries that take longer than others to heal and every patient is different. Some athletes get injured frequently not because they did anything wrong and not because they received poor medical care but due to their genetic makeup along with a lot of other factors.

The Achilles will also typically respond very well to ExtraCorporeal Shockwave therapy. A study by Dr. Amol Saxena showed a 78% success rate in the three common posterior heel injuries. Using a low energy device a sound wave is emitted up to 3000 times typically in less than 5 minutes. No anesthesia is required and 3-5 treatments are commonly performed.

Dr Saxena also published a paper analyzing 219 achilles surgeries in athletes and return to activity with each particular Achilles surgery being carefully measured (

Average Return to Activity following Achilles surgery

  1. Peritenolysis 2–6 weeks
  2. Debridement 6–16 weeks
  3. Excision of insertional calcification with tenodesis 12–26 weeks
  4. Retrocalcaneal exostectomy 12–26 weeks
  5. Rupture repair 12–26 weeks
  6. Chronic repair 26+ weeks

Surgery for midsubstance tendonosis may be required if a mucoud cyst or significant degeneration of the tendon has occurred and the procedure involves debriding the disease portion of the tendon.  Surgery for paratenonitis involves cutting the paratenon.

Insertional Achilles surgery, when the pain is lower and due to bone spurs or a boney prominence in the back of the heel bone involves removing the prominent bone. In order to be able to remove bone from the back of the heel some portion of the Achilles will be compromised and require some protected immobilization. In fact the current medical evidence shows that the medial and lateral aspects of the Achilles attachment, also known as the expansion, are most important to the structure and functional strength of the Achilles’ tendon. Many surgeons will now approach the tendon through the middle of the tendon and utilize bone anchors and a medial approach is much safer than lateral due to the location of the nerves.

Treatment needs to be based on evidence based medicine and a treatment plan should be a collaborative affair between the Physician and patient.  It is extremely important to know what the evidence based medicine states and understand the risks of jumping into something as serious as surgery.

My next blog post will highlight the successful conservative treatment for Achilles tendonosis of Zap Fitness star, Tyler Pennel. Click ‘Join the Conversation‘ and tell me about your experiences with these type of injuries.

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