Posts for: October, 2012

By Dr. Brad Legge
October 30, 2012
Category: Uncategorized

What is it?
The Achilles tendon is the largest and strongest tendon in the body. It can support up to 12x your body weight! It is made up of two muscles: the Gastrocnemius and the Soleus. The Gastrocnemius muscle inserts above the knee and the Soleus muscle below the knee. Tightness in the Achilles tendon (called Equinus) can lead to pathology usually manifesting as pain in the tendon about 2-6cm above its insertion into the back of the heel (Non-insertional Achilles Tendonitis) or at the insertion itself (Insertional Achilles Tendonitis).  Sudden increases in the intensity or amount of exercises can also lead to pain in the Achilles tendon.

Common symptoms of Achilles tendinitis include:

  • Pain in the Achilles tendon with the first few steps in the morning
  • Pain with increased activity
  • Thickening of the tendon which you can feel  approx. 2-6 cm above the insertion
  • Bone spur on the back of the heel which you can sometimes feel if it is large
  • Swelling and pain which worsen throughout the day

Diagnosing Achilles Tendonitis
The following are usually required for the physician to make an accurate diagnosis: a complete history of the complaint; a lower extremity physical exam including: assessing the Achilles range of motion (specifically a decrease in ankle joint dorsiflexion), palpation for signs of thickening of the Achilles and bone spurs, finding the point of maximum tenderness etc …

X-rays are helpful to assess for heel spurs and to rule out other causes of heel pain including stress fracture.  Ultrasound examination can give the physician a dynamic view of the Achilles tendon. The thickness of the tendon, any possible tearing, or the existence of an inflamed bursa can be assessed with the ultrasound.  MRI is also sometimes useful and can give a full picture of the tendon and the degenerative changes that may exist.

Treating Achilles Tendonitis
Treatment depends on severity. Most of my patients have already tried some kind of home therapy including anti-inflammatory medications, ice, rest, stretching etc… In some mild cases of Achilles tendonitis these treatments may be sufficient, but in many cases they are not. A physician may treat Achilles tendonitis with heel lifts, orthotics, adaptive shoe gear, a below knee cast or walker, NSAIDs, Medrol Dose Pak, Physical Therapy, etc… The average recovery time is 3-6 months. 

If conservative care fails then surgical treatment may be an option. For insertional Achilles tendonitis this usually involves removal of the heel spur, debridement of the Achilles (removal of diseased portions), with or without lengthening of the Achilles (Gastrocnemius recession). To remove the heel spurs, the Achilles must be partially or completely released from its insertion into the calcaneus (heel bone).  Following this release, strong anchors are placed in the bone to reattach the Achilles. Following surgery, a period of non-weight bearing is required which is usually anywhere from 4-8 weeks.  Sometimes physical therapy is required as part of the recovery process.  Statistically, Achilles tendon repairs have a high success rate and are a good alternative to living in pain.

I certainly believe, if you are able to read this blog, you likely can espouse numerous detrimental effects smoking can have on your overall health. After all, in 1997, the tobacco industry agreed to pay 360 billion dollars over a 25 year period to fund antismoking campaigns and public health efforts. The well documented and supported relationship between cigarette smoking and cardiovascular disease, lung cancer, and pulmonary disease are, for the most part, well understood, or at least has been well engrained into much of our society.  However, despite these well-known effects, nearly 20.8% of Americans smoke tobacco cigarettes. In fact, according to a 2005 report by the Centers for Disease Control and Prevention, smoking remains the leading preventable cause of death, accounting for approximately 1 of every 5 deaths. These are interesting facts and I understand a family physician emphasizing the need to quit, but what does this have to do with foot & ankle surgery?

There are numerous reasons your tobacco use matters to us as foot & ankle surgeons, one of which is we are physicians and your overall well-being and health matter to us, not just the state of your feet. However, three specific and crucial effects of cigarette smoking on the lower extremity, that are worth briefly highlighting are peripheral arterial disease (PAD), wound healing, and bone healing.

Cigarette smoking has been shown to be the most important variable risk factor causing peripheral arterial disease. A 2008 animal study, showed that nicotine exposure can increase vessel density, which results in decreased blood flow. PAD is a significant risk factor for lower extremity amputation, and the risk of PAD for smokers is 4 times that of nonsmokers. It has been proven that smoking cessation slows the progression of PAD, and decreases the risk of amputation.

Cigarette smoking has been implicated in poor wound healing and bone healing as well. Consider the following information gleaned from a 2002 study conducted by a group of plastic surgeons. “Smoking a single cigarette may cause cutaneous vasoconstriction for up to 90 minutes; hence, a pack-a-day smoker remains tissue hypoxic for most of each day.” In other words, the skin lacks the blood flow and oxygen levels needed to heal when exposed to cigarette smoke. Nicotine, carbon monoxide, and hydrogen cyanide are three components of cigarette smoke, in addition to the 43 cancer-causing substances, that are particularly detrimental to the healing process. These substances decrease tissue perfusion, inhibit oxygen from getting to the tissue, alter the cells responsible for laying down the necessary materials for wound healing, and delay bone formation across bone cuts and fusion sites.

Numerous studies have been conducted indicating the effects smoking tobacco can have on the human body. Foot & ankle surgeons have noted, specifically in foot & ankle surgery, that smokers take nearly twice as long to heal and are at risk for significantly greater complications following surgery, than nonsmokers. In fact, it is not rare to find surgeons who will simply refuse to do surgery if a patient admits to tobacco use. Research has ranges all over the spectrum as to how far out from surgery and for how long after surgery one should limit their exposure to tobacco. It is best to simply begin the road of complete cessation, and never waiver from the path as your body will thank you and your foot & ankle surgeon will thank you.  

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