Achilles tendon lengthening- an effective way to get rid of chronic pain
The Achilles tendon is a very tough band of fibrous tissue which connects the heel bone (calcaneus) to the calf muscle. It is also called the calcaneal tendon.
Calf muscles ( soleus and gastrocnemius) unite into one band of tissue, that becomes the Achilles tendon and then inserts into the heel bone.The Achilles tendon is the strongest, and the largest tendon in the body.
When the calf muscles flex, the Achilles tendon pulls on the heel- that movement allows us to stand on our toes when jumping, walking or running.
Despite the strength of this tendon, it is vulnerable to injury, because of its limited blood supply ad the high tensions which are placed on it.
The structure of Achilles tendon tends to weaken with age, which can make it more prone to injury- especially in people who participate in sports. And if you are an active runner, I suggest using running shoes and socks that prevent Achilles tendinitis and ensure the longevity of your Achilles' tendons (If you are an active walker, I suggest using shoes and walking shoes).
People with a tight Achilles tendon tend to walk on their toes. The tight Achilles tendon prevents the foot from sitting flat on the floor, and ankle motion can be limited. When this tightness cannot be treated with nonsurgical stretching or physical therapy, surgery is indicated.
What is Achilles tendon lengthening surgery (ATL)?
Achilles tendon lengthening is a surgical procedure which goal is to stretch the Achilles tendon to relieve a person of chronic pain or to allow it to walk flat-footed, without a bend in the knee. This surgical procedure makes small cuts on the tendons at the back of the angle, which elongates a contracted Achilles tendon- it lengthens as the wounds heal.
Two most used methods are:
1) Gastrocnemius recession
Gastrocnemius recession targets only the gastrocnemius muscle and helps to loosen the muscle fibers which are attached to the cord. This method is used for mild cases only.
2) Z-plasty method
This method is the most common. The surgeon makes a Z-shaped incision in the tendon of a patient and then stretches it to a particular length.
Causes of Achilles tendon contracture
When it comes to the causes of Achilles tendon contracture, several conditions can cause it, and these can cause issues with the mobility of the ankle too. They include:
- Congenital disabilities
- Chronic tendinitis
- Cerebral palsy
- Spinal cord injury
- Foot deformity which is caused by clubfoot or diabetes
Some of the symptoms of Achilles contracture are:
- Foot remaining in a bent position, which causes a flat foot, forcing the knees to bend
- Discomfort at the back of the feet
- Extensive pain in the Achilles tendon
- Abnormal toes position
- Poor posture
- Muscle spasticity (a muscle control disorder that is caused by stiff muscles)
Percutaneous Achilles tendon lengthening (PTAL)
This surgery is performed to improve your walking and standing, and it can also be used to correct muscle spasticity. Before surgery, a person is placed under anesthesia, and the back of the ankle is positioned to face the surgeon. The procedure is done through a series of small incisions over the Achilles tendon.
This surgery is needed if the ankle joint has a limited range of motion in an upward direction. A tight or shortened calf muscle is called an equinus contracture, and the surgery improves ankle ability to move upwards (dorsiflexion).
Recovery after the surgery depends on the number of incisions that are required, but on average it takes at least six weeks in a walking cast. During that time, there is limited aggressive physical activity and movement to allow for healing of the Achilles tendon. Partial weight-bearing is typically possible early on and is often followed by another six weeks of gradually increasing of activity.
The recovery may be dictated more by the other procedures which are often done in addition to the Achilles tendon lengthening. Patients may experience cramping or aching of the calf muscle for a couple of days after surgery. The incision sites may be initially tender but heal quickly.
Like other surgical procedures, there are some general complications which may occur when a percutaneous tendon lengthening is performed. General complications that can happen when this type of operational process is performed are much less severe in children, but they can still occur. These complications are relatively uncommon but may include wound healing problems, infection, pulmonary embolism and deep vein thrombosis.
Complications which are specific to this procedure include:
- Sural neuritis
Sural nerve injury may occur when this procedure is performed. Sural nerve runs on the outer side of the lower leg, and it can be accidentally injured during the incisions. If the nerve is damaged or cut, there may be numbness on the outside of the foot or some burning-type pain at the site of the injury.
- Rupture of the Achilles tendon
When performing this surgical procedure, it is entirely possible to rupture or over-lengthen the Achilles during the surgery. This may lead to a longer period of bracing/casting and specific exercises to promote healing of the tendon at the desired length.
- Calf weakness
The lengthened tendon means that the calf muscle may function differently, or the new position of the foot may feel weak or awkward when walking up ladders or stairs, or if attempting to stand on the toes, sprint or jump.
- Post-operative swelling
This surgery causes the weakness of the calf muscle and the muscle usually “pumps” fluid up the leg. This can last for a short period, or for several months.
Gastrocnemius recession or release is a procedure which is used to lengthen gastrocnemius muscle (the most significant muscle in the calf), that is contracted. Most often, the first treatment is a physical therapy to stretch the Achilles tendon, and if this proves unsuccessful, gastrocnemius recession is usually indicated.
This procedure includes making an incision on the back of the calf and then accessing the gastrocnemius tendon. The surgeon will cut the tendon and stitch it to other tissue or allow it to heal on its own. Once the tendon is fully healed, it should be adequately elongated and allow full functioning of the foot and leg.
Selective gastrocnemius recession is often useful but is insufficient in severe equinus deformities in which the Achilles tendon needs to be lengthened. Z plasty is sufficient to correct severe equinus deformities, but it is associated with tension on the wound after correction of the deformity and marked scarring.
The method involves three longitudinal incisions of 1 to 1.5cm to be done, one over the most distal portion of the tendon and the second and the third one over the upper end and mid portion of the tendon.
The distal part of the tendon is split into two halves through the distal incision, and the medial half is detached from the calcaneus and stitched. Then, the stitch is passed using an artery forceps to the middle and the superior incision with gentle pulling to complete the splitting of the two halves.
After that, the lateral half is detached from the tendon proximally, and the equinus is corrected, and the two halves are sutured through the middle incision with removal of the excess tendon.
Achilles tendon contracture can be very limiting and frustrating. Sometimes, the Percutaneous Achilles tendon lengthening may be the only option, especially when physical therapy gives no results.