What is an Achilles Tendon Repair?
When the Achilles Tendon has completely ruptured (see Achilles Tendon Rupture), surgery is required to stitch the frayed edges back together. There are a number of different surgical procedures that can be performed, but the most common involves an open cut over the tendon.
You should expect to be in rehabilitation for a number of months after the operation (around three but this will vary). During the early recovery period, your leg will be in a special ‘equinus’ cast that prevents the tendon re-rupturing. Within two weeks, most people are able to begin using a cam walker boot and eventually careful weight-bearing with crutches.
The usual total rehabilitation is between six weeks to months, but you should expect to need some form of physiotherapy and/or exercises, as well as avoiding your usual high-stress activities for a number of weeks. Running and restarting sports will generally not be possible until around four to six months after the operation (again, this varies between individuals).
The operation for Achilles repair is generally very effective and is rarely associated with major complications like massive bleeding. Some people unfortunately do suffer a re-rupture of their tendon, and require further treatment, Most people are very happy with their long-term results and eventually return to their normal exercise program.
Who is this operation for?
This operation is for those who have suffered a full-thickness rupture of the Achilles tendon, and/or when other, less invasive methods of repair (like casts and physiotherapy) have failed.
What are the benefits of the operation?
This surgery is usually very effective, with most people having no noticeable change in function long term (and providing rehabilitation is complete).
Risks of not having the surgery
Choosing intensive physiotherapy and splinting/orthotics is a very appropriate alternative to surgery. In many cases, non-operative and operative (surgery) treatment have similar long-term results.
Surgery does however carry lower risk of re-tearing the tendon. It also is often recommended for those with high demands on the ankles, including athletes, especially runners. The down side is that surgery carries multiple risks, including infection and injury to nerves. While these are usually minor they are not negligible.
As with many cases in orthopaedics, the decision to operate or not will be made on a case by case basis. You should discuss your options and any concerns with your physiotherapist and surgeon.
Who should not have this surgery?
As the major concern with this surgery is related to infection, those at higher risk (for example diabetics, long term smokers) may by less advised to pursue surgery.
However, your surgeon will have a lot of experience in this issue, and can discuss the benefits versus the potential risks with you.
Complications
Complications following repair of full-thickness rupture:
- Skin injury. The skin overlying the Achilles tendon can become strained by the chronic swelling. This can lead to breakdown in the skin, requiring further treatment from a podiatrist, the local doctor, or in rare cases a surgeon.
- Sural nerve injury – the sural nerve is the nerve providing sensation (touch) to the patch of skin on the outer surface of the foot. Injury to this nerve can result in tingling or numbness over this area.
- Re-rupture of the tendon & tendon necrosis. Necrosis is a medical term meaning death of the tissue. As stated earlier, the Achilles tendon has a somewhat vulnerable blood supply, and necrosis of the tendon is an unfortunate, though rare, complication of rupture.
- Achilles tendonitis and/or pain.
- Infection – this can occur deep in the ankle or in the skin.
- Deep vein thrombosis (DVT) – the formation of clots in the large veins in the leg is a well-known result of long-term immobilisation. In hospital the doctors will use preventative measures, including heparin administration and Ted stockings, to prevent these clots from forming.
There are a number of other risks involved in any surgery. For more information on these, see Complications of Surgery.
Before the operation
Before reaching the hospital, you can apply ice to your ankle and keep it elevated. Other measures like over the counter pain relief can also be helpful with symptoms.
Emergency Department | Preadmission Clinic
If you have a sudden rupture, you will probably be in so much pain that you come into the emergency department. The staff can assess whether you are safe to have surgery and organise an operation.
If your rupture occurs gradually over time, you will be seen at the Preadmission clinic to make sure you are fit for the operation and all the necessary tests are performed in preparation for the operation.
During the visit, you will be seen by a
- doctor
- nurse
- anaesthetist (if necessary)
Tests
Tests that may be ordered for you include:
- Ultrasound scan of your ankle.
Other tests that are used to assess whether you are fit for surgery include:
- Blood tests
- Xray of your Chest
- Urine Test
- ECG
Preparing Your Skin
Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for a program to improve your skin before surgery.
Tip
Carry a list of your medications with you including the name, dosage and how often you take it.
Medications
Our doctors will advise you which medications you should stop or can continue taking before surgery.
Get some help from your friends and family
Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry. If you live alone, your orthopaedic surgeon’s office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home.
About the Operation
Repair of the achilles is a relatively short operation, usually lasting less than 1 hour. It is generally a very safe operation, with few major complications.
Minimally invasive repair – in this method, the surgeon makes a short incision along the back of the heel, opening up the skin. From here, the tendon can be easily accessed, pulled back into place and the free ends stitched together.
When the free edges of the tendon are badly frayed, your surgeon may need to bring the threads together in a knot. This should not be visible, painful or have any impact of function, but you may be able to feel it above your heel.
If the rupture is very severe, your surgeon may need to reinforce the damaged Achilles. Usually, this will involve taking a small section of tendon from the sole of your foot and grafting it onto the Achilles.
Your surgeon will then carefully replace the paratenon over the repaired tendon. This is a thin covering that supplies the tendon with nutrients and speeds healing.
The scar from this approach is small, but visible. The advantage of this surgical method is that the results are generally very good.
Percutaneous repair – in this method, the surgeon makes a number of small incisions in the skin and sews the tendon together ‘blind’. While the cosmetic result of this approach is usually better than minimally invasive repair, there may be a higher risk of sural nerve injury (see complications), though other risks, like infection, may be reduced.
After the Operation
When you wake up after your operation, your ankle will be immobilised in an equinus cast (with toes pointing down) to prevent tearing of the stitches.
If your doctor is satisfied you are safe, you can usually go home without spending the night in hospital. The nurses will make sure you have enough pain medication to keep you comfortable.
You will need to return to your hospital to have the ankle and the incision evaluated by a nurse or surgeon. If everything is going well, your cast will be replaced by a hinged brace.In most cases, you cannot take any weight (complete non-weight-bearing) through the leg for 4 weeks. This means you will be hopping on your other leg, so as not to take weight on your affected foot. A Physiotherapist will show you how to do this safely with crutches.
Recovery and Rehabilitation
Your ankle will only recover to normal with physiotherapy. With this in mind, you should follow as closely as possible the exercises set out by your physio.
During the rehabilitation period, you may experience ongoing pain and swelling. This should decrease quickly over time, however you can help these symptoms by:
- Keeping your leg elevated as much as possible. When sitting you should try to put your leg up on a chair so that it is at least level with your hip. At night, try to sleep with several pillows below your foot.
- Occasionally applying ice to your foot.
- Simple over the counter medications like panadol can also help.
If your ankle or leg suddenly becomes red and swollen, or you develop a fever you should see your GP.
The long rehabilitation period needed for Achilles repair can be very frustrating, especially for very active people. Despite this, you are encouraged to discuss any extra exercises you want with your physio rather than striking out on your own at the gym. The Achilles tendon is crucial for normal walking, let alone running, and your physiotherapist will be well-placed to advise you on when it is safe to continue.
The First Month
In there first six weeks after your operation, your tendon is very fragile. During this time, you must not:
- Flex (‘dorsiflex’) your foot. This stretches your tendon and can cause re-rupture.
- Allow anyone to move your foot around, or force your foot beyond what is comfortable for you.
- Put ANY weight on your foot until recommended by your physiotherapist or surgeon.
- Apply heat or perform intense massages on your ankle.
In this early period of rehabilitation, you will gradually begin to weight bear, and your physiotherapist will teach you stretches that increase your flexibility.
- Weight-bearing. Your surgeon will recommend when you can start to weight-bear. During this time, your physiotherapist will show you how to walk with crutches, and when you are ready, how to carefully carry some of your weight in your foot.
- Range of Motion Exercises. Your physiotherapist will show you a number of exercises that will help build strength in the tendon and prevent your muscles from wasting. You will need to practice these at home.
- You must not flex your foot beyond the level your physiotherapist has suggested. Most physios will allow you to bring your foot into a 90 angle to your leg, but you must not pull you foot up beyond this point as the tendon may be over stretched.
- Exercises for the rest of your body. While you are avoiding weight-bearing on your ankle, your other muscles, especially the large thigh muscles (quadriceps) begin to waste. To prevent this, your physio will show you a number of exercises to keep the rest of your body fit and strong. This may involve going to a gym and using a stationary bike.
During this period, you should see the incision site over your heel form a thick scar as it heals over. This will usually become smaller and paler over time.
You should have a follow-up appointment with your surgeon within the first two months after surgery. He or she can discuss your progress and decide if you’re ready to move onto the next phase of rehabilitation.
The First Three Months
Once your surgeon is satisfied your tendon is sufficiently strong, you can begin to move onto more advance flexibility and strengthening exercises, as well as increasing the weight you can put through your foot. You will still however need a cam walker boot or other form of protection.
- Weight-bearing. During this time, you will move from weight-bearing with crutches to walking relatively normally.
- Strengthening exercises.
- Range of movement exercises. Your physio may now recommend you flex your foot farther than you were allowed to before. This helps to stretch out the healing tendon. By the end of this period, you should have full range of motion.
- Proprioception excerises to help you regain balance.
Your physio may recommend you start using large elastic bands to stretch your ankle. You will also start to using stairs to improve your ankle.
By the end of this period you should start to feel able to walk normally. After this time, exercises will focus on rebuilding strength in your leg.
The First Six Months
Once your physio and surgeon think you’re ready, you can gradually start to run. It is very important that when beginning this phase you do not push yourself harder than you can tolerate. At this point, both your muscles and Achilles are at risk of injury from the long period of reduced activity.
F.A.Q.s | Frequently Asked Questions
What are the alternative treatments to having a Achilles Tendon Repair?
It is possible to avoid surgery by placing the injured ankle in a cast for a long period of time. However, this does not return the full strength and function of the Achilles. It does however avoid complications like infection and bleeding.
When can I return to sports?
This will vary depending on the severity of the rupture, but most people are able to begin light jogging at 3 months, and then return to sports at around 6 months. The same can be expected from surgical and non- surgical management.
During this period, your physiotherapist will gradually change the frequency and type of exercises you perform. If you are returning to sports, you may also need to practice functional exercises.
These exact timeframes will vary and will ultimately be decided by your physiotherapist and surgeon.
When can I return to driving?
You must be free of pain and able to perform an emergency stop. This will also depend on which foot was operated on (right or left). If you have had left sided surgery and drive an automatic car you may be able to drive 2-4 weeks following surgery.
What should I do if I have a problem?
If you experience severe pain, excessive swelling, inflammation or discharge from the incision site please report it to your GP.
If you cannot contact your GP you should contact the Emergency Department at your local hospital.