Achilles Tendon Pathologies

Specialized care for a strengthened tendon

The Achilles tendon is the strongest tendon in the body. The calf muscles forming the triceps surae give rise to the Achilles tendon:

The Achilles tendon inserts into the calcaneus. It is part of the sural-plantar Achilles system, consisting of the triceps surae, the Achilles tendon, and the plantar aponeurosis.

There is a satellite tendon of the Achilles tendon, called the plantaris tendon, which can be involved in certain Achilles pathologies or used as a tendon graft.

Pathologies of the Achilles tendon have significantly increased with the rise in training and sports performance.

Achilles tendon injuries can affect high-level athletes, but also recreational athletes and more sedentary individuals who will present with overuse of the Achilles tendon, that is, repeated trauma with significant tension in the Achilles tendon.

What are the most common Achilles tendon disorders?

Achilles Paratendinopathies

The paratenon is a structure that completely surrounds the Achilles tendon. It acts as a kind of sliding membrane for the Achilles tendon, allowing it to move freely in relation to the surrounding tissues.

The paratenon is rich in blood vessels and enables the vascularization of the Achilles tendon. Nerve fibers follow the blood vessels and end at the level of the paratenon and the Achilles tendon.

In cases of overuse of the Achilles tendon, there is an increase in vascularization and consequently in the number of nerve endings that will adhere to the Achilles tendon. Nerve adhesions to the Achilles tendon, and adhesions of the paratenon to surrounding tissues, will block the normal movement of the Achilles tendon and be responsible for pain in the context of paratendinopathy.

Achilles paratendinopathies are promoted by intensive sports practice, which can also lead to other complications such as compartment syndrome, requiring a global preventive approach.

It is necessary to be well equipped and to have shoes adapted to each sporting activity and its specificities.

Running shoes should be changed every year, or every 6 months depending on the annual distance covered. Do not hesitate to change your shoes even if they do not appear damaged, as their cushioning effect may be worn out.

The quality of the terrain is important. The harder the ground, the more it encourages the appearance of Achilles paratendinopathies.

If exertion is done in a cold environment, and if the ground is slippery or icy, the risk of Achilles paratendinopathy is increased.

An overly abrupt increase in the length or pace of a workout can be a source of Achilles pain.

Inequality in lower limb length, around 2 cm, must be corrected in experienced athletes by placing a compensatory heel pad in the shoes.

Rearfoot axis defects require correction with orthopedic insoles in order to relieve tension in the Achilles tendon, especially in the case of flat valgus feet.

The diagnosis of Achilles paratendinopathy is clinical, with pain triggered by palpation of the Achilles tendon, which appears thickened. Crepitus may be felt when moving the Achilles tendon.

Medical treatment is symptomatic, with the use of non-steroidal anti-inflammatory drugs. Rehabilitation sessions consist of eccentric contraction exercises of the triceps surae and releasing painful adhesions of the paratenon.

Mid-portion Achilles Tendinopathies

Mid-portion tendinopathies are injuries of the Achilles tendon between the calf muscles and the calcaneal insertion.

30% of patients presenting with mid-portion Achilles tendinopathies do not play sports.

Poor vascularization of the lower limb and especially the tendons, age, being overweight, a high-arched foot, and ankle instability are factors promoting mid-portion Achilles tendinopathies.

Excessive and vigorous tension on the Achilles tendon can exceed the tendon’s capacity for adaptation and elasticity, causing pain.

A significant increase in sports training will rapidly increase muscle volume and strength, while the tendon volume does not change.

The quality of tendon fibers will alter with time, but not as quickly as the muscle.

Degenerative intratendinous lesions can appear in chronic cases and cause a loss of tendon elasticity.

Clinically, Achilles pain appears at the start and end of an activity, with a relatively calm period in between.

In the inflammatory stage, the Achilles tendon is generally swollen and painful, and in chronic cases fibrous nodules may develop.

Rehabilitation sessions consist of stretching the triceps and performing eccentric contractions. Firm massage of the Achilles tendon can help release its adhesions to the plantaris tendon.

Insertional Achilles Tendinopathies

Insertional Achilles tendinopathies involve pain at the Achilles’ insertion on the calcaneus. They can be part of Haglund's disease.

There is no factor significantly correlated with the occurrence of insertional Achilles tendinopathy, although poor-quality footwear, intensive or inappropriate sports training, and shortening of the posterior muscle chains can be implicated in this condition.

Significant and repetitive tension on the Achilles’ insertion can cause degenerative lesions with the production of calcifications or even tendon ossifications.

The rigidity of the Achilles tendon can also affect the insertion. An overly rigid tendon can abnormally stress the insertion, a phenomenon known as "stress shielding".

If the calcifications or ossifications are large, they can cause conflict with footwear and be part of Haglund’s disease.

Clinically, the pain is located at the Achilles’ insertion, worsens with exertion, and can eventually become constant.

Most patients respond to medical treatment consisting of taking anti-inflammatories, modifying footwear, and correcting a sporting technique.

Wearing a silicone heel pad can help modify the level of support at the shoe’s counter and relieve pain. A pair of orthopedic insoles correcting a rearfoot axis defect or simply providing cushioning can be added to everyday or sports shoes.

Rehabilitation consists of stretching the posterior muscle chains, performing eccentric contractions of the triceps surae, and massaging the Achilles insertion.

Acute Achilles Tendon Ruptures

Broadly speaking, there are two categories of patients likely to rupture their Achilles tendon:

The traumatic mechanism is forced eccentric contraction of the triceps surae, that is, contraction of the calf muscles during their stretching.

The diagnosis of acute Achilles tendon rupture is clinical.

There is a loss of physiological equinus, with a Simmonds or Thompson sign, in other words, compression of the calf muscles does not produce plantar flexion of the ankle in case of Achilles rupture.

There is no such thing as a partial rupture of the Achilles tendon.

Ultrasound will often show a "partial rupture", which in the end corresponds to a complete rupture of the Achilles tendon with:

Treatment may be orthopedic or surgical. The debate remains open, depending on the patients, their lifestyles, and their sporting activities.

The main advantages of conservative (orthopedic) treatment are the absence of postoperative complications, notably skin complications.

The advantages of surgical treatment are:

Chronic Achilles Tendon Ruptures

Chronic Achilles tendon ruptures are of two types:

Missed ruptures manifest as persistent functional problems related to elongation of the Achilles tendon, resulting in loss of calf muscle effectiveness and balance problems.

Chronic ruptures diagnosed after more than 4 weeks represent delayed management.

If neglected or late ruptures are seen in consultation, there are therefore associated functional problems such as:

The Achilles tendon is generally poor in quality, and repair requires surgical reinforcement of the tendon, or even a palliative tendon transfer to compensate for Achilles tendon deficiency.

Achilles tendon surgery

Surgery for Achilles Paratendinopathies

The surgical procedure involves releasing the adhesions between the Achilles tendon and the paratenon, as well as the adhesions between the paratenon and the surrounding tissues. These release maneuvers are frequently performed under arthroscopy.

Surgery for Achilles Mid-portion Tendinopathies

The surgical procedure involves releasing the adhesions between the Achilles tendon and the surrounding tissues. These release maneuvers are frequently performed under arthroscopy.

Any conflict with the plantaris tendon must be addressed at the same time by resecting a short segment of the plantaris tendon to prevent it from restricting the mobility of the Achilles tendon.

If there are intratendinous degenerative lesions that do not threaten the strength of the Achilles tendon, localized tendon splitting can be performed percutaneously.

If the degenerative lesions weaken the Achilles tendon, Achilles debridement with tendon reconstruction using the plantaris tendon is considered.

Surgery for Achilles Insertional Tendinopathies

The surgical treatment consists of:

If the skin is fragile and at risk of healing problems, the procedure can be performed by arthroscopy.

In the majority of cases, the surgical procedure is performed as open surgery…

Surgery for Acute Achilles Tendon Ruptures.

There are several surgical techniques for Achilles tendon repair:

Each technique has advantages and disadvantages, and their indication depends on factors such as:

Surgery for Chronic Achilles Tendon Ruptures.

The goal is to "retighten" the Achilles tendon to improve the muscular contraction efficiency of the calf muscles.

The repair consists of resecting the tendinous callus, which corresponds to the tissue interposed between the ruptured tendon ends, suturing Achilles to bring the ends together, and performing a tendon reinforcement.

We can perform:

When the rupture is old or after a failed Achilles tendon repair, we perform tendon transfers, notably from the flexor hallucis longus. This procedure is performed by arthroscopy.

Achilles tendon surgery in Nice

We specialize in the management of acute, chronic, and post-injury Achilles tendon lesions.

Achilles Tendon FAQ

The Achilles tendon is subjected to strong tensile forces daily and during sports activities. Overuse of the tendon can cause intra-tendinous lesions that will progressively replace tendon tissue with scar tissue or even calcifications. These are then degenerative lesions that will worsen tendon stiffness.

The diagnosis of an Achilles tendon disorder is clinical. Imaging assessments provide information on tendon quality.

X-rays are used to look for calcifications or ossifications; ultrasound and MRI show intra-tendinous lesions and paratendinous involvement.

The general practitioner and sports doctor regularly manage Achilles tendon disorders.

If there is resistance to medical treatment, care is provided by an orthopedic specialist in ankle and foot disorders.