Hi,
I have been diagnosed with Chronic Achilles tendonitis. The xrays showed bone spurs on the back of both heels. There is also indication of Equinus deformity. I have had pain on the back of my heels since the first of the year. This occurs when awakening and anytime I am off my feet for a while. The pain will diminish with excersise, but will reoccur after strenuous exercise.
I was given orthodics and those sticky silicone cushions for the back of the heel. I did a series of ultrasound treatments along with anti inflammatory drugs. Then I tried Prolotherapy and I am currently doing Physical Therapy sessions to try to stretch and strengthen the tenons and muscles of the lower leg. This does not seem to be helping to relieve the pain.
The Pod said that the next step would be cortisone injections and casting, but I have been reluctant to do this, because of the weakening effect on the tendons. The Pod said that the surgery would be a Achilles tendon lengthening procedure, but my PT said that the Achilles tendon is fine. Would endoscopic gastrocnemius recession surgery be a option? Would the heels spur also need to be removed? Being that it is both heels, would this be done seperatly or one procedure?
Thanks for any insight you can give.
Jon

Hi Jon and welcome.

Good question. I've tried a couple of times now to treat chronic Achilles tendonitis with an endoscopic gastroc recession. Neither has fared well. With a tendo Achilles lengthening though, I've always had reliable results. The Achilles lengthening can be done with or without a partial resection of the back of the heel. I'd recommend partial resection of the heel only if you're having pain from direct pressure on the back of the heel.

Have you been using a heel lift and avoiding going barefoot?

Jeff

Hi,
I have been using prescribed orthodics, and shoes or sandals that have a lift in the heel. This condition started a year ago, I checked my records, and was surprised it has been so long!
I went to a new podiatrist yesterday, I found him after doing research on my problem and noticed he has published a number of papers on this problem. He is now using a Topaz Microdebrider, to eliminate the scar tissue on the tendon and to stimulate healing.
He checked my range of motion and said that the tendon length is not that bad. He checked the movement with both a straight and bent knee. This might have been improved after almost 2 months of PT, stretching and strengthening the lower leg muscles. He thought the pain was not from the spur, but rather a build up of scar tissue at the connection point of the tendon, from micro tearing. There is pain from pressure on the back of the heel.
He thinks I would be a good candidate for the Topaz Microdebridement treatment. He said that this procedure will remove the scar tissue and have a much shorted recovery time of 3-4 weeks of non load bearing, versus the 6 month recovery with the tendon lengthening technique. Have you used this technique yet?
If this does not improve the condition, then I would have to get the standard tendon lengthening operation.
He may try to do the procedure with a local anesthetics in-house, in his office, rather then how he usually does it in a operating theater, to save me money. Being that it will take two procedures, one for both heels, it will get a little pricey...It is all up to the amount of pain that I could handle. Since it is done with a local anesthetic, there would mainly be the pain from the needle injections. Also it is a little less risky, avoiding the anesthetics in the supine position. If the first heel treatment is very painful, I can go for the full anesthetics for the other foot!
I guess there is the chance that there would be complications, if he notices some additional work to be done, that being in a operating theater would facilitate more flexability.
Does this sound like a good approach?
Thanks for the information!
Jon

Jon,

Yes, it does sound reasonable. Let me give you some impressions...

What's the reason why you developed Achilles tendonitis? In most cases, the load applied to the tendon is too great and the tendon begins to fatigue. This fatigue is called tendonitis. the early symptoms of tendonitis include pain at the onset of an activity and at the end of an activity. As the tendonitis becomes a bit worse, you'll see a knot form at the site of the tendonitis. Most would agree that this knot is an area of small micro tears in the tendon. As they heal, they cause inflammation and the tendon swells.

So how do you fix this problem? You have to remember that first and foremost is weakening the pull on the tendon. Initially that can be done with heel lift, wedged sole shoes, etc. You've been there done that, eh?

Second thing to try is some method of anti-inflammatory. This could be accomplished with either a medical approach or a surgical (procedure oriented) approach. Medical care would include use of a steroid (oral or injectable) or other NSAID. The procedure methods would include prolotherapy or microabrasion techniques such as Topaz.

I've not gotten on the Topaz band wagon, and maybe I should give it a bit of a chance. In theory I can see how it works, but I do also have some doubts. I think I need to have my logic proved wrong. There's a strong part of me that thinks that without lengthening the Achilles, you're still going to have problems in the long run.

I don't want to sound pessimistic, and as an entry surgical procedure, it's worth a try.

Jeff

Hi,
Thanks for your input, I agree with your synopsis of the train of the cause and effect of tendinitis.
Yes, I am at the point of the knot at the back of the heel. I have done Prolotherapy, and it did seem to help some. I thought of the Topaz as a more intense Prolo also.
As far as correcting the strain from the tendon tightness, both the podiatrist and the PT I have seen, didn't feel the tendon was that tight. I have been doing PT stretching and strengthening the muscles in the front of the leg, to balance the equinus condition, rather then weaken the calf or lengthen the tendon. I have been doing 3 days a week for over a month of intense PT. Another possible cause could be, working on ladders for 30 years, put a lot of strain on this area.

So for my plan of attack, I figured if I can remove the build up of scar tissue, then work to stretch this area, this may eliminate further problems. Does this sound like a good approach?
Like you say it is a good entry point. That is what the doctor said, if it is not successful, being low intrusive, the loss isn't that much.(Just the cost!)
Thanks again for the clarification,
Jon

That's a good way of describing the Topaz method...more invasive prolotherapy. I'm sure the Topaz folks would argue that point with you, but I think that's a reasonable way to describe it.

Jon, there's something described in biomechanics called Poisonn's effect. Poison's effect goes something like this; when you apply traction (pull) on a structure, if the structure lengthens, the lengthening has to be compensated by thinning of the structure. That thinning or strain on the structure is Poisonn's Effect. It's a bit heady and theoretical but that's the root of what I believe to be the cause of every case of Achilles tendonitis, both insertional (at the heel) and in the mid-body of the tendon.

Jeff

Well, I got the procedure done on my left foot yesterday.
You are right they did not like the analogy, comparing it to Prolo! They are both causing trauma to the area, to stimulate healing. I think the difference in the two, with the Topaz treatment they are dissolving the scar tissue, to increasing the blood flow.

Your comments on the Poisonn's effect make sense, as I do silver smithing, I can relate to stretching and and thinning. But isn't it possible to thicken the tendon also, with exercise? Providing there is a free flow of blood and nutriants in the area? I would think that is how the problem can be improved. Or does the tendon maintain the same dimension, even if the muscles are increased in strength? This is why the PT was trying to stretch and strengthen the area. I am just trying to understand the process.
So the procedure went like this; I was laid out in the supine position, they prepped the area, pressed the area for the probelem spots, marked the 1/4" grid on the back of the heel. Injections of a local anesthetic. That was the most pain, just the injections,once the second injection is done I was pretty numb. The Topaz unit is controlled with 2 foot pedals, one I guess for the radio frequency, the other for the irrigation of the saline solution. The process laster about 25 minutes. The probe resembles a ice pick with a hole in the middle for the saline solution. As I understand it, The saline does multiple tasks, it irrigates, helps transmit the radio frequency, and helps cool the area. The stabs,that is what had to be done to get the "ice pick" in the skin, caused a strange feeling in the numb area, kind of a tugging... Occasionally, he would hit a tender spot, especially if he went deeper by the tendon. (hitting nerves?) All in all, I was impressed with the procedure,I like the idea of not being cut. It did cost $2,500 for the treatment, for a hour office visit, versus $5k for the operating theater. I don't know how much the Topaz is to rent, but if this works, it might be a viable choice for some cases, say replacing the cortisone shots, wit this procedure?
Now I have 10 days of non load bearing, and then another 15 days of using a walking boot. It is a little difficult to get around with crutches, especially since I have tendinitis in the other foot too! I have never broke anything, so this is a challenge to get used to. Then if it works out, I will do the other foot...
There is a lot of pain in the area now, so I think there is more pain in healing then during the procedure. I will have to look at some trick products to make life easier for the next 3 weeks, like a better boot for sleeping, then the walking boot. It would be nice to have something that is not making contact with the treated area!
Thanks for the input,
Jon

Hey Jon,
As a pro when it comes to walking boots (I've had 5 different tall ones & 2 short over the last 2 years) I think I can truly say that none are what I would call "comfortable". I'm really interested in the outcome of your procedure, so keep us informed, ok?
Katherine
Good luck & speedy recovery!

Hey Jon,

Let's keep an eye on you. I'll be interested in seeing how you fare over time.....got my fingers crossed.

Jeff

Thanks, only time will tell...
Getting more used to hobbling around.
Take care,
jon