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Sunday, February 24, 2013

Achilles Tendon Pain + 2 Surgeries: Still Painful

Hi Doctor Blake,

My name is John (name changed). I now live in Valley Springs California. I have been on the internet researching Achilles tendinitis/heel pain and found your blog.

 I have been having Achilles tendon/heel problems since July 2010. I have been dealing with another podiatrist. I was told in July 2010 I had a partial tear of my Achilles tendon and some real large bone spurs.

 Because I am a diabetic they did not want to do surgery at this time. I was placed in a cam walker, but the pain got worst and I was placed in a NWB short leg cast. I was in the cast until October 2010. The pain got better, but as soon as I started rehab, the pain returned.

 I was put back in the SLC walking cast until the 1st of November. At this time an MRI was done. The MRI showed the tear and the bone spurs. The podiatrist wanted me to go back into a cast. Being from the old school of sport medicine, I suggested a long leg cast to completely keep my heel from moving. The podiatrist finally agreed to my request. My foot was plantar flexed for the first 3 weeks, then the foot was raised about 10 degrees for another 3 weeks. The last 3 weeks my foot was at 90 degrees. After that I was put in a SLWC for the next two weeks. Finally I was put back in the cam walker. While in the long leg cast my heel felt much better, but when I when back into the cam walker and started rehab the pain returned just like nothing had been done.

 Finally in March 2011, the podiatrist decided to do surgery. She was to repair the tendon nd remove the spurs and scrape the heel smooth. She decided to use the Topaz procedure on the tendon. Everything felt good until I had my knee scoped to clean up a partial tear of the cartilage. Soon after the scope of the knee the Achilles tendon pain returned. By September 2011 the pain felt like I had just injury my heel. X-ray showed that bone spurs had returned.

 I changed podiatrist and had to start my treatment all over. He place my leg in a SLWC for the next 2 weeks. But it did not help. He suggested the long leg cast again. I was in it for 6 weeks. After that I was placed in a air cam walker. This lasted until April 2012 until a second surgery was done. Again the tendon was removed the spurs removed and the tendon reattached.

 In December 2012 I started a rehab program. Near the end of January 2013 the pain has returned. The podiatrist had earlier tried injecting the heel and putting it in a cast, but it did show any sign of improvement. The podiatrist had order ultrasound treatments but was over ruled.

 I worked for 25 years as an athletic trainer and started my own rehab program. The more I do the exercises the more painful it becomes. The podiatrist asked me to look into calf lengthening surgery. I have very high arches. The podiatrist now feel I have a very bad case of Achilles tendinitis. He feels that because I have very tight calf muscles lengthening the tendon might helps.

 What do you think about calf lengthening surgery?

 Or do you have any other suggestions for treating my Achilles tendinitis?

 What can you tell me about the Topaz procedure and it success or failure in Achilles Tendon repair?

Dr Blake's comment: Let me start out by saying that achilles tendons are very tricky to deal with. You simply look at an achilles the wrong way and it starts to hurt. And, every day you have pain in the achilles you lose up to 1% of your strength, so let us assume you have no strength in that achilles. The weaker and weaker the achilles gets, intensified by prolonged casting, by the time you had the second surgery your achilles is jello!!! And it will hurt if you use it. And you must get it strong again. Stay away from surgery if they are just guessing. If you lengthen the tendon, you will make it weaker. You know about force length curves!!!!  Your tendon must be so weak you can not even walk without straining it. Why was there no mention of tightness issue until now? 

     What do you think is going on now? Are the spurs finally gone? Is the tendon intact? Topaz is fine as a technique to repair, but did they do it correctly is a whole other question? But, if there was concerns, I hope they would have addressed that in the second surgery.

     Without further info, let us assume you have repaired the stuff you needed to have been repaired, and now you have a weak, tight, swollen, strained, fragile achilles on one side of your body and a strong healthy one on the other side. And you begin to rehab without more casts. You get orthotics that center your heel from a good orthotics guy/gal, you limit your activities to pain free as much as possible, you ice 5 to 10 minutes multiple times a day, you stretch and stretch and stretch (see my blog videos), and you find what strengthening you can do for the achilles that does not hurt, and you slowly get stronger, and stronger, and stronger over the next 12 months. 

     Since, no one bothered to look at the sciatic nerve as a possible cause or aggravating factor for you, definitely have a physiatrist look into this as one of your pain triggers. Why are people saying you hurt this much? Just tendinitis? 

     I hope this points you somehow in some direction that is good. I am sorry for your struggles. Rich Blake

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.