Conservative and Surgical Treatment of Achilles Tendinopathies

Inflammation, degeneration, and ruptures of the Achilles tendon are common afflictions for people of all ages, ranging from athletes and other active individuals to chronic conditions in older people. Surgeons at HSS at NYP Weill Cornell Medicine Orthopedics and Physiatrists in the Department of Rehabilitation Medicine at Weill Cornell Medicine take a collaborative approach to the management of Achilles tendinopathies, offering comprehensive evaluation and in-office diagnosis as well as nonsurgical treatment modalities and surgical repair of ruptures.  

Diagnosing the Cause of Achilles Pain 

When we first see a patient with pain or instability in the Achilles tendon area, one of our physicians performs a comprehensive assessment that includes: 

  • Medical history to ascertain symptoms and what the patient was doing when the discomfort began. Pain and swelling behind the ankle are the most common symptoms. 
  • Physical examination of the foot and ankle to check for a tear. The doctor may perform the Thompson Test by squeezing the calf muscle. If the foot does not move downward with this maneuver, the Achilles is not attached to the muscle, indicating a ruptured tendon. 
  • Ultrasound diagnosis during the office visit to visualize the tendon and determine the location of injury. Ultrasound is useful for assessing the early stages of chronic tendinosis and to determine if microtears are present. 
  • MRI may be ordered to confirm a suspected tear and provide additional information to guide surgical repair. 

Treating a Ruptured Achilles 

Not all Achilles tendon tears are treated with surgery. Older patients as well as smokers and those with diabetes are more likely to be treated with nonsurgical interventions. Surgical repair is individualized and is typically reserved for people with: 

  • Acute complete and high-grade partial tears. 
  • Active and healthy adults with tears resulting from chronic tendinosis — enabling them to get back to their desired activities.  
  • Patients with insertional tears (an injury where the tendon meets the calcaneus). 
  • People with Achilles pain that persists despite nonsurgical treatments. 

The choice of an open versus minimally invasive surgical approach depends on the location of the injury and the condition of the tendon. During minimally invasive Achilles tendon surgery, the repair can be accomplished through a one-inch incision.  

For insertional tears, the surgeon cleans out the diseased areas and uses suture anchors to repair and reconnect the tendon directly to the calcaneus. For non-insertional ruptures, the surgeon cuts and reconnects the ends of the torn tendon. 

The operation is performed on an outpatient basis using regional anesthesia. Patients will be non-weightbearing and use crutches for 3-4 weeks, followed by physical therapy. Full resumption of all activities may take 6-9 months. 

Nonsurgical Therapies for Achilles Tendinopathies 

Whenever possible, we try to treat Achilles tendon injuries and chronic tendinosis using targeted physical therapy (ice massages, stretching, strengthening exercises, and correction of alignment problems) to reduce load on the tendon and relieve pain. Physical therapy may be accompanied by other surgery-free approaches such as: 

  • Shock wave therapy. Use of sound waves applied to the injured area to trigger a healing response in people with mild tendinosis. 
  • Platelet-rich plasma (PRP). Injections of a concentration of a patient's own platelets to promote healing of the injured tendon in people with moderate to severe tendinosis. 
  • Minimally invasive debridement. With the Tenex procedure, a large-gauge needle probe is guided by ultrasound to remove scar tissue from the tendon while sparing healthy tissue. This treatment is performed on an outpatient basis in a procedure suite with a local anesthetic. We may combine it with PRP and/or shockwave therapy in specific cases. 
  • Corticosteroid injections are NOT advised for treatment of Achilles tendinosis, since they may actually raise the risk of a rupture. 

After all treatments, patients wear a stabilizing boot to maintain proper positioning of the foot and ankle and allow the tendon to heal without shortening. 

Referring a Patient 

When you refer a patient to HSS at NYP Weill Cornell Medicine for Achilles pain treatment, they will be seen by either a physiatrist or orthopedic surgeon. Physiatrists oversee nonsurgical treatments, and our surgeons perform tendon repairs. Contact us at 212-746-4500 to refer a patient.