Achilles Tendon Lengthening (ATL) surgery is a procedure designed to increase the length of the tendon connecting the calf muscles to the heel bone. This surgery is typically necessary when a condition, such as Achilles contracture, causes the tendon to become too tight, preventing the foot from moving upward normally. The inability to fully lift the foot can lead to complications like foot drop, chronic pain, or difficulty walking flat-footed. ATL involves making controlled cuts in the tendon—either through small stab incisions (percutaneous) or a larger incision (open Z-plasty)—to allow it to stretch and heal in a lengthened position.
Anesthesia and Pain Prevention During Surgery
Surgeons often combine general anesthesia, which keeps the patient asleep, with regional anesthesia techniques that specifically numb the surgical area. A common approach involves an ultrasound-guided nerve block, such as a popliteal or ankle block, where a local anesthetic is injected near the nerves supplying the lower leg.
The primary purpose of this regional block is to provide pain relief that extends well beyond the operating room. The anesthetic agent keeps the surgical site completely numb for an initial period, typically lasting between 12 and 24 hours post-surgery. This targeted pain prevention allows the patient to awaken from general anesthesia with a significantly reduced, or even absent, sensation of immediate surgical pain, effectively managing the first day of recovery.
Expectations for Acute Post-Operative Pain
Once the regional nerve block begins to wear off, usually between 12 and 36 hours after the procedure, patients will experience the onset of acute post-operative pain. This pain is a direct result of the surgical trauma to the soft tissues and the intentional lengthening of the tendon. In the first 48 to 72 hours, the pain level can be significant, often requiring powerful prescription pain medication to keep it manageable.
Standard pain management protocols involve using opioid analgesics for the initial period of high pain, which usually lasts about three to five days. It is important to transition away from these prescription medications as quickly as possible, moving to over-the-counter options like nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.
Swelling is a major contributor to pain, and managing it is done through consistent elevation of the affected limb above the level of the heart. Applying ice packs to the surgical site for 15 to 20 minutes is another effective strategy to reduce swelling and numb the area. This combination of rest, elevation, and cold therapy works alongside medication to suppress the inflammatory response. While the pain is expected to be highest in the first few days, it should gradually and noticeably decrease over the course of the first week as the body begins the healing process. Patients are typically kept immobilized in a cast or boot for several weeks, which also helps to control movement that could otherwise trigger pain.
Discomfort During the Rehabilitation Phase
After the initial acute pain subsides, the patient enters the rehabilitation phase, where a different kind of discomfort begins. This phase is marked by stiffness, deep soreness, and a sensation of tightness, rather than the sharp pain of a fresh surgical incision. Physical therapy (PT) is introduced to restore strength and range of motion, and it may intentionally cause a sensation of stretching discomfort.
During PT sessions, the therapist works to regain the ankle’s ability to flex upward. This necessary stretching of the newly lengthened tendon and surrounding muscles can feel like a deep ache or a burning sensation, especially as the patient begins to bear weight or perform exercises. This discomfort is a sign of progress, indicating that the soft tissues are adapting to their new, longer state.
Patients may also experience tingling, numbness, or a persistent burning feeling along the incision site. These sensations are often related to the healing of small nerve endings or pressure caused by internal swelling or scar tissue formation. While this type of discomfort can be alarming, it is a common occurrence in the months following surgery. Consistency in physical therapy and adherence to a home exercise program are the primary methods for managing this long-term discomfort, which typically improves gradually over several months as the tissues mature and strengthen.