The Achilles tendon connects the calf muscles to the heel bone (calcaneus). When this structure is compromised, typically through a sudden, acute rupture or long-term, painful degeneration called chronic tendinosis, surgical intervention may be required to restore strength and mobility. The specific procedure chosen depends heavily on the nature, severity, and duration of the injury. There are three distinct surgical approaches tailored to address the different types of damage affecting the Achilles tendon.
Repairing Acute Achilles Ruptures
The first category of surgery addresses a complete, sudden tear of the tendon, known as an acute rupture. The primary goal is to physically sew the two torn ends back together to facilitate proper healing. This approach is reserved for recent tears where the tendon tissue quality is good and the gap between the torn ends is minimal.
Two main techniques are used for acute repair: open repair and minimally invasive repair. Open repair involves a single, larger incision made along the back of the leg, which provides the surgeon with direct visualization of the tendon ends for a strong, anatomically precise repair. While this method offers a highly secure connection with a low re-rupture rate, the larger incision can carry a higher risk of wound healing complications or infection.
Minimally invasive, or percutaneous, repair uses several small incisions or punctures to pass sutures through the skin and weave them into the torn tendon ends. This technique reduces the risk of major wound issues and can often lead to a quicker recovery time and smaller scarring. However, because the repair is done without direct visualization, there is an increased risk of injury to the sural nerve, which runs close to the Achilles tendon.
Addressing Chronic Tendinosis Through Debridement
The second surgical approach addresses chronic degeneration, known as Achilles tendinosis. This condition results from long-term overuse, causing the tendon to become thickened, painful, and contain damaged tissue. The procedure involves debridement, which is the surgical removal of the diseased, calcified, or scarred tissue within the tendon.
If the tendinosis affects the point where the tendon attaches to the heel bone (insertional tendinopathy), the procedure is more complex. The surgeon may need to temporarily detach the tendon from the calcaneus to remove bone spurs, such as Haglund’s deformity, and excise the damaged tissue. The healthy tendon must then be securely reattached to the heel bone, often using specialized suture anchors.
The extent of the damage dictates whether the tendon can be left partially intact or requires full reattachment. Surgeons aim to remove all unhealthy tissue to allow the remaining healthy tendon to heal properly.
Complex Reconstruction Using Tendon Transfers
The third type of surgery is reserved for the most challenging cases, typically involving large, chronic defects, neglected tears, or re-ruptures. In these situations, simple end-to-end repair or debridement is not possible because the gap between the remaining tendon ends is too large to bridge without excessive tension. The remaining tendon tissue is often of poor quality, requiring a more robust solution.
To reconstruct the tendon and restore function, the surgeon must use supplementary tissue, most commonly involving a tendon transfer. The Flexor Hallucis Longus (FHL) tendon, which controls the movement of the big toe, is frequently selected for this purpose. The FHL tendon is harvested through an incision and then rerouted and anchored into the heel bone, effectively creating a new or significantly reinforced Achilles tendon.
The FHL is an ideal candidate because it provides significant local tissue, and its absence causes only a minor loss of strength in the big toe. By anchoring the transferred tendon into the calcaneus and weaving it into the remaining Achilles tissue, the surgeon restores the power necessary for ankle push-off. This complex reconstructive effort may involve grafts or synthetic materials to bridge defects that can measure up to six centimeters or more.
The Road to Recovery After Surgery
Recovery follows a progression focused on protecting the repair and gradually restoring function. The initial post-operative phase involves strict immobilization, where the foot is held in a cast or splint in a downward-pointing position for the first two weeks to minimize strain. During this time, the leg is kept non-weight-bearing, requiring the use of crutches or a knee scooter for mobility.
Around the two to four-week mark, patients usually transition to a controlled ankle motion (CAM) boot, often equipped with removable heel wedges. These wedges are gradually taken out over several weeks to slowly allow the ankle to move closer to a neutral position without overstretching the healing repair. This phase marks the beginning of partial weight-bearing, which progresses as the tendon demonstrates sufficient strength and the surgeon permits.
Physical therapy is essential for the intermediate and late recovery process, starting within the first few weeks to regain flexibility and prevent scar tissue formation. Therapy intensifies over time, incorporating exercises for strength, balance, and gait retraining to address muscle atrophy from immobilization. A full return to high-impact activities like running or sports generally takes between six to twelve months.