Treatment of the foot, ankle and Achilles tendon

The hindfoot is divided into the upper ankle joint and the lower ankle joint. With the help of these joints, lifting and lowering, inward and outward rotation of the foot is possible. The Achilles tendon is the thickest and strongest tendon we have. It attaches to the very top of the calcaneal tuberosity at the back.

Learn below how diseases of the foot, ankle and Achilles tendon become noticeable. What symptoms should you look out for and when is the best time to see a specialist? You can also find out what treatment options are available today and what rehabilitation can look like afterwards.

Foot diseases

Forefoot deformities are one of the most common diseases of civilisation. They are caused by genetic predisposition, but also by social influences such as wearing pointed, high-heeled shoes. The incidence of hallux valgus surgery has increased enormously with the spread of foot surgery.

Basics of hallux valgus

It should be noted that the indication for surgery must be clear. Cosmetic surgery or hallux valgus surgery at the onset of symptoms is completely unnecessary and will only lead to complications that will worsen the overall situation of the forefoot due to surgery that is not optimally successful.

What are the main indications for hallux valgus surgery?

The main indications for hallux valgus surgery are persistent pain in the hallux with frequent redness and the formation of a pseudoexostosis, as well as severe deformity. If the deformity is severe, the articular surfaces lose their congruence and become prone to arthrotic changes, which cannot be operated on to preserve the joint. The principles of hallux valgus surgery and the application of the various methods depend on the changes in the area of the deformity and the changes in the area of the big toe and the interphalangeal joint. Reconstruction is only successful if the bony correction is optimal (the lateral sesamoid needs to be reconsidered). Scientific studies have shown that soft tissue corrections are not permanent.

What surgical technique is recommended?

For simple hallux valgus, the chevron osteotomy is the operation that can be performed in a shortening length-preserving or lengthening technique for the first metatarsal, depending on the technique and the position of the entire forefoot. This very stable bone separation is usually only fixed with a small cribwire, which is removed after 4 weeks to ensure that no foreign bodies remain in the bone.

What about moderate misalignment? What techniques can be used?

A scarf osteotomy involves cutting the bone in a Z-shape, moving the head laterally and fixing it with 2 titanium screws.

The Ludlofosteotomy is an oblique separation of the bone in the proximal (closer to the body) part, with the distal (farther from the body) bone being rotated outwards into an anatomical position using the screw without shortening. Titanium screws are used, which sink into the bone and do not need to be removed.

What are severe deformities and what needs to be considered?

In cases of severe malalignment that have already resulted in arthrotic changes and instability of the base of the metatarsal to the proximal cuneiform bone, the only way to correct both the malalignment and the instability or arthrosis is to stiffen the foot in combination with an axis correction (Lapidus operation). In this case, the function of the forefoot is in no way compromised by the fusion. On the contrary, the restoration of the anatomically correct axes in particular eliminates considerable discomfort thanks to the additional gain in stability.

Why are soft tissue lifts performed?

Restoring the anatomical relationship between the sesamoid bones and the first toe is also important for cosmetically pleasing alignment. Soft tissue tightening is performed to reattach the sesamoid bones under the metatarsal head. In addition, in some cases where the toe is severely bowed, a small bone chip may need to be removed to restore a completely straight toe.

What kind of prosthetic shoes are available?

All patients are fitted with a so-called forefoot relief shoe, of which there are many suitable models. We have developed our own in conjunction with the Albrecht company which, unlike any other shoe, includes both a foot bed and a correction of the big toe and little toe to maintain a good post-operative position. It is also the only relief shoe that has an interchangeable sole, so that if the forefoot is still swollen after four weeks of relief, it can be used with a different sole.

Hallux rigidus means ‘stiff big toe’ and is caused by osteoarthritis in the metatarsophalangeal joint of the big toe. It not only hurts when you walk (rolling of the foot), but also leads to restricted movement. People often complain of pressure pain in the shoe and there is a bony deformity of the big toe.

How is hallux rigidus treated?

In the early stages of hallux rigidus, when stiffness and pain are present but the cartilage damage is still limited, surgery is very effective in preserving the joint. Unfortunately, it should be noted that wedgectomy alone, as often propagated, is by no means sufficient in the pathology, as the pathology has a significant causal relationship with the sesamoid bones with short flexors and the plantar capsule, the plantar release is crucial, as the mobility of the joint cannot always be optimised by wedgectomy alone.

What is an AMIC procedure and when is it used?

We are one of the few centres in the world to perform cartilage reconstruction using the AMIC procedure, as we do for knee, hip and ankle joints. This involves the application of a hyaluronic acid or collagen matrix with stem cells from the iliac crest by needle aspiration with a Jamshidi needle, almost like a lawn. After an ingrowth phase of 2-3 days, intensive mobilisation with a forefoot relief shoe is required for 6 weeks, which has to be carried out mainly by the patient. This technique has been in use for 3 years now and we can clearly see that it achieves significantly better and more sustainable results than wedgectomy alone.

When is arthrodesis (fusion) an option?

Complete osteoarthritis with total joint degeneration can only be made pain-free by arthrodesis and fusion surgery. It is important to note that the fusion is performed in the axis of the forefoot, with slight dorsiflexion, so that the patient can roll and swing. The idea that fusion results in a significant loss of walking and running function is not true. Many patients can even play tennis again after a well performed and optimally healed metatarsophalangeal fusion.

What are the indications for Freyberg-Koehler disease?

Special indications such as necrosis of the metatarsal head (Freyberg-Koehler disease) cannot be successfully treated a la longue with fusion or matrix grafting. In the early stages, we have recently introduced a new conservative treatment with growth factor injections, which in some cases has led to complete freedom from symptoms. If the head collapses due to necrosis, the only option is to reconstruct the entire head. This is done using a special technique involving a cartilage-bone graft from the caudal talus. This restores the proper contour of the joint, improving function and reducing pain.

As the name claw toe suggests, the toe is bent. This painful deformity is often associated with hallux valgus. The term hammer toe refers mainly to the joint at the end of the toe, which is noticeably bent.

What is the diagnosis of claw toe?

The misalignment of the little toes usually leads to painful bunion pain, or metatarsalgia, which is particularly distressing. Conservative treatment initially consists of orthotics and toe exercises to restore the mobility and elasticity of the flexor and extensor tendons of the little toes.

Patients are encouraged to exercise regularly on their own. In the case of persistent pain, hammertoes should be operated on with simple procedures that precisely correct the pathology. Due to extensive experience in revision forefoot surgery, many surgeons have a tendency to operate on all toes. Without going into detail, it must be said that the popular Weil osteotomies to correct metatarsalgia have repeatedly led to adhesions and so-called floating toes. In our opinion, this is only suitable for achieving optimal results in individual cases.

The principles of toe surgery often lie in the area of the overlong second toe, i.e. shortening of the PIP joint and additional arthrodesis as well as plantar release and release of the flexor and extensor tendons. This principle should be applied algorithmically for the individual severity of the pathology. If the 2nd ray is unstable, the plantar plate must be reconstructed.

A hollow foot (also known as pes cavovarus) is when the longitudinal arch of the foot is raised. In addition, the foot tilts outwards, which can quickly lead to strain on the foot ligaments.

How do you know if you have a hollow foot? When does it become a problem?

The main problem with a hollow foot is the inward rotation of the hindfoot, the high instep with overloading of the lateral column of the foot and, as a result, the problem that the outer ligament structures become unstable due to the incorrect position and the patient frequently twists the ankle. In addition, the steep inclination of the metatarsal bones shortens the extensor and flexor tendons, resulting in hammertoe, which naturally leads to considerable pain under the metatarsal head with callus formation due to the exposure of the metatarsal head.

What is the treatment approach?

The main therapeutic approach is to correct the alignment of the hindfoot. This is done by cutting through the bone around the heel to push the inwardly rotated hindfoot outwards. This will also bring the Achilles tendon back into its correct anatomical shape and the patient will no longer walk on the outer edge of the hindfoot but straight (plantigrade).

The second is that the heel bone is too high. This can be elegantly solved by cutting the heel bone using a technique we have developed.

The third is that the inclination of the first metatarsal in the forefoot, particularly in the area of the first ray if it is too steeply forward, is changed so that the foot strike becomes flatter. In order to eliminate this position once and for all and allow the big toe to push off without pain, the distal phalanx of the big toe must be stiffened to provide the necessary stability; in addition, in some cases, due to the high callosity and pressure under the feet, extensor tendon lengthening, osteotomies or osteotomies in the area of the metatarsals must be carried out, depending on the extent of the malposition.

What happens after surgery?

Because of the changes to the tendon and the tendon surgery, you will need to wear a plaster cast for 6 weeks, which can be used for partial weight bearing. If the situation is very stable, a forefoot relief shoe can be used, and as the change is usually bilateral, the operations must be carried out one after the other. Once one side has healed, surgery on the other side should begin after about a year, and once the treatment is complete, the patient can usually wear normal shoes again and straighten the foot, which is particularly comfortable when walking barefoot.

How do you recognise a flat foot?

A flat foot (pes plano valgus) is a lowering of the longitudinal arch of the foot. The deformity is usually associated with an outward rotation of the forefoot and an X-position of the hindfoot. As the condition progresses, hallux valgus and possibly hammer toes develop.

What causes flat feet?

This deformity is very often caused by a hereditary predisposition, as well as degenerative (inflammatory) changes to the tendons and ligaments that are important for straightening the longitudinal arch of the foot. Flat feet can also be the result of poorly healed, complicated fractures of the foot. In many people, these changes can last a lifetime without symptoms. If symptoms occur, an attempt should be made to treat them with insoles in the early stages. Severe deformities require surgery to relieve pain or prevent secondary osteoarthritis in other joints.

Depending on the severity, a distinction is made between
  1. Flexible flat foot: In this case, the deformity can still be returned to a normal position manually. These changes can still be corrected with hindfoot corrections, tendon and ligament surgery.
  2. Fixed flatfoot: In fixed flatfoot, the deformities cannot be corrected by the methods described above, especially as there are often significant osteoarthritic changes. Joint fusions must be carried out to achieve a normal position and thus freedom from pai

What exactly are heel spurs?

There are two different types of heel spur: One is the cranial variant, which forms above the heel bone, where the Achilles tendon attaches. The plantar variant affects the underside of the heel and therefore the plantar fascia. In both cases, pressure and traction – for example from incorrect footwear, one-sided stress, poor posture or obesity – cause the fascia (connective tissue on the foot) to become overstressed and ossify.

How do you notice a heel spur?

At first, hardly anyone notices a heel or calcaneal spur. It is only with increasing stress over time that inflammation of the fascia and surrounding tissues can occur. Bone proliferation also increases.

Eventually, the person feels a sharp pain in the heel and the sole of the foot. It can be very painful, especially when standing and under heavy weight. People also complain of pain when they get up in the morning and walking on hard surfaces becomes increasingly painful.

How is a heel or calcaneal spur diagnosed?

Experienced orthopaedic surgeons can feel a shortened plantar fascia from the bony prominence. X-rays provide additional information about the bony structure. Other imaging techniques, such as magnetic resonance imaging, are used to rule out other conditions such as gout or rheumatism.

Is there a non-surgical treatment?

Conservative treatment of plantar fasciitis consists initially of stretching exercises under the guidance of a physiotherapist. Special insoles, made to measure for the patient using foot pressure measurement, can provide relief. The inflammation is treated with various injections (e.g. ACP, hyaluronic acid, Botox, cortisone). Our foot specialists will be happy to advise you.

What if that doesn’t help?

If the symptoms persist despite conservative treatment, heel spur surgery should be considered. Heavily inflamed tissue can lead to a tear in the plantar fascia, in which case minimally invasive surgery is recommended to remove the inflamed tissue. The patient can usually put some weight on the foot immediately after surgery (1-2 weeks).

Ankle joint

How does joint wear and tear (osteoarthritis) develop in the ankle?

Because the ankle joint is exposed to a lot of stress every day, it is particularly susceptible to injury and wear and tear. Just walking puts seven times your body weight on the joint. This can lead to increased wear and tear on the cartilage, especially if the load is increased over time. Injuries or poor posture can also contribute to osteoarthritis.

What are the symptoms of ankle osteoarthritis?

Common symptoms include difficulty starting to walk, combined with a sharp pain and a resulting relieving posture. Walking on uneven ground also becomes difficult. It is no longer possible to roll properly and the ankle becomes stiff. Depending on the severity of the arthritis, the pain can get worse or become chronic.

How can osteoarthritis be treated conservatively?

The onset of wear and tear can be treated with physiotherapy, special insoles or hyaluronic acid injections. Autologous conditioned plasma  (ACP) is also an option. Medication may be used to relieve existing pain.

When does surgery need to be done and what are the best treatments for osteoarthritis?

Surgery is needed when conservative treatments do not work.

Arthroscopy – a gentle, minimally invasive procedure – provides a direct view into the joint. Any unstable cartilage can be removed, any growths on the bone can be removed and the cartilage can be smoothed.

Another procedure is a realignment osteotomy, where the leg axis is misaligned and causing wear and tear. By correcting the leg axis, it is possible to return to a natural position and relieve the affected part of the joint.

Artificial joints or fusion surgery (arthrodesis) may be considered in cases of advanced osteoarthritis.

When can I return to full weight bearing on the ankle?

Depending on the surgical technique, the ankle can be weight-bearing after three months. It is often necessary to rest the foot for eight to twelve months. Wearing an orthosis also helps to keep the joint immobilised for longer.

Shortly you will learn more about it here

When and how does a collateral ligament injury happen?

Frequent sprains of the ankle can lead to mechanical failure of the lateral ligaments, despite good treatment, so that the ankle joint cannot be stabilised properly and twisting occurs. This may initially only occur during sports activities, but can also occur with increasing instability when walking on uneven terrain or similar conditions. The frequent twisting of the ankle, which no longer causes massive swelling or severe pain, can of course lead to damage to the articular cartilage in the upper ankle joint, requiring reconstruction of the mechanical stabiliser.

It is particularly important for surgical technique that anatomical reconstructions are performed today. The tenodeses performed in the 1980s have shown that they lead to ankle arthrosis in the medium term due to the restriction of movement, so they are practically no longer performed.

Conservative or surgical – how should a collateral ligament injury be treated?

The lateral ligament complex consists of three ligaments (anterior, medial and posterior). In 98% of injuries (twisting traumas of the upper ankle), only single or double ligament injuries occur. Many international and in-house studies have clearly shown that surgical treatment of this injury does not produce better results than functional treatment, which is why our treatment concept is functional treatment with an orthosis (Aircast).

What is special about the Aircast ankle brace?

This orthosis restricts movements that are detrimental to ligament healing (e.g. supination). It must be worn for 5 weeks. The patient wears it in the shoe and can put full weight on it (i.e. can return to work after one week at the latest). The orthosis treatment is followed by a specific physiotherapy rehabilitation programme.

When is surgical intervention advisable?

In the case of particularly severe injuries with massive instability, an MRI scan is performed to rule out a triple ligament injury or cartilage injury. In these cases, we recommend a surgical procedure.

In the case of fresh collateral ligament ruptures, there is also a consensus among experts today that in the case of a 3-ligament lesion, i.e. rupture of all 3 ligaments, especially the posterior fibulotalar ligament, the chances of success are better with surgical treatment of such severe instability.

And what accelerates the healing process?

Our own experience with severe twisting traumas and lateral ligament ruptures in professional athletes shows that additional arthroscopic irrigation alongside surgical treatment leads to faster healing. On the one hand, because the haematoma is completely removed from the joint and, on the other hand, the entire joint can be viewed during this examination without any problems in order to detect and treat potential cartilage damage.

What about aftercare? What is important?

Aftercare for fresh surgical external ligament ruptures corresponds to conservative functional treatment after the wound has healed, treatment in an orthosis, e.g. an aircast splint, and without a plaster cast. From the 5th/6th week, follow-up treatment includes training of the peroneal muscles, which are always affected by this type of injury, as well as proprioceptive training (wobble board, etc.) in order to achieve a good muscular response to changes in joint position.

What are the two options for anatomical reconstruction?

Firstly, there is the Carlsson reconstruction. In this operation, the structure of the ligaments is relatively well preserved, but they are loosened so that they can be retracted into the bone. In addition, the joint capsule, which is also stretched by the constant twisting, can be tightened.

What are the two options for anatomical reconstruction?

Firstly, there is the Carlsson reconstruction. In this operation, the ligaments are relatively well preserved in their structure, but are loosened so that they can be pulled back into the bone. In addition, the joint capsule, which is also stretched by constant twisting, can be tightened.

The second method is periosteal flap plasty. In the second option, the joint structures are so reduced by the constant twisting that local reconstruction is not possible. In this case, the periosteum of the fibula is prepared for a new ligament, so that a new lateral ligament can be anatomically reconstructed, and the follow-up treatment consists of wearing a plaster cast for 14 days. If the reconstruction is stable, an orthosis (aircast or similar) can be used.

How are medial collateral ligament injuries treated?

In rare cases, instability can occur in the area of the deltoid ligament on the inside of the foot. The deltoid ligament is divided into 2 layers – a deep layer and a superficial layer. In this technically demanding operation, the individual ligaments have to be tightened.

The main problem for patients is bending and pain in the middle ankle. After the operation, a plaster cast is applied for 6 weeks. The injury is most common in competitive athletes, but can also occur as a result of a twisted ankle.

What injuries can occur in the upper ankle and how are they treated?

Scarring after an ankle fracture or ligament rupture, or even a simple ankle sprain, can cause pain and restricted movement in the upper ankle joint. Particularly in the joint between the outer ankle and the ankle bone, but also between the inner ankle and the ankle bone, these scar strands cause impingement syndrome, which can be easily removed by arthroscopic surgery using fine rotating knives and forceps, without opening the ankle joint through a large incision. Minor cartilage damage can also be repaired in the same operation, which means a much shorter rehabilitation period with an early return to work and sport, and prevents the development of osteoarthritis due to restricted movement.

What is anterior impingement?

Over the years, many athletes develop bony protrusions in the area of the front of the lower leg that make it painful to lift the foot (dorsiflexion) (e.g. when climbing stairs, running uphill) (medical term: “anterior impingement”). These bony projections can be removed arthroscopically using small ball burrs, restoring the ankle to its former pain-free mobility.

When is microfracturing of the upper ankle joint useful?

Localised cartilage damage in the ankle occurs as a result of accidents (e.g. fractures, ligament tears) or as a result of blood supply to the cartilage (osteochondrosis dissecans).

If left untreated cartilage destruction leads to progression to full ankle osteoarthritis. As described in the treatment of osteoarthritis of the knee joint, small holes (similar to a checkerboard pattern) can be made in the bone under the missing cartilage layer in the ankle joint using a pointed awl. This causes bleeding from the bone. Blood stem cells adhere to the microfracture site (superclot). When the upper ankle joint is unloaded (8 weeks) and moved with a motorised splint (CPM = continuous passive motion), these blood stem cells differentiate into fibrocartilage after a few months and fill the cartilage defect. This allows the patient to be pain-free and to regain normal mobility.

What is the state of the art?

In a prospective study with a 5-year follow-up, we found that the method produced good or very good results in 90% of cases. However, the cartilage damage should not be larger than 1 x 1 cm.

When is a cartilage-bone transplant performed?

Cartilage-bone transplantation of the upper ankle is used when microfracture has not been successful or when cysts have formed under the cartilage. In principle, cartilage-bone transplantation is also indicated in primary conditions with cartilage lesions and a cystic background.

What problems can occur?

The disadvantage of cartilage-bone transplants is that the grafts must be taken from a healthy knee joint. There is a risk of painful changes in the knee joint around the donor site. From our point of view, we are very reluctant to remove cartilage-bone grafts for the ankle joint from the knee. Overall, there is still a major problem in the scientific evaluation in that we have no long-term studies of more than 2 years on symptomatic complaints in the knee joint.

We only see an indication for our cartilage cell and matrix transplantation in individual cases, as the disadvantages outweigh the benefits.

What is chondrocyte transplantation?

Chondrocyte transplantation (cartilage cell transplantation) was developed by a Swedish research team. During an arthroscopy, a small piece of cartilage is removed from a non-weight-bearing area of the joint. The cartilage fibres are then removed using a special procedure and the cartilage cells are cultivated in a test tube. After about three to six weeks, the cartilage defect is sewn over with a periosteum in an open procedure. The cultured cartilage cells are then injected into the resulting pocket. Over the course of several months, new cartilage is produced that is very similar to natural cartilage. There are only a few centres in the world with experience of using this method on the ankle.

Why is there a problem with ACT in the ankle joint?

Autologous chondrocyte transplantation with a periosteal flap, as used in the knee, has not been successful in the ankle due to the anatomical conditions. The cartilage of the ankle bone (talus) is so thin that a periosteal flap cannot be sutured.

We are therefore one of the first clinics to use matrix-induced chondrocyte transplantation. This technique involves preparing chondrocytes in a kind of carpet (matrix). This carpet can then be placed in the defect of the talus bone.

We have been using this method since 2000 and the results have been good to very good. However, it must be said that we are still in the development phase, but it is already clear that there is great potential for significant therapeutic improvements, particularly in the case of cartilage damage in the ankle and/or other joints.

In 2007, we became the first clinic in the world to perform cartilage cell transplants on the upper ankle joint using a purely arthroscopic technique. Codon® spheroids are used to ‘seed’ the cartilage cells with a pipette. As this very new procedure is still undergoing clinical trials, we are currently restricting it to very young patients and competitive athletes.

Which method has proven most successful in recent years?

Both microfracture and competing techniques have limitations depending on the size and location of the defect.

In recent years, matrix grafting into the defect area has received increasing attention, especially as it no longer necessarily requires impregnation with autologous chondrocytes, as was the case with its predecessors. The use of an AMIC procedure in more than 300 patients over the last 5 years has shown consistent therapeutic success.

The use of a matrix to ‘seal the defect’ raised the question of whether the indication for cartilage reconstruction in the foot and ankle could be expanded. The proprietary technique of the AMIC procedure involves complete arthroscopic debridement. Microfractures are then performed, cysts are removed and filled with conditioned bone marrow aspirate. The matrix is then impregnated with growth factors, applied redundantly and sealed with fibrin. Precise cutting of the matrix is not required. In our experience, after a short healing period of 3-4 days, redundant, overlapping parts dissolve through movement. In addition, biosupplements such as conditioned bone marrow aspirate or platelet-associated platelet rich plasma were regularly used in the low leukocyte fraction (e.g. ACP). Initially, the focus was on expanding the indications to include reconstruction of larger defects in the talus. After these proved very promising, the AMIC procedure was extended to tibial plafond lesions.

What exactly is the lower ankle joint and what are its characteristics?

The lower ankle joint is the connection between the ankle bone and the bones of the tarsus and calcaneus. It is less mobile than the upper ankle. The lower ankle joint allows a slight lateral rolling movement and allows you to turn inwards and outwards.

What are the methods for treating ankle injuries?

Significant advances have been made with the development of our own range of instruments for arthroscopy of the smaller joints and new arthroscopic surgical techniques. The most common application for arthroscopy of the lower ankle joint is usually secondary to overlooked injuries to the talus or calcaneus, resulting in joint stiffness and pain. Particularly in very stiff lower ankle joints, removal of scar tissue and adhesions by debridement and cartilage stimulation by microfracture can significantly improve mobility and pain. This can delay or prevent stiffening.

What is tarsi syndrome?

Another application is for what is known as tarsi syndrome. This is a painful condition in the area of the lower ankle joint, especially after injuries such as ankle sprains or ankle fractures. Magnetic resonance imaging (MRI), x-rays and CT scans usually show no pathological changes. Arthroscopy of the lower ankle joint may reveal tears in the ligaments of the lower ankle joint, tears in the capsule and slight changes in the cartilage. We can then put an end to the patient’s often very long suffering with surgery.

What surgical techniques are used?

Arthroscopic and arthroscopically assisted surgery on the lower ankle is only performed by a small number of specialists. These include the following procedures

  • Arthroscopic debridement / lavage resection Sinus tarsi syndrome
  • Posterior impingement (Os trigonum syndrome)
  • Microfracture with chondrogides
  • Arthroscopically assisted lower ankle fusion
Achilles tendon

What is an acute Achilles tendon injury?

An acute Achilles tendon rupture usually happens during sports activities such as running or jumping. Sometimes, however, all it takes is for the foot to “stretch” or slip slightly.

What are the symptoms of a rupture?

A rupture (Latin: ruptura, ‘tear’, ‘break’) is a sensation of being kicked in the calf, sometimes accompanied by a cracking sound. The site of the rupture is usually in the middle of the Achilles tendon, but sometimes directly at the insertion or at the muscle/tendon junction. After the event, the patient is usually unable to push off with the foot when walking. There is often swelling and the formation of a haematoma, which can extend into the foot.

How is an Achilles tendon injury diagnosed?

An experienced orthopaedic surgeon can tell if the Achilles tendon is injured by palpating the surface of the skin. A dent can often be felt in the area of the rupture. When lying on the stomach, the foot is often in a flexed position of about 20° due to the tension on the tendon. This is no longer the case with a complete rupture and the foot hangs straight down. The so-called Thompson test (in the prone position) confirms a rupture if the sole of the foot does not move backwards due to compression of the calf.

Modern imaging techniques such as ultrasound and magnetic resonance imaging (MRI) help to make an accurate diagnosis.

How is an Achilles tendon rupture treated conservatively?

An acute Achilles tendon rupture can be treated conservatively with a therapeutic boot. With the correct indication and use of the therapeutic shoe, safe healing of the tendon is guaranteed, which is no worse than surgical treatment if the therapy is carried out correctly. The therapeutic shoe must be worn almost constantly. It is removed at night and replaced with a plaster splint in a toe position. The therapeutic shoe with integrated heel elevation must be worn for at least eight weeks. The patient should be able to perform the treatment correctly in the shoe for a period of eight weeks, as interrupting the treatment in the shoe can lead to treatment failure.

Conservative treatment must be carefully considered. In particular, an ultrasound scan must show complete adaptation of the tendon ends when the foot is flexed. These scans should be repeated at four and eight weeks to monitor healing.

How is an Achilles tendon rupture treated surgically?

Open suturing of the tendon is still the standard procedure, but this carries an increased risk of complications such as infection or increased scarring. We always operate on an Achilles tendon rupture using a minimally invasive technique, which provides both a secure fit for the torn tendon ends and a degree of mechanical stability.

This allows us to reduce pain, minimise scarring, speed up rehabilitation and generally reduce post-operative complications.

As with conservative therapy, post-operative treatment requires the wearing of a therapeutic shoe with heel elevation. The degree of elevation and the length of time the shoe must be worn will be determined on an individual basis. Physiotherapy and lymphatic drainage begin immediately after surgery. An individualised treatment plan helps the patient and therapist to ensure optimal rehabilitation.

After eight weeks, ultrasound should be used to check good normal healing. As the healing process continues, an individualised exercise programme is carried out, including training to strengthen the calf muscles and improve proprioception and coordination. The total rehabilitation time is usually 5-8 months.

When do we talk about a chronic Achilles tendon rupture?

A chronic rupture can occur as early as four weeks after an acute rupture. It can also develop gradually as a result of degenerative processes. Misdiagnosed acute ruptures with incorrect treatment are often the cause. Retraction of the tendon ends with the formation of a “gap” between the tendon ends is always problematic. Over time, an inadequate scar forms, leading to a significant loss of strength.

How does chronic rupture manifest itself (symptoms)?

The main symptom of a chronic Achilles tendon rupture is a loss of strength with an impaired ability to walk. It is no longer possible to stand on tiptoe on one leg. Pain usually plays a secondary role.

How is a chronic Achilles tendon rupture diagnosed?

Diagnosing a chronic Achilles tendon rupture is generally much more difficult than diagnosing an acute rupture. The clinical examination is not uniform and therefore requires a detailed medical history. The gait pattern is often limping with a lack of foot strike in the push-off phase of the gait cycle. The one-legged toe-to-toe stance is no longer possible. In the prone position, the foot often hangs straight down. In the so-called Thompson test, compression of the calf results in a weakened or absent posterior plantar movement. When the calf muscles are relaxed, the foot can be moved upwards more than on the opposite side.

Modern imaging techniques, such as ultrasound/sonography and magnetic resonance imaging (MRI), help to make an accurate diagnosis.

How is a chronic Achilles tendon rupture treated surgically?

Surgical treatment depends on the extent of the injury. A healed chronic rupture is a special case in which the tendon ends have healed with sufficient tissue, so there is no disruption in the contour of the tendon, but there is a significant strength deficit due to the lengthening of the muscle-tendon complex. In this case, the tension of the muscle-tendon complex can be restored by shortening the tendon.

For smaller defects, the tendon ends can be rejoined in a minimally invasive procedure similar to an acute rupture. Larger defects require a replacement graft, e.g. using the semitendinosus tendon to connect the retracted ends of the Achilles tendon or using the flexor hallucis longus tendon with refixation to the calcaneus. Whenever possible, this technique is performed using a minimally invasive approach, as the risk of complications is significantly higher than in the case of an acute rupture due to the frequent defect situation, the poor blood supply to the tendon and surrounding soft tissue, and the frequent need for revision.

What does the follow-up treatment look like?

Once the wound has healed safely, the patient will need to wear a therapeutic shoe with a raised heel. The amount of elevation and the length of time the shoe is worn will be determined on an individual basis. Physiotherapy and lymphatic drainage begin immediately after surgery. A personalised treatment plan helps the patient and therapist to ensure optimal rehabilitation. Regular ultrasound scans are used to monitor tendon healing. As the healing process continues, an exercise programme is followed to strengthen the calf muscles and improve proprioception and coordination. The whole rehabilitation programme usually takes 6-9 months.

Achillodynia is the general term for pain in the Achilles tendon. Achillodynia is a disorder of the tendon. The pain is usually concentrated in the middle part of the tendon or where it attaches to the heel bone.

What is Achilles tendinopathy and what are the symptoms?

Achilles tendinopathy is a painful, acute or chronic condition in the area where the Achilles tendon meets the heel bone.

Midportion tendinopathy is characterised by a painful thickening of the Achilles tendon in the middle (midportion area of the Achilles tendon). Endurance athletes are often affected, but it can also occur in non-athletes.

Typical symptoms are pain on starting after resting (e.g. after getting up in the morning) and pain on prolonged weight-bearing, especially if there has been no weight-bearing or no (more) starting pain for a long time. The intensity of the pain is variable and often occurs in phases with periods of less discomfort, which can then increase sharply to pain at rest.

This is usually caused by micro-injuries with a disturbed regeneration process. As part of the healing response, vessels (neovascularisation) sprout, accompanied by nerves, which ultimately manifest the painfulness of the change. There is also swelling of the surrounding tendon and soft tissue. The affected swollen part of the tendon is usually painful to pressure.

How is Achilles tendinopathy diagnosed?

In addition to the medical history, the clinical examination is the most important part of the diagnosis. Possible causes, such as foot deformity, should also be identified. Manual examination is used to detect pain to pressure, stiffness, interruption of continuity or crepitation.

Modern imaging techniques such as ultrasound and magnetic resonance imaging (MRI) can help to make a more accurate diagnosis. If the foot is misaligned, an x-ray may also be helpful.

How is Achilles tendonitis treated conservatively?

Conservative treatment is always the first line of defence for Achilles tendinopathy. For acute inflammatory swelling, the usual measures of cryotherapy and analgesia are used. Stress should also be reduced.

In the case of acute inflammatory swelling, the usual measures of cryotherapy (application of cold) and analgesia (pain therapy) are also used. Activity should also be reduced. Physiotherapy with stretching and so-called eccentric training, extracorporeal shock wave therapy and peritendinous injections with a PRP preparation (platelet rich plasma) are particularly promising in the course of the disease.

Physiotherapeutic measures (also necessary on the patient’s own initiative) form the basis of therapy. Extracorporeal shock wave therapy (ESWT) uses high-energy pressure waves. By activating self-healing processes, regeneration is stimulated with remodelling of the Achilles tendon. The treatment takes about 5 minutes and is performed three to six times at weekly intervals.

Injections of a PRP preparation (autologous blood therapy) may be given at the same time as or during treatment. For more information, see the Conservative Therapy section of our website. Typically, three to six injections are given one week apart.

How is Achilles tendonitis treated surgically?

If conservative treatment is unsuccessful, surgery on the Achilles tendon is an option. The operation is minimally invasive, often assisted by endoscopy, and consists of debridement: Firstly, the ingrown vessels and nerves are removed, and secondly, the so-called peritendineum (a loose fibrous sheath of connective tissue) is removed. In addition, degenerative changes in the tendon, which can be seen on MRI, are removed.

In simple cases without severe tendon weakness, only a short period of partial weight-bearing over two weeks is required, followed by a gradual increase in weight-bearing. Physiotherapy and lymphatic drainage begin immediately after surgery. A personalised treatment plan helps the patient and therapist to ensure optimal rehabilitation. Regular ultrasound scans are used to monitor tendon healing. As the healing process continues, an exercise programme is followed to strengthen the calf muscles and improve proprioception and coordination. The whole rehabilitation programme usually takes 4 to 6 months.

How does pain at the insertion of the Achilles tendon manifest itself (symptoms)?

Approximately 20-25% of patients with Achilles tendinopathies experience pain at the insertion of the Achilles tendon. The symptoms are often a mixture of Achilles tendinopathy and bursitis. The cause is usually a prominent bony prominence of the calcaneus, also known as Haglund’s exostosis or posterior heel spur.

Typical symptoms are initial pain after rest (e.g. getting up in the morning) and pain on exertion after prolonged exercise, followed by a period of minimal or no pain after the initial pain has disappeared. The intensity of the pain varies and often progresses in phases with periods of mild pain and periods of severe pain, including pain at rest. Due to the widening of the heel and the localised pressure pain, the choice of footwear is often limited by the pressure on the heel.

How are Achilles tendon insertion problems diagnosed?

In addition to the manual clinical examination, which is typically accompanied by tenderness in the area of the Achilles tendon insertion, imaging is of particular importance.

The bony changes are shown on an X-ray, preferably a digital volume tomography (DVT) scan. Calcifications at the insertion of the Achilles tendon can also be better detected in this way; this is known as calcified insertional tendinopathy of the Achilles tendon. Sonography and magnetic resonance imaging (MRI) help to make an accurate diagnosis.

How are Achilles tendon insertion problems treated conservatively?

Conservative treatment is always the first line of defence for Achilles tendon insertion problems. For acute inflammatory swelling, the usual measures of cryotherapy (cooling) and analgesia (pain relief) are used. Activity should also be reduced. Adjusting footwear to avoid pressure on the affected areas is also an effective measure.

Physiotherapy, such as stretching and eccentric training, extracorporeal shock wave therapy (ESWT) and injections (around the tendon or into a bursa) with a platelet rich plasma (PRP) preparation are promising. Overall, the success rates are lower than for medial Achilles tendinopathy, particularly in the presence of severe bony changes and calcification of the tendon.

Physiotherapy (also on the patient’s own initiative) forms the basis of therapy. Extracorporeal shock wave therapy uses high-energy pressure waves. By activating self-healing processes, regeneration is stimulated with remodelling of the Achilles tendon. The treatment takes about 5 minutes and is performed 3-6 times at weekly intervals.

PRP injections (autologous blood therapy) can be performed simultaneously or during the course of treatment. Usually 3-6 injections at weekly intervals are sufficient.

How is Achilles tendon pain treated surgically?

Achilles tendon pain can be treated surgically if conservative treatment has failed. The type of surgery depends on the pathology.

For example, Haglund’s exostosis with concomitant bursitis and mild insertional tendinopathy of the Achilles tendon can be treated by a minimally invasive approach with endoscopically assisted resection of the pathological tissue. In simple cases where there is no severe weakening of the tendon, only a short period of partial weight-bearing for two weeks is required, followed by a gradual increase in weight-bearing. The rehabilitation period in this case is usually 4-6 months.

If the tendon insertion is affected by calcification and a posterior heel spur, the Achilles tendon will usually need to be partially or almost completely detached from its insertion in order to safely and completely remove the structures causing the problem.

As the tendon then needs to be reattached to the heel bone, follow-up treatment is based on the same rehabilitation measures that are used for Achilles tendon ruptures.  After the wound has healed, the patient will need to wear a therapeutic shoe with a raised heel. The degree of elevation and the length of time the shoe must be worn are determined on an individual basis. Physiotherapy and lymphatic drainage begin immediately after surgery. A personalised treatment plan helps the patient and therapist to ensure optimal rehabilitation. Regular ultrasound scans are used to monitor tendon healing. As your recovery progresses, you will be given an exercise programme, which may include strengthening exercises for the calf muscles, as well as proprioception and coordination exercises. The whole rehabilitation programme usually takes 5 to 8 months.

Further therapy options

In orthopaedics, conservative therapy refers to the non-surgical treatment of joint problems and diseases of the musculoskeletal system. We use a variety of treatment approaches. These include:

  • Cryptotherapy
  • Chirotherapy
  • Shock wave therapy
  • Medication (for pain and inflammation)
  • Trauma relief with orthotics
  • Injection and enzyme therapy (with hyaluronic acid, ACP, PRP, APC)
  • Functional aftercare for early return to work and sport

Contact us, we will be happy to advise you.

What to look out for when having an ankle arthroscopic procedure?

The arthroscopy of the upper ankle joint is in fact a very special technique. Due to the narrowness of the joint and the technical requirements, it is only performed by specialists. Our centre has many years of experience. Over the past 25 years, almost 100 arthroscopies of the ankle joint and arthroscopic reconstructions of cartilage damage have been carried out every year. That makes the International Centre for Orthopaedics one of the world’s leading experts.

The majority of cases are osteochondral lesions, which are local cartilage damage, usually on the medial side of the joint, but also throughout the joint.

How to treat the ankle joint?

An ankle joint can be treated with either an AMIC procedure (insertion of a matrix containing iliac crest stem cells and growth factors) or an autologous chondrocyte transplant (ACT). The success rate is very high at over 90%, especially in younger people.

We also do revisions and major defects because of our experience with AMIC matrix transplantation. For the first time, we have performed endoscopic reconstruction of defects in the tibial plateau or combined defects in the form of kissing lesions of the talus and tibial plateau.

The treatment requires partial weight bearing for 8 to 10 weeks. The ankle must be in continuous motion, either independently or with a continuous passive motion (CPM) machine. Growth factors (ACP) are injected at 2-4 week intervals to aid the healing process.

When is an arthroscopy performed?

Indications include post-traumatic arthrofibrosis, often also tissue stiffening after fractures, removal of anterior ossifications – in competitive athletes such as basketball and volleyball players also diseases of the synovia.

What is meant by fusion (arthrodesis) of the ankle joint?

The arthroscopic technique allows for arthrodesis (fusion). Endoscopic debridement and percutaneous screw fixation is used in the upper ankle. If arthrodesis is indicated, it is possible in 80% of cases using our endoscopic debridement and percutaneous screw technique (4 small stab incisions). The advantages of this technique are the very low morbidity, the low risk of infection and the very rapid healing of the bony fusion. Only in cases of large defects in the area of the talus or tibial plateau is an open technique with screws and plating applied.

What does “posterior endoscopy” actually mean?

Posterior endoscopy was introduced in 1992 by Nick van Dijk. This technique has been used in our centre since 1994 following early visits to Amsterdam. It is now standard practice. For the first time, cartilage damage to the lower ankle joint was reconstructed arthroscopically using posterior endoscopy at our centre a few years ago. We are using autologous matrix-induced chondrogenesis (AMIC for short). Only the AMIC procedure with stem cells from the iliac crest was able to show satisfactory clinical results in the treatment of subtalar cartilage damage. Only a few experts worldwide specialise in this arthroscopic technique. The follow-up treatment is the same as for AMIC procedures of the upper ankle joint.

What is the procedure for ankle endoscopy and which approaches are used?

Depending on the location of the cartilage damage, the defect is treated using lateral (anterior) endoscopy and arthroscopy. Here, so-called auxiliary posterior approaches are used, but also approaches partially under the fibula for an optimal view into the joint, which is very difficult to arthroscope. This allows cartilage reconstruction or removal of scars and ossifications.

Osteoarthritis of the lower ankle joint often occurs in post-traumatic calcaneus fractures or as a result of instability, flat feet or after endoprosthesis implantation, as a consequence of further osteoarthritis development.

We generally perform lower ankle joint fusion almost exclusively using posterior arthroscopy with joint debridement and screw fixation. This is a very gentle procedure. It involves adding bone chips from the tibial plateau as well as stem cells with bone marrow from the posterior iliac crest via needle aspiration. This provides biological reinforcement and a faster healing process with regard to fusion.

What are the benefits of arthroscopic treatment?

Patients have almost no pain with the arthroscopic technique and can quickly mobilise the upper ankle joint further with partial weight-bearing in a short walker (orthosis).

There are two different foot deformities: pes planovalgus (better known as flatfoot). This implies an X position of the hindfoot. This means that there is an unnatural outward longitudinal arch. As a result, the entire sole of the foot lies flat on the ground. The opposite is pes cavovarus (hollow foot) with an O-position of the hindfoot, which means that there is a particularly pronounced arch of the foot.

What happens over time with improper weight bearing?

Due to the anatomical and kinematic changes of the ankle, the cartilage of the talus becomes “worn out”. This refers to damage to the cartilage and a deep defect in the area of the talus and the plafond of the tibia.

What can be done to prevent ankle osteoarthritis?

To prevent complete destruction of the upper ankle joint due to irreversible osteoarthritis, the patient must undergo corrective osteotomy to restore the natural axis at an early stage. This is the only way to reduce the stress on the affected part of the joint.

What is the best age to have an osteotomy?

Joint-preserving osteotomy is especially recommended for middle-aged patients (between 40 and 55 years of age). A corrective osteotomy eliminates the need for an artificial joint by correcting the joint axis. Endoprosthetic treatment of the upper ankle joint does not have the same longevity and results as hip or knee replacement and is not recommended for patients in this age group.

What is the goal of a foot osteotomy?

The goal of a realignment osteotomy (or corrective osteotomy) is to reduce cartilage damage. This is caused by axial misalignment, which results in asymmetrical pressure distribution on the cartilage. In some cases, additional soft tissue procedures may be needed, such as ligament reconstruction or tendon transfer.

When is surgery necessary?

Corrective surgery is indicated for symptomatic deformity and asymmetric osteoarthritis. In cases of advanced osteoarthritis with medial or lateral joint space widening, the previous osteotomy can restore a straight hindfoot axis. This can be done even if joint-preserving surgery (osteotomy with cartilage reconstruction) fails.

Osteotomy is not indicated in severe instabilities with pronounced neurological deficits and various systemic diseases or in advanced severe osteoarthritis.

What is ankle arthroplasty (endoprosthetics)?

In the next few years, ankle arthroplasty will become a standard indication for osteoarthritis of the upper ankle. The International Center for Orthopaedics is playing a major international role in establishing these standards. A wide variety of prostheses are now available on the European market. The most important scientifically tested prostheses are used in our center.

Based on our experience, we believe that no single prosthesis can be used for all changes in ankle arthrosis. That is why we make a distinction. We decide which prosthesis to use for which patient on an individual basis.

What exactly is a talus shoulder replacement?

Although the name may sound confusing, the talus is part of the ankle bone (not the shoulder joint). The talus is located between the medial and lateral ankle bones. Accordingly, the talus shoulder prosthesis is characterized by the fact that it has a cap, according to which the talus is cut and then inserted and fixed in various shapes. Obviously, the implantation of such a prosthesis requires the presence of a corresponding talus shoulder. However, there are a number of cases in which the talus shoulder is no longer present in sufficient form due to the progression of osteoarthritis or other conditions. In these cases, implantation of a talus cap prosthesis is not appropriate.

Why is it so problematic?

A critical aspect of prosthesis use is the change in the lower part of the leg bone (tibial plateau). All prostheses on the market are no longer implanted with cement. Therefore, conditions must exist that make it likely that the prosthesis will grow into the bone. In our opinion, this type of prosthesis is problematic, especially in cases of severe comminuted fractures of the lower leg with bone defects (pilon fractures) and severe circulatory disorders of the bone of any kind. We doubt that a good bone-prosthesis bond can be achieved.

What other prostheses are available?

To increase the stability of the tibial component, there are prostheses that have a flat support on the tibia, as well as a stem that is incorporated into the tibia to increase stability. These prostheses are certainly useful in tibial plateau defects. They provide greater mechanical stability similar to revision knee arthroplasty.

In our opinion, a different type of prosthesis should be used in this case. This type of prosthesis is designed with a flat incision in the talus and then a component is placed on top of the flat incision. We call this an onlay prosthesis.

Talus onlay prosthesis – what are the latest developments?

Since November 2004, we have been one of the first clinics in Europe to perform the latest development in ankle arthroplasty. The advantages of the new prosthesis are greater precision in the centering of the lower leg component (tibial component) compared to the ankle component (talar component).

What are the results?

The first implantations show a very good restoration of ankle mobility. The prosthesis ensures a very secure and stable ingrowth into the bone thanks to the surface coating, which is a porous coating (ingrowth into porous surfaces through the bone) as opposed to the hydroxyapatide coating used previously.

When does an ankle prosthesis become loose? What needs to be considered?

Particularly in defect situations and in situations where a conventional prosthesis has loosened, it is now possible to treat defect situations with a stem prosthesis in the tibial region and with a coupled prosthesis (Agility air) and thus to avoid arthrodesis (fusion). The latter prosthesis requires a very large bone resection, so in our opinion it is not suitable for primary implantation, but can be used for defects or in revision situations.

How will ankle arthroplasty develop over the next few years?

The outlook for ankle arthroplasty is very promising. With the increasing number of ankle replacements being implanted, there is a growing interest in the industry to invest in research, so that in the next 5-10 years ankle arthroplasty will certainly be the standard of care for the treatment of osteoarthritis of the upper ankle.