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

Shortly you will learn more about it here

Shortly you will learn more about it here

Shortly you will learn more about it here

Shortly you will learn more about it here

Shortly you will learn more about it here

Ankle joint

Shortly you will learn more about it here

How does joint wear (arthrosis) occur in the ankle joint?

Because the ankle joint is subjected to high stress on a daily basis, it is particularly susceptible to injury and joint wear. One’s own body weight has a sevenfold effect on the joint when walking alone. This can lead to increased wear and tear of the cartilage, especially if a higher load occurs over a longer period of time. Injuries or poor posture can also increase the risk of arthrosis.

What are the typical symptoms of arthrosis in the ankle joint?

Common symptoms are difficulty getting started, associated with stabbing pain. The affected person automatically adopts a protective posture. Walking on uneven ground also makes problems.The foot can no longer roll correctly and the ankle joint stiffens. Depending on the severity of the arthrosis, the pain can increase in intensity or become chronic.

How can arthrosis be treated conservatively?

The first signs of wear and tear can be treated with the help of Physiotherapy, special shoe inserts or injections of hyaluronic acid. Autologous blood therapy is also an option. To alleviate existing pain, therapy with medication is recommended.

When is surgery advised and what therapeutic methods are useful for arthrosis?

Surgical measures are necessary when conservative treatment methods do not achieve their goal.

Arthroscopy (joint endoscopy) – a gentle minimally invasive procedure – offers the possibility of looking directly into the joint. In the process, unstable cartilage parts that occur and outgrowths on the bone can be removed, the cartilage can be smoothed.

Another method is the realignment osteotomy if a leg axis malposition is present and the cause of the wear. With the correction of the leg axis, it is possible to return to a natural position and relieve the affected joint part.

In cases of advanced arthrosis, artificial joints or stiffening surgery (arthrodesis) may be considered.

And when can you put normal weight on the ankle again?

Depending on the surgical technique, an ankle joint can be loaded again after three months. The foot should be immobilized for eight to twelve months. Wearing an orthosis also helps rest the joint for a longer period of time.

Do you have any further questions?

Sie möchten mehr erfahren oder sind direkt betroffen? Dann wenden Sie sich direkt an Dr. Müller oder Prof. Dr. Thermann. Sie helfen Ihnen gerne weiter.

Shortly you will learn more about it here

Shortly you will learn more about it here

Achilles tendon

Pain in the Achilles tendon can mean very different diseases. They are long-lasting and unfortunately often persistent processes. Untreated pain caused, for example, by external influences such as bruising or crushing can develop into inflammation of the Achilles tendon.

What are the Achilles tendon disorders?

The most common disorders of the Achilles tendon include pain syndrome, also known as Achillodynia, tendonitis (paratendinitis), Achilles tendon necrosis, Haglund’s deformity or Achilles tendon rupture.

How is Achilles tendon disease diagnosed?

The experienced orthopedist can already recognize whether the Achilles tendon is injured by palpating the skin surface. If it is a rupture, the affected person is no longer able to stand on the front toes and lift the heel when standing on one leg. The so-called Thomson test (in prone position) confirms a rupture if the patient is again unable to move the sole of his foot backwards.

Modern imaging supports the clinical examination: Tears in the Achilles tendon can be precisely localized and visualized by ultrasound.

What are the requirements for conservative therapy?

Eine Achillessehnenverletzung kann konservativ mithilfe eines Therapieschuhs erfolgen. Die entsprechende Indikation und Anwendung des Therapieschuhs gewährleisten eine sichere Sehnenheilung, die einer operativen Behandlung nicht nachsteht.

However, the prerequisites for conservative treatment must be very precisely highlighted. Above all, there must be complete adaptation of the tendon ends in plantar flexion in an ultrasound examination.

How long must the patient wear the therapeutic shoe?

Die konservative Behandlung sieht vor, dass dem Patienten nach erfolgter Ruptur und Feststellung der geeigneten Indikation ein Therapieschuh (Variostabil) angelegt wird. Dieser Schuh muss praktisch durchgehend getragen werden. Zur Nachtzeit wird er abgelegt und durch eine Gipsschiene ins Spitzfußstellung ersetzt. Der Patient sollte in der Lage sein, die Behandlung im Schuh für acht Wochen richtig durchzuführen, da das Aussetzen der Behandlung im Schuh zu einem Therapieversagen führen kann.

Und was sind die Besonderheiten des Therapieschuhs?

Einerseits ist es die Absatzerhöhung von zwei Zentimetern, die die Adaptation der Sehnenenden gewährleistet. Des Weiteren verhindert eine dorsale Plastiklasche, dass die so genannte Dorsalextension, das Hochziehen des Fußes, zu einem Auseinanderweichen der Sehnenenden führen würde. Verstärkungen im seitlichen Bereich des Hochschaftstiefels sorgen für weitere Stabilisation. Der Patient kann nach Anlage des Schuhs und nach Schmerzrückgang den Fuß wieder voll belasten. Er kann seinen beruflichen Tätigkeiten nachgehen und ist somit schnell wieder im gewohnten Alltag integriert. Zur Kontrolle der Heilung sollte nach vier Wochen eine Ultraschalluntersuchung durchgeführt werden.

After how many weeks is the treatment in the shoe finished?

Nach acht Wochen sollte mithilfe der Ultraschalluntersuchung eine gute normale Sehnenheilung verifiziert werden. Im weiteren Genesungsprozess wird ein Sportprogramm durchgeführt, ein Aufbautraining für die Wadenmuskulatur, aber auch für die Propriozeption und Koordination.

Which surgery is useful on the Achilles tendon and why?

Die minimal-invasive Chirurgie in der Behandlung einer Achillessehnenruptur ist in den letzten Jahren durch neue Entwicklungen fast zum Standard geworden. Die Ziele der minimal-Invasiven Chirurgie (MIC) beinhalten geringere perioperative Schmerzen, kleinere Narben, geringer Blutverlust, schnelle Rehabilitation und eine Reduktion der postoperativen Komplikationen.

Are there also disadvantages of the method and how to avoid them?

The disadvantage of MIS is the relatively poor visibility into the sensitive structures of the foot. Likewise, the limited identification of tendon pathologies is problematic with regard to visual control during open surgery.

Das endoskopisch-assistierte chirurgische Vorgehen kombiniert MIC mit der Kontrolle durch direkte Visualisation, erfordert jedoch höhere technische Fähigkeiten und Erfahrungen durch den behandelnden Chirurgen. Durch die Bildvergrößerung bei der Arthroskopie kann die endoskopische Prozedur einen sehr guten Überblick über die gesamten Strukturen geben. So ist sogar die Identifikation von subtilen pathologischen oder nicht pathologischen Sehnenstrukturen möglich.

Sometimes the Achilles tendon is very swollen. What is the problem here? 

This can be a so-called midportion tendinopathy. It shows a painful thickening of the Achilles tendon in the middle area (midportion area of the Achilles tendon). Endurance athletes and marathon runners are frequently affected, but this can also occur in patients in middle age between 40 and 50 years as a sign of degenerative changes. Pathophysiologically, degeneration is defined with healing disturbances. There is an increase of neo vessels and consequently of neon nerves on the ventral side of the Achilles tendon, which manifest the painfulness of the change. In addition, there is a swelling of the surrounding peritendineum as a sign of irritation during acute stress, which can cause a kind of compartment syndrome due to the swelling.

What is the surgical approach?

Der operative Ansatz der Behandlung der Midportiontendinopathie besteht in einem endoskopischen Debridement (= Entfernung) zum einen der eingewachsenen Gefäße und Nerven ventralseitig, als auch des Peritendineums. Des Weiteren werden dem MRT entsprechende degenerative Veränderungen gezielt mit dem Shaver herausgeschnitten.

What exactly does the aftercare look like? What do you have to be prepared for?

In simple cases, after debridement without weakening the tendon, movement exercises are done immediately, especially also of the flexor muscle chain, in order to restore the mobility of the ankle joint and the Achilles tendon.

For this reason, a partial load should be applied for two weeks so that the load does not cause too much swelling and pain. After 14 days, a full load can be applied. Since the tendon has changed as a whole, the tendon must be completely rebuilt again. This should be done in four and six months. If there is no positive result, impact sports should be avoided for at least four to six months. Rehabilitation includes aqua jogging, crawl swimming, cycling and cross trainer for muscle building.

Do you have any further questions?

Would you like to learn more or are you directly affected? Then contact Prof. Becher or Prof. Thermann directly. They will be glad to help you.

What is a chronic Achilles tendon rupture?

Chronic rupture is defined by massive degeneration of the Achilles tendon, with insufficiency of power transmission of the soleus- gastrocnemius complex muscle.

What is particularly notable here?

Due to the degeneratively weakened and lengthened tendon, there is a significant loss of strength. A one-legged toe stance is usually not possible. In the examination, a lengthened Achilles tendon is shown by an increased dorsal extension of 20°.

How do you notice a chronic Achilles tendon rupture?

Klinisch zeigt sich eine massive Verdickung der Sehne. Pathologisch muss man sich ein geflochtenes Seil vorstellen (bestehend aus einzelnen Strukturen der Achillessehne), dass nach und nach reißt und somit die Kraftübertragung immer stärker beeinträchtigt. Patienten klagen weniger über Schmerzen als vielmehr über eine Beeinträchtigung im Alltag und Kraftlosigkeit.

Welche operative Optionen gibt es?

The surgical technique is similar to that used for midportion tendinopathy (see previous section). However, a so-called shaver – which is a medical instrument used to remove soft tissue – is used to extensively clear out degenerative structures. This leads to considerable weakening, so that in the case of an acute rupture, the tendon must be strengthened with a 1.3′ PDS cord. Growth factors are then injected into the area of degeneration/resection and fibrin sealant is applied.

What is the aftercare like?

The patient receives a Vario Stabil shoe and can perform light plantar flexion exercises from the shoe. The shoe should be worn for six weeks. Growth factors are injected primarily intraoperatively, after 14 days and again after four weeks to accelerate the healing process. The load build-up is done with cycling and aqua jogging.

When do defect and infection situations occur after Achilles tendon ruptures and reruptures?

They occur after unsuccessful Achilles tendon surgery or infections with resection of the Achilles tendon. Here the question of a complete tendon replacement arises. Until now, tendon transfers such as VY plastics, flexor hallucis longus and peroneus brevis plastics have been used.

What are other problems of revision surgery besides the complex, traumatic, and open surgery?

The main problem is massive soft tissue problems, which are sometimes unmanageable in infections, so that open surgery almost always has to be accompanied by flap coverage. To avoid this, we introduced for the first time the endoscopic free tendon transfer with the semitendinosus tendon (also called semi-T-transfer). In this procedure, the Achilles tendon is brought back into a stable functional situation by means of the tendon transfer. Furthermore, the minimally invasive technique avoids costly reconstruction of the soft tissues by plastic surgery.

Do you have any further questions?

Would you like to learn more or are you directly affected? Then contact Prof. Becher or Prof. Thermann directly. They will be glad to help you.

Heel spur – people often talk about it. What exactly is meant by it?

A heel spur manifests itself in two different ways: one speaks of the cranial variant, which forms above the calcaneus, Achilles tendon attachment. The plantar variant affects the underside and thus the plantar fascia. In both cases, pressure and tensile stress – for example, due to incorrect footwear, one-sided loading, malpositions or overweight of the patient – are the reason for the overloading and ossification of the fascia (the connective tissue on the foot).

How to identify a heel spur?

At the beginning, very few people notice a heel spur. Only with increasing stress over a longer period of time can the fascia and the surrounding tissue become inflamed. Bone outgrowth also increases.

Over time, the affected person experiences stabbing pressure pain in the heel and sole of the foot. It can become very painful, especially when standing, when the weight bearing is particularly high. Affected individuals also complain of morning start-up pain and walking on hard ground is felt to be increasingly painful.

How to diagnose a heel spur?

Dass es sich um eine verkürzte Plantarfascie handelt, lässt sich der knöcherne Auswuchs vom erfahrenen Orthopäden bereits ertasten. Zusätzlich geben Röntgenaufnahmen Auskunft über die knöcherne Struktur. Um weitere Erkrankungen wie Gicht oder Rheuma auszuschließen, werden weitere bildgebende Verfahren wie MRT hinzugezogen.

Can a plantar fascitis be treated conservatively?

Conservative plantar fascitis treatment initially implies stretching exercises, under the guidance of physiotherapeutic experts. Special shoe insoles can provide relief, which are individually adapted to the patient with the help of a foot pressure measurement. Inflammations are treated with various injections (such as ACP, hyaluron, Botox, cortisone). Our foot experts will be happy to advise you on this.

And if that doesn’t work?

If the pain does not subside despite conservative treatment methods, heel spur surgery should be considered.

Severely inflamed tissue can lead to tearing of the plantar fascia, which is why minimally invasive surgery is advised, during which the inflamed tissue is removed.

Usually, the patient can put partial weight on his foot immediately after surgery (1-2 weeks).

Do you have any further questions?

Would you like to learn more or are you directly affected? Then contact Prof. Becher or Dr. Müller directly. They will be glad to help you.

Further therapy options

Shortly you will learn more about it here

Shortly you will learn more about it here

Shortly you will learn more about it here

Shortly you will learn more about it here

Shortly you will learn more about it here