Achilles Tendon Lengthening in Jalandhar: Procedure, Benefits & More

Achilles tendon lengthening (ATL) is a surgical procedure that elongates a contracted (tight) Achilles tendon with a series of tiny incisions (cuts) on the affected tendon behind your ankle. As the cuts heal,, the tendon gains length. The Achilles tendon contracture can occur due to atypical foot formation or during an injury (often due to high-impact sports). It impairs your ability to bend your foot down, making it difficult for you to carry out activities like climbing the stairs and standing on tip-toes.

Read more about the Achilles tendon lengthening procedure, its benefits, and its risks.

Achilles tendon lengthening is a surgery to lengthen, stretch, or elongate the Achilles tendon to treat muscle spasticity (muscle stiffness). An Achilles tendon lengthening is usually recommended if other conservative methods fail to provide relief from symptoms (poor posture, muscle spasticity, etc.) or treat the condition. Four primary procedures are used in ATL surgery: percutaneous method, gastrocnemius recession, Z-plasty, and endoscopic Achilles tendon lengthening.

The Achilles tendon is a fibrous connective tissue that joins the bottom of your calf muscle to your heel behind the ankle. It lets you point your foot downwards and helps you raise your heels. It is usually an outpatient procedure performed under general anesthesia. The procedure helps relieve chronic pain and allows you to walk flat-footed without a bend in the knee. 

The goal of this surgery can be summarized as follows:

• Improves walking pattern
• Enhances ankle movements
• Improves positioning of a brace or cast provided

Achilles tendon lengthening is recommended to correct a contracted (tight) Achilles tendon, which causes severe pain and problems like the inability to walk or stand. 

Some associated medical conditions that may cause Achilles tendon contracture include:

• A birth defect or deformity (like clubfoot)
• Cerebral palsy (a condition causing impaired muscle coordination due to damage to the brain before or at birth)
• Chronic tendinitis (long-lasting inflammation of the tendon causing soreness)
• Spinal cord injury
• Stroke (damage to the brain due to interruption in the blood supply)
• Diabetes-related deformities 

Achilles tendon lengthening surgery becomes necessary when other conservative methods (night splints, physiotherapy, arch supports, and bracing, injectables) fail to correct and relieve symptoms, even after about 12 months.

During your initial visit, your doctor will evaluate the condition in the following ways:

Record your medical history

• To evaluate symptoms like severe pain in the Achilles tendon, discomfort behind the ankle, calf cramps, poor posture, and abnormal toes position.
• To check for other medical conditions like diabetes (increased blood sugar levels), asthma, hypertension (high blood pressure), and other disorders associated with the thyroid, lungs, or heart. 
• To identify any history of allergies to anesthesia, latex, or other substances.

A thorough physical examination

• To check the range of motion of the ankle when the knee is flexed (bent) and extended (straightened), which helps check if the tendon is tight.

Imaging techniques

• Helps to confirm the diagnosis through X-rays, MRI (Magnetic Resonance Imaging) scans, blood tests, and electromyography (a test to evaluate and record the electrical activity produced by skeletal muscles). 

Preparing for the surgery in the following ways helps prevent the risk of any complications during or after the surgery and facilitates faster recovery.

• Inform your doctor if you are pregnant or planning to get pregnant anytime soon.
• You must discontinue medications like blood thinners, anti-inflammatory drugs, and other herbal supplements 2 weeks before the surgery. These may increase your risk of bleeding.
• Quit smoking and alcohol at least 2 to 3 weeks before the surgery since they delay wound healing. 
• Make sure to arrange for someone to drive you back home and help you during your recovery period.
• You must fast for at least 8 to 12 hours before surgery since it is performed under general anesthesia. This helps to prevent the food particles from being aspirated into the lungs.

Achilles tendon lengthening is usually an outpatient procedure that does not require hospitalization. 

• The surgical site will be cleansed with an antiseptic solution to remove surface contaminants.
• Your surgeon will administer general anesthesia through IV (intravenous) infusion and put you to sleep during the entire surgery. The IV line will help you with fluids and antibiotics administration.
• You will be made to lie face down on an operating table to allow access to the back of the ankle.
• The tendon is repaired using the preferred method.
• Once the procedure is completed, your surgeon will close the skin incisions using stitches. 
• A surgical dressing will be placed over it for protection.
• Your operated leg will be placed in a protective cast or splint that needs to be kept for 3 to 4 weeks. 
• The surgery usually takes 45 to 60 minutes, depending on the severity of the tendon stiffness and the type of surgery chosen.

The procedure is performed in one of the following ways:

Percutaneous method

During this procedure, your surgeon will make small incisions in the Achilles tendon through the outside of your skin. The incisions heal and elongate to lengthen the tendon. 

Gastrocnemius recession

This procedure is used for mild cases of Achilles tendon contracture. Here, the incisions will be made along the gastrocnemius muscle present in the calf. 

Z-Plasty

Most commonly used procedure. Here, your surgeon will make an incision in the skin behind the ankle to expose the Achilles tendon. Then, a Z-shaped incision will be made in the tendon. As the tendon is stretched, the Z-shaped incision will also stretch, thereby elongating the Achilles tendon. The surgeon will then sew the tendon in place using stitches. 

Endoscopic Achilles tendon lengthening

Here, the surgeon will make 2 to 3 small keyhole-sized incisions behind the ankle, along the length of the Achilles tendon. An endoscope will be inserted by your surgeon through one of the incisions. It consists of a light source to help visualize the surgical area and a tiny camera to capture images and project them on the screen to guide the surgeon in performing the surgery. Your surgeon will insert small surgical instruments through other incisions to make tiny cuts on the tendon and stretch/elongate the tendon.

The postoperative care and recovery after Achilles tendon lengthening surgery will involve the following steps:

• You will be shifted to a recovery room, where your nurse in charge will observe you and monitor your vitals (blood pressure, sugar levels, pulse, heart rate, oxygen levels, urine output) until you regain consciousness. 
• You will be instructed to elevate your operated leg above the heart level to reduce swelling and discomfort.
• You may use ice packs for 15 to 20 minutes every one to two hours to reduce post-op pain and swelling. 
• Pain can also be easily managed through painkillers once you return home. You will also be prescribed antibiotics to prevent the risk of post-op infection. 
• You will be provided crutches to help you move around since it helps to promote good blood circulation.
• Make sure to keep your surgical site clean and dry. Avoid swimming and tub baths to prevent soaking the incision site.
• The protective leg cast or splint may be removed after 3 to 4 weeks. 
• Rehabilitation (physical therapy) will begin once the cast is removed to help strengthen your calf and ankle muscles and optimize your leg function.
• Refrain from lifting heavy objects and strenuous exercises and activities for at least 6 weeks.
• You may return to sports once your leg has regained its normal strength and function.
• Recovery may usually take around 6 to 8 weeks.

The benefits and risks of Achilles tendon lengthening surgery should be evaluated to prepare yourself before the procedure.

Benefits 

• Helps relieve the pressure or tension within the Achilles tendon caused due to abnormal contracture of the tendon. 
• Relieves symptoms and improves your quality of life. 
• The endoscopic method benefits from quick procedure time, shorter recovery, minimal blood loss, scarring, and muscle trauma.

Risks 

• Over-lengthening of the Achilles tendon may put excess pressure or weight on your operated foot.
• Damage to the surrounding structures may prevent blood flow to the tendon.
• Longer recovery time.
• Over a period of time, pressure injuries can form, such as foot ulcers.
• The tendon may fail to loosen even after the surgery.
• Injury or tearing of the tendon during or after ATL surgery.
• Additional surgery may be required to correct complications post-ATL surgery.
• Bacterial infections can occur, which may delay wound healing.

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