[Music]
Hi,
I'm Ali. I'm one of the physios from
treatmyachilles.com.
Today, I'm going to be talking about
surgical options - when and should you
have surgery or not if you have an
Achilles tendinopathy.
So we need to look at what does a normal
healthy tendon look at,
what are the surgical options that are
there, and
whether they are something that we
should be considering or not.
So a normal healthy tendon is made up of
lots and lots of collagen fibers in a
straight line -
in one big bundle - and then another and
another and another bundle and so on,
until the multiple
bundles make up one tendon, in this case
the Achilles tendon.
When you have a tendinopathy or a
pathology of the tendon,
what's that showing is that instead of
having those collagen fibers in a nice
straight lines now,
they become a bit more disorganized and
it also changes
different things within the cells that
are in the gaps in between, such as they
take on more water.
Now, this isn't in all of those fibers
and it's not in all of those bundles.
So depending on how many has been
affected, may depend on your
options for surgery. So surgical options
can either be keyhole -
and that's keyhole would have minimal
little scars on each side -
or you could have a more open surgical
type operation and that open surgery
leaves you with a bigger scar and
therefore it is less likely, it is less
common to do that.
What you tend to do with a tendon is
something called a debridement.
And that means that those fibers that
aren't in that nice
alignment anymore, that are a bit more
disorganized, are removed
whilst those other fibers that are still
nice and healthy and in those straight
long lines
are remaining. Now obviously this
can
change the dynamics of your tendon
because you're removing some of those
fibers,
and therefore it needs to be carefully
loaded and carefully rehabilitated
afterwards to enable you to get back to
doing
different activities. Now if we look at
the
evidence base about surgery and why
don't we all suddenly
leap on and do this debridement and then
everything's absolutely fine,
is that it actually doesn't be... isn't the
be-all and end-all - it doesn't have a
massive success rate.
What it tends to be is a last resort. So
what you would want to do
first, is have a look at what other
options you've got, which is called
conservative management.
And that conservative management, the
best and most available treatment
is exercise therapy and strengthening
those collagen
fibers. So the theory behind the
strengthening is twofold, and we're not
sure which one happens:
Is it that the fibers become
back to that organized fashion again? Or
is it that all of the other fibers
around the outside and all the other
bundles
splint and look after that area that's
been changed by the Achilles tendon?
And this is something that's been looked
at and keeping being looked at on a
repeated basis
during research. What we're looking at
when we're strengthening,
is to strengthen those collagen fibers
and therefore we have to strengthen the
muscles that
create that Achilles tendon, which are
your calf muscles.
So this is the most important part of
your treatment
and it is something that needs to be
progressed over a period of time.
So there's a school of thought - in a
recent research article in 2019 -
that is saying that you need to have
done a good year
- nine months to a year but preferably
over a year - of this rehabilitation
where it's progressively got more
difficult as time has got on, and that's
the important part:
that you are doing more and keep
progressing and getting
stronger over that period of time. So if
something's not going right,
you have a look about what might not be
happening and you go
back to that rehabilitation and you
start again, or you change slightly what
you're doing
and you keep progressing. So if after a
year of doing that progressive
loading there hasn't been much change,
that's an option for them for surgery.
But there are things that can occur
before that,
which are injection therapy, and I know
Maryke has discussed
injection therapy options on previous
blogs and also
on some other videos. So in summary:
Surgery is an option - it is an option
that is a last resort,
and this is an option done after all of
the loading
programs have been progressed for at
least nine months
and preferably over a year.