Surgery for Non-Insertional Tendinopathy

Surgery for Non-Insertional Tendinopathy is considered when non operative treatment has been unsuccessful. The choice of procedure depends on factors such as how long symptoms have been present for and the severity of the injury to the tendon. At your consultation Mr Goldbloom will discuss which option is best for you.

Surgery may include:

  • A Paratenon Excision (scraping the sheath in front of the tendon) is a relatively minor procedure that may work if the disease process is in its early stages. It is aimed at removing the inflammatory stimulus without disrupting the tendon itself.
  • Tendon Debridement involves removal of poor-quality tendon and re-joining the ends.
  • Tendon Reconstruction is required when there is not enough left-over healthy tendon to repair. This will involve a longer incision and a procedure such as a V-Y advancement or a Gastrocnemius Turndown.
  • A Tendon Transfer of Flexor Hallucis Longus (FHL), the muscle that controls big toe flexion, may also be required if the original Achilles tendon cannot be relied upon after surgery.
Site of insertional tendinopathy

Post-Operative Care

  • When you go home it is very important to elevate the foot 23 hours a day above the level of your heart for two weeks.
  • Patients usually wear a plaster slab for the first two weeks and remain non weight bearing on the side of surgery.
  • A Physiotherapist will provide you instructions regarding exercises at home.
  • You will have a wound review 2-3 weeks with Mr Goldbloom and a Wound Nurse Specialist.Your dressings are to stay dry and intact until this appointment.
  • The plaster slab will be exchanged for a specialised CAM boot and weight bearing can commence 4 weeks after the surgery.
  • You will then be required to wear a boot until approximately 10 weeks after the surgery.
  • You will have an appointment with Mr Goldbloom 6 weeks and 3 months after surgery to assess your recovery.

Refer to the Foot and Ankle Surgery information sheet for further post-operative instructions.

Rehabilitation Following Surgery For Non- Insertional Tendinopathy

A physio should lead you through your rehabilitation program after surgery. This table is a guide and changes may be required depending on your progress.

Week Exercises Footwear Weight bearing Other
0-2 Foot intrinsic strength work, STW plantar foot, kinetic chain strength (hip/knee w/o WB op-site). Plaster Cast Non-weight bearing Foot elevated above heart for 23 hours/day.
2-4 PROM. CAM BOOT with 30mm heel lift or VACOPED (3) with wedge Non-weight bearing Post surgical consultation at East Melbourne<br /> SItting duties can commence at about 3 weeks after surgery
4-6 CAM BOOT with 10-20mm heel lift or VACOPED (2-1) with wedge 50% weight bearing
6-8 Achilles strength program. CAM BOOT with 0-10mm heel lift or VACOPED (1) wedge moving towards (0) no wedge Full Weight bearing Weight bearing duties in a boot at about 6-8 weeks<br /> Patient to see Mr Goldbloom at choice of location
8-10** Achilles strength program. Transitioning to regular footwear from weeks 8-12 Full Weight bearing Patient can return to driving automatic car short distances (1 hour)
10-12* Achilles strength program. Regular Footwear Full Weight bearing Patient can return to unrestricted driving
12+ Strength program and sustained weighted stretch into Ankle DF. Regular Footwear Full Weight bearing

Achilles Strengthening Program

Week Type of contraction Exercise Dosage Marker for progression
6-10 Isometric (in neutral) and slow contraction against band – DL PF – 5 x 30-60” hold<br /> – 3 x daily each VAS score 1/10 or less 24 hours after completion on 2 consecutive days
8-12 Slow eccentric – SL CR to plantargrade<br /> – Bent knee DL seated CR (conc/ecc) – 3x10, 5” reps<br /> – 3x15, 2-2-2 rep pace<br /> Performed every 2nd day<br /> Continue iso’s a/a VAS score 1/10 or less 48 hours after completing for 4-6 consecutive days
12-14 Heavy slow concentric eccentric Weighted CR off floor and DL seated CR – 3 x 6 reps maximum weight possible, 3 x p/week Progress weight on each exercise for next session when able to complete 3 x 6 and VAS <3/10 for following 48 hours.
14-16 Closed chain plyometric – Cont. strength program a/a<br /> – DL CR ‘bouncing’<br /> – Explosive SL CRs Bouncing: 5 sets 30 reps, twice per week.<br /> Explosive CRs: 3 sets 15 reps, 1-1-1 rep pace. VAS <3/10 for following 48 hours.
16-18 Open chain plyometric – DL CR pogo<br /> – Box jumps, hopping, landing practice Two session p/week as guided by PT VAS <3/10 for following 48 hours or PT clinical impression.
18+ Graduated return to training Return to running, low load predictable non-contact sports specific drills 2-3 sessions p/week<br /> Continue plyo’s and strength work on 2-3 other days p/week PT guidance

*VAS pain score max 4/10.
^limit ankle DF ROM for insertional tendinopathy with debridement.
+limit ankle PF ROM for mid-portion tendinopathy.

These programs have been developed by Mr Goldbloom in conjunction with Physiotherapists, Brodie Leonard-Shannon and Brendan Mason from Back in Motion, Aspendale Gardens.

Disclaimer: These tables are a guide only to base rehabilitation. Your Physiotherapist has a very important role in monitoring rehabilitation in case changes to fit your personal progress are required.

The information provided here is for general educational purposes only. Please contact Mr Goldbloom's rooms to discuss if surgery is appropriate for your situation.