A tendon is a strong, rope-like, fibrous tissue connecting muscle to bone. When the muscle contracts, the tendon pulls the bone and causes movement of a joint. The strongest tendon in the body is the Achilles tendon, which gets its name from the mythological Achilles and means an area of great weakness despite its overall strength. The Achilles tendon attaches the calf muscle of the leg to the heel enabling a person to walk, stand, run and jump. In children, the Achilles tendon is connected to a growth plate in the heel and is susceptible to injury. Tendon lengthening, also known as cord release or tenotomy, is performed in children primarily because the Achilles tendon has shortened or contracted.
Your health care provider will use physical examination, subjective examination, X-rays and ultrasound to diagnose the need for straightening the Achilles tendon.
According to Natarajan and Ribbans, causes of paediatric Achilles tendon involvement are: congenital, developmental, traumatic and neurological.
Congenital causes can include, congenital vertical talus, an uncommon birth defect which is characterised by a severe, rigid flat foot; and club foot, a common birth defect in which the Achilles tendon may be contracted and the bones of the foot are malrotated. A common developmental cause is idiopathic toe-walking which is walking on tiptoes for no apparent reason. Initially, most toddlers toe-walk but, eventually grow out of it. A child that continues to toe-walk after three years should be evaluated by your health care provider for neurological or neuromuscular disorders. Neuromuscular causes include cerebral palsy, spina bifida, spinal cord injury or tumours, paralysis, and various types of muscular dystrophies such as Duchannes. Traumatic causes can include Server's Syndrome which is a temporary inflammation of the Achilles tendon secondary to overuse through athletics or growth spurts.
Benefits of Treatment
Benefits of treatment include decreased ankle, leg, or foot pain; increased flexibility of ankle and foot; realignment of foot for improved gait (manner in which one walks), and enabling ambulation if the child cannot walk. Treatment also can prevent contractures (stiffening of a joint in one position).
According to Maffulli and Almenkinders, the initial treatment of shortened tendons should be non-operative. Corrective manipulation and serial application of casts, followed by calcaneal tenotomy and release of an aberrant tendoachilles tendon if found, should be successful in at least 85 per cent of patients who are initially treated a few days after birth. Serial casting is similar to wearing orthodontic braces. As the foot straightens, the previous cast is removed and replaced with another cast. Some physicians prefer the use of braces that parents can place and remove themselves. This method can take two years to four years. With serial casting, the child usually can play and walk. Children with less severe clubbing may be able to wear orthotic shoes rather than casts. Physiotherapy and regular stretching exercises can stretch the Achilles tendon and help relieve pain.
Traditional open surgery in which a 6 to 8 centimetres incision is made above the heel. The tendon is cut, stretched, and then reattached. The child is put in a below-the-knee cast for about six weeks to immobilise the area. Percutaneous lengthening involves inserting a tenotomy knife just above the heel and again just below the tendon's insertion point into the calf. This procedure should loosen the tendon. Again, the child is place in a below-the-knee cast for about six weeks. Percutaneous lengthening can be performed under local anaesthesia and as an outpatient procedure.
After surgical or non-surgical lengthening, the patient should continue exercising the area at home according to the therapist's instructions. Failure to do so can lead to stiffness and contractures. The ankle/foot brace must be used consistently for reliable results. The child usually maintains the ability to walk/run with the brace on. Tenotomy (Achilles tendon lengthening) can be done on an outpatient basis.
The risks of any surgery include bleeding, infection, and death (usually secondary to anaesthesia). Risks specific to tenotomy include the aforementioned plus a chance that another surgery may be needed for further correction.
- Everything About Achilles tendons, Griffin Global Systems, 2006.
- Book: Achilles tendon, 236, Nicola Maffulli, Louis Almenkinders, 2007, January
- Aberrant Tendo-Achilles tendon in Club Foot : A case report, Terrence Jose Jerome, MBBS, DNB (Ortho), MNAMS (Ortho) 1 , Mathew Varghese, M.S. (Ortho) 2, February 2009