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Achilles Tendon Contracture

Achilles tendon contracture is a shortening of the Achilles tendon (tendon calcaneus or heel cord), which causes foot pain and strain, with limited ankle dorsiflexion

Causes of achilles tendon contracture

Achilles tendon contracture may reflect a congenital structural anomaly or a muscular reaction to chronic poor posture, especially in women who wear high-heeled shoes and joggers who land on the balls of their feet instead of their heels. Other causes include paralytic conditions of the legs, such as poliomyelitis and cerebral palsy.

Signs and symptoms of achilles tendon contracture

Sharp, spasmodic pain during dorsiflexion of the foot characterizes the reflex type of Achilles tendon contracture. In footdrop (fixed equinus), contracture of the flexor foot muscle prevents placing the heel on the ground.

Diagnosis

Physical examination and patient history suggest Achilles tendon contracture. A simple test confirms the condition: While the patient keeps his knee flexed, the examiner places the foot in dorsiflexion; gradual knee extension forces the foot into plantar flexion.

Treatment of achilles tendon contracture

Achilles tendon contracture is treated conservatively by raising the inside heel of the shoe (in the reflex type); gradually lowering the heels of shoes (sudden lowering can aggravate the problem), and stretching exercises, if the cause is high heels; or using support braces or casting to prevent foot drop in a paralyzed patient. Alternative therapy includes using wedged plaster casts or stretching the tendon by manipulation. Analgesics may be given to relieve pain.

With fixed foot drop, treatment may include surgery (tenotomy), although this procedure may weaken the tendon. Tenotomy allows further stretching by cutting the tendon. After surgery, a short leg cast maintains the foot in 90-degree dorsiflexion for 6 weeks. Some surgeons allow partial weight bearing on a walking cast after 2 weeks.

Special considerations

• After surgery to lengthen the Achilles tendon, elevate the casted foot to decrease venous pressure and edema by raising the foot of the bed or supporting the foot with pillows.
• Record the neurovascular status of the toes (temperature, color, sensation, capillary refill time, toe mobility) every hour for the first 24 hours, then every 4 hours. If any changes are detected, increase the elevation of the patient's leg and notify the surgeon immediately.
• Prepare the patient for ambulation by having him dangle his foot over the side of the bed for short periods (5 to 15 minutes) before he gets out of bed, allowing for gradual increase of venous pressure.
• Assist the patient in walking (usually within 24 hours of surgery), using crutches and a non-weight-bearing or touch-down gait.
• Protect the patient's skin with mole­skin or by "petaling" the edges of the cast.
• Before discharge, teach the patient how to care for the cast, and advise him to elevate his foot regularly when sitting or whenever the foot throbs or becomes edematous.
• Make sure the patient understands how much exercise and walking are recommended after discharge.