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What is Endoscopic Achilles Lengthening?

Endoscopic Achilles lengthening is a minimally invasive surgical procedure for the treatment of a tight Achilles tendon. The procedure involves stretching the tight Achilles tendon at the ankle and increasing motion at the ankle joint for uninterrupted flexion and extension of the foot.

Endoscopic refers to the surgery being performed using an endoscope - a thin tubular instrument with a camera, light, and a magnifying lens attached at the end – that is used to inspect the Achilles tendon and the surrounding structures.

Anatomy of the Achilles Tendon

Tendons are the soft tissues connecting muscle to bone. The Achilles tendon is the longest tendon in the body and is present behind the ankle, joining the calf muscles with the heel bone. Contraction of the calf muscles tightens the Achilles tendon and pulls the heel, enabling the foot and toe movements necessary for walking, running, pivoting, and jumping.

Indications for Endoscopic Achilles Lengthening Surgery

Individuals with a stiff Achilles tendon have difficulty walking on their feet and tend to walk on their toes as the tight Achilles tendon prevents the foot from sitting flat on the floor as well as limits ankle motion. When this stiffness cannot be treated with non-surgical remedies such as medications, injections, or stretching/physical therapy, endoscopic Achilles lengthening surgery is recommended due to its advantages over traditional open tendon lengthening procedure.

Benefits of Endoscopic Achilles Lengthening Surgery

Some of the benefits of endoscopic Achilles lengthening surgery over traditional open surgery include:

  • Less post-operative pain
  • Less scarring
  • Less blood loss
  • Less damage to the surrounding tissues
  • Shorter hospital stay
  • Smaller incisions
  • Minimal muscle trauma
  • Faster recovery
  • Quick return to normal activities

Preparation for Endoscopic Achilles Lengthening Surgery

Preoperative preparation for endoscopic Achilles lengthening surgery may involve the following steps:

  • A thorough examination is performed by your doctor to check for any medical issues that need to be addressed prior to surgery.
  • Depending on your medical history, social history, and age, you may need to undergo tests such as bloodwork and imaging to help detect any abnormalities that could compromise the safety of the procedure.
  • You will be asked if you have allergies to medications, anesthesia, or latex.
  • You should inform your doctor of any medications, vitamins, or supplements you are taking.
  • You may need to stop taking supplements or medications such as blood thinners or anti-inflammatories for a week or two prior to surgery.
  • You should refrain from alcohol or tobacco at least a few days prior to surgery.
  • You should not consume solids or liquids at least 8 hours prior to surgery.
  • Arrange for someone to drive you home after surgery.
  • A written consent will be obtained from you after the surgical procedure has been explained in detail.

Procedure for Endoscopic Achilles Lengthening Surgery

The procedure for endoscopic Achilles lengthening surgery will involve the following steps:

  • You will lie on the operating table in a face-down position with the foot to be treated hanging over the end to allow access to the back of the ankle.
  • You will be typically administered regional or general anesthesia.
  • Your surgeon makes 2 to 3 small incisions at the back of the ankle along the Achilles tendon.
  • Care is taken to avoid any harm to surrounding structures such as nerves and vessels.
  • An endoscope is inserted through one of the incisions. The endoscope is connected to an external monitor and enables your surgeon to visualize the condition of the Achilles tendon and its surrounding structures in the monitor as the scope is advanced along the treatment area.
  • Your surgeon passes small miniature surgical instruments through other incisions and carries out the necessary repair by making small cuts on the tendons and elongating/stretching the tight/contracted Achilles tendon while looking at the monitor.
  • After satisfactory repair is confirmed, the scope and the instruments are withdrawn and the incisions are closed and bandaged.
  • Your surgeon may place your foot in a postoperative shoe, walking boot, or splint depending on your need.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after Endoscopic Achilles tendon lengthening surgery will involve the following steps:

  • You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs as you recover.
  • Keep the foot elevated at or above the level of your heart to help minimize swelling and discomfort.
  • You may apply ice bags over a towel to the affected area for about 15-20 minutes for a specified period of time to reduce postoperative pain and swelling.
  • You will be prescribed medications for pain relief and for prevention of deep vein thrombosis (DVT) as needed.
  • Antibiotics may also be prescribed as needed to address the risk of surgery-related infection.
  • You will be provided with crutches to ambulate safely as soon as you feel comfortable.
  • The sutures and cast are removed after two weeks, and you may be transitioned into a CAM boot with heel raises/wedges.
  • Rehabilitation (physical therapy exercises) will be started to strengthen calf and ankle muscles and optimize leg function. Your leg will heal within 6 to 8 weeks.
  • Keep the surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
  • Refrain from strenuous activities for the first few months and lifting heavy weights for at least 3 months. A gradual increase in activities over a period of time is recommended.
  • You may return to sports once the leg has regained its normal strength and function, and with your surgeon's approval.
  • A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Endoscopic Achilles tendon lengthening surgery is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:  

  • Infection
  • Bleeding
  • Damage to surrounding structures
  • Thromboembolism or blood clots
  • Anesthetic/allergic reactions
  • Persistent pain
  • Loss of leg function
  • Muscle weakness
  • Wound dehiscence