Achilles Tendon Lengthening Surgery

Idiopathic Toe Walking Surgery

Achilles Tendon Lengthening Surgery for Toe Walking

What Is Achilles Tendon Lengthening Surgery?

Achilles tendon lengthening is a surgical procedure that does exactly what it sounds like, lengthens the Achilles tendon. It allows the child to walk with their knees straight and feet flat on the floor. This type of surgery is generally used to correct toe walking in young patients that haven’t responded to conservative solutions.

Typically, surgery is only performed after physical therapy, bracing, and other conservative treatments have failed.

Evelina’s parents had taken her to see several doctors over the years, but they were not able to find a solution for her toe walking. Eventually, they decided to get a second opinion from Dr. Mikkel Jarman with Pediatric Foot & Ankle. Dr. Jarman was able to diagnose Evelina with idiopathic toe walking. After considering all conservative treatment methods, in this case he recommended surgery.

After Dr. Jarman performed the surgery, Evelina wore a cast for 4 weeks, and the boot for 2 weeks. Evelina’s toe walking has significantly improved and she is able to walk with her heel and toes.

What is Idiopathic Toe Walking?

Idiopathic Toe Walking (ITW) is a condition in which children over the age of three continue to walk on their toes while showing no evidence of neurological, orthopaedic, or psychological disorders. The National Library of Medicine says ITW effects 7 to 24 percent of children.

Children who walk on their toes for an extended period of time are putting an inordinate amount of stress on their knees, hips, and lower back bones and ligaments. Children are at risk of injury and joint discomfort as they become older if their bones develop wrongly or their ligaments are overstretched as a result of ITW.

Toe-walking can be caused by conditions like cerebral palsy, a tight Achilles tendon from birth, or diseases that make muscles weak, like Duchenne Muscular Dystrophy. Toe-walking may be linked to developmental disorders like autism or other myopathic or neuropathic disorders.

Physical therapy to gently stretch the Achilles tendon and calf muscles, splints or leg braces to promote a normal gait, or a series of casts to progressively relocate the toes toward the shin are all treatment options if we decide that a physical condition is affecting toe walking.

Without medical assistance, the majority of youngsters quit toe walking on their own. For those who don’t, ITW is treated with physical therapy, bracing, and casting, with surgical options available if these approaches fail.

When Does a Child Need Achilles Tendon Lengthening Surgery?

Achilles tendon lengthening (ATL) corrects a tight or contracted tendon. The Achilles tendon connect the heel bone to the calf muscles. Every time your child moves his or her foot – walking, running, jumping, or just pointing their toes – they use their Achilles tendon. When the tendon is too tight, it may cause pain and problems walking. This often manifests as toe walking.

Although toe walking is very common, especially when children first learn how to walk, it may indicate an issue. One of these is a too-short Achilles tendon.

Other issues that may require Achilles tendon
lengthening surgery include:

  • Birth defect or deformity, e.g. clubfoot and congenital vertical talus (CVT)
  • Cerebral palsy
  • Chronic tendinitis

The pediatric podiatrist almost always pursues conservative (non-surgical) treatment first. This may include physical therapy exercises, leg braces, a splint, or below-the-knee casting. If conservative treatment fails, your doctor may then discuss ATL surgery with you.

How Is Achilles Tendon Lengthening Surgery Performed?

ATL surgery requires a general anesthesia. From there, the surgery varies according to the extent of your child’s particular issue. ATL surgery options include:

  • Z-plasty: This is the most common method, utilizing z-shaped incisions in the tendon to stretch it before sewing the tendon back into place
  • Percutaneous: Uses small incisions that allow the podiatric surgeon to elongate the tendon via tiny cuts
  • Gastrocnemius recession: Lengthens and loosens the fibers of the gastrocnemius muscle in the calf

The surgeon then closes the incisions. The same day, your child receives a walking cast.

Achilles tendon and calf muscle illustration

What Are the Risks of Achilles Tendon Lengthening Surgery?

All surgery carries some level of risk. The most common risks with ATL surgery are infection, pain, swelling, and nerve damage.

If your child experiences any of the following symptoms, call your doctor right away. If you can’t reach your podiatrist, seek emergency medical care.

  • Chest pain or shortness of breath
  • Fever over 101
  • Pain that doesn’t respond to medication
  • Extremities that feel cold or appear pale or purple
  • Bleeding or pus draining near the incision
  • Skin discoloration near the incision
  • Numbness in the fingers or toes
  • Increased swelling
  • Dehydration (signs include lack of tears when crying, fewer than 6-8 diapers per day, dry mouth, chapped lips, yellow urine, constipation)
  • Excessive diarrhea or vomiting

What Happens After Achilles Tendon Lengthening Surgery?

The full recovery time takes between 3 and 6 months, depending on your child’s unique circumstances. Always follow your doctor’s instructions. The following is general advice to help you understand what to expect.

Your child leaves with a walking cast and likely a prescription for pain medication. This may be ibuprofen or Tylenol, but it may also be something stronger if indicated. Follow your doctor’s instructions exactly when administering pain medication. And if a prescription-strength medication includes Tylenol, never give your child Tylenol in between doses.

Nausea is a common side effect, particularly as the anesthesia wears off. This feeling may last for 24 hours. During this time, stick to a diet of clear liquids and foods that are easy to digest. Avoid heavy or greasy foods. And if your child throws up, avoid any foods or liquids for 30 to 60 minutes.

Have your child rest the leg as much as possible for the first 48 hours, keeping it elevated. Pillows work well for this. It’s also helpful for them to wiggle their toes occasionally to help prevent swelling.

Your child will likely need assistance standing and walking at first. But they should be back to most normal activities within a week (assuming they can keep the cast dry). And school age children may be able to go back to school within two weeks. Much depends on your child’s specific needs and recovery time.

If your doctor prescribes ice packs, place them on the side of the cast, not the top, and always protect the cast from moisture.

When to Talk to a Pediatric Podiatrist about Achilles Tendon Lengthening Surgery

If your child continues toe walking past age 3, particularly if they have one of the conditions listed above, schedule an appointment with Pediatric Foot & Ankle. Dr. Jarman will examine your child and explain all of your treatment options.

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