I failed physical therapy for an Achilles tendon rupture. The injury happened too long ago. And I think I’m too old and too heavy for the tissue to repair itself. Are there any other treatment options? I’m not terribly active (okay, I’m a total couch potato) but maybe I could get out more if the foot didn’t hurt so much all of the time. What do you recommend?

Older adults who rupture the Achilles (heel) tendon may end up with a case of Achilles tendinosis that does not respond to conservative (nonoperative) care. Tendinosis refers to replacement of normal collagen fibers in the tendon with scar tissue or fibrous material. The substandard replacement tissue is weak resulting in pain, decreased strength, and loss of function.

When conservative care is not enough and traditional surgical repair is not possible, then an alternate two-part procedure may be necessary. Older adults who are inactive and overweight are the main candidates for this type of treatment.

The first step is debridement and involves removing the diseased tissue from the damaged and poorly repaired Achilles tendon. Any bone spurs that may have developed around the heel where the Achilles tendon attaches are also shaved away.

The second half of the surgery is a tendon transfer of the flexor hallucis longus (FHL). This tendon/muscle helps the big toe flex or bend. A portion of the FHL tendon was removed and threaded through a tunnel in the calcaneus (heel bone) made by the surgeon. The flexor hallucis longus (FHL) was then attached to the calcaneus where the Achilles tendon normally inserts.

In a recent study of 48 adults between the ages of 44 and 64 who had this procedure done, all were in the obese category (Body Mass Index of 30 or more). Everyone was followed for two years. Results were reported based on improvements in pain intensity, physical function, and disability. Ability to rise on one foot (called a single-leg heel rise) and balance were also evaluated for any changes.

Significant improvement was reported in all areas except the single-leg heel rise. But even though the heel-rise was not normal (due to loss of toe motion and weakness), no one seemed to be having any trouble walking normally. No one seemed to be having any problems with balance. Both of these functions do depend on the flexor hallucis’s ability to flex or bend the big toe. And almost everyone (97 per cent of the group) had no difficulty walking in sandals (keeping them on the feet).

There may be other options available for you as well. The first step is to go back to your surgeon and report your current situation and ask this question. Knowing of this one particular two-step procedure may help get the conversation going around options for you.