Research Review By Dr. Jeff Muir©


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Date Posted:

December 2019

Study Title:

Achilles insertional tendinopathy: state of the art


Maffulli N, Saxena A, Wagner E & Torre G

Author's Affiliations:

Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Fisciano, Italy; Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, UK; Department of Sports Medicine, Palo Alto, California, USA; Department of Orthopedics and Traumatology, Clinica Alemana, Faculty of Medicine, Universidad del Desarrollo, Santiago, Chile; Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy.

Publication Information:

Journal of ISAKOS 2019; 4: 48–57.

Background Information:

Achilles tendinopathy is a relatively common condition in active individuals and athletes, with a lifetime prevalence of 6% (1, 2). Tendinopathies (particularly those affecting the Achilles) tend to be sub-grouped based on their location of either midportion or insertional (3). Midportion Achilles tendinopathies account for 55-60% of diagnoses while insertional diagnoses account for 20-25% (1). Insertional Achilles tendinopathies (IAT) can occur alone or in combination with midportion tendinopathies.

IATs are more likely to occur in older patients, retired athletes, less athletic or overweight individuals. IAT generally affects the interface between the tendon and the bone as well as adjacent structures such as the retrocalcaneal bursa. As such, proper treatment requires accurate differential diagnosis to eliminate non-tendinopathic conditions.

The purpose of this article was to collect and present the latest evidence regarding diagnosis and treatment of IAT.


Essential Features of Insertional Achilles Tendinopathy (IAT):
  • Common among adults undertaking physical activities without specific training or people with lower extremity deformities, leg length discrepancy or limited subtalar mobility.
  • Intrinsic risk factors include: age, chronic comorbidities, limb alignment defects
  • Extrinsic risk factors include: unaccustomed activities
  • Patients often describe symptoms worsening at night, during rest or during restart of activity.
  • Local pain and tenderness are common, including with palpation of the medial and lateral aspects of the insertion of the Achilles tendon.
Diagnosis & Differentials:

Regarding diagnosis, symptoms tend to worsen with training, stair climbing, hill running or similar activities. As such, a recent history of increased training may be present (4). Stiffness following periods of inactivity and decreased plantar flexor strength may be present, as well as calcific tendinopathy, which is generally diagnosed via radiographic or ultrasonic imaging (5, 6). MR imaging can be useful in excluding pathologies of the surrounding soft tissues (7).

Regarding differential diagnoses, bursitis related to the retrocalcaneal and/or superficial bursa must be considered. Likewise, bone spurs and Haglund deformities (bony outgrowth on the posterior aspect of the calcaneus) are not uncommon in chronic tendinopathies. Other differential diagnoses to consider include: os trigonum, posterior ankle impingement, talar or calcaneal fractures and flexor hallucis longus or peroneal/fibular tendinopathies.

Management of IAT:

Initial Conservative Treatment:
Initially, the RICE protocol (rest, immobilization, compression, elevation) is recommended (8). Non-steroidal anti-inflammatories (NSAIDs) may modulate pain severity, but may also interfere with healing and should be used only in those with significant inflammation.

Eccentric Training:
The value of eccentric exercises and the effects on tendon pathology is currently undefined. Various studies comparing eccentric exercise to other treatments have shown a 64% success when avoiding dorsiflexion loading (9); however, a comparison to extracorporeal shockwave therapy (ESWT) showed relative benefits of ESWT over eccentric exercise (10, 11). Endoscopic surgery has proven more effective than eccentric exercise (12) and a combination of ‘Astym’ soft tissue mobilization plus eccentric exercises were more effective than eccentric exercise alone (13).

Paratendinous Injections:
Neovascularization of the tendon in tendinopathy is associated with functional impairment and pain, and sclerosing therapies to control angiogenesis have proven somewhat effective. The use of polidocanol is controversial, with reports of tendon rupture in high-level athletes (14). Prolotherapy with dextrose showed no such rupture risk and, when coupled with eccentric exercise, has been associated with improved outcomes (15).

Regenerative approaches, including platelet-rich plasma (PRP) represent the likely future of injection therapy. Several studies have demonstrated promising early results with PRP, either alone or in combination with ESWT or eccentric exercise (15), but do not differentiate between insertional and non-insertional tendinopathies. While the early evidence is promising, evidence from high-level studies is lacking.

Other Conservative Treatments:
No investigations using other conservative treatments have examined IAT alone; however, heel lifts may provide transient pain relief (8). Limiting the tension on the tendon may prove helpful (no exact recommendations on how to do this, however). Night splints and orthotics have not been suitably investigated.

Open Surgery:
Debridement of the insertional portion of the Achilles tendon is the classic surgical treatment for IAT. While associated with high rates of patient satisfaction, complication rates of 6-30% have been reported (16, 17). Average recovery time ranges from 12-31 weeks (4), with return to sport at 38 weeks in some patients (18).

Tendon Augmentation:
Transfer of the flexor hallucis longus (FHL) tendon is used in cases where > 50% of the original Achilles tendon is resected (19). Accidental resection of the medial or lateral plantar nerves is a potential complication (16). Ipsilateral hamstring tendon augmentation and gastrocnemius lengthening have also been proposed as treatment options for chronic IAT, with the latter demonstrating 91% satisfaction in a single-surgeon, 11-patient case series (20).

Endoscopic/Minimally Invasive Surgery:
Tendon sheath endoscopy (“tendoscopy”) has been developed as a minimally invasive surgical option; however, few investigations (all at low level of evidence) have been completed. In a single, comparative study (21), percutaneous debridement showed a lower complication rate and improved AOFAS scores when compared with open surgery.

Post-op Management:
Open and endoscopic surgeries are performed as day surgeries. The ankle is casted and crutches are then used. Weight-bearing is prescribed to tolerance. In general, casting remains for 2 weeks, with isometric gastroc/soleus and calf muscle contractions recommended prior to removal. Complete return to sport is common within 6-9 months.

Geographical Differences:
  • Europe: Early treatment follows RICE protocols. Heel wedges with the ankle in slight plantarflexion limit stress on the Achilles tendon. Rehabilitation includes eccentric exercise and ESWT, with a 70% success rate. PRP is often administered in refractory cases. Surgery is recommended when conservative treatment fails.
  • North America: Non-surgical treatment involves a period of immobilization, with radial ESWT (rESWT) employed after 6 months of failed conservative treatment. Early implementation of rESWT may improve outcomes for non-surgical treatment. Surgical treatment generally employs anchors loaded with non-absorbable sutures.
  • South America: Non-surgical treatment generally includes physiotherapy (eccentric exercises) for 6 weeks to 3 months. ESWT is standard in non-responsive patients, with a 60% success rate. Open debridement is the preferred surgical approach, with tendoscopy applied in patients with mild tendinopathy. No long-term data is available in comparison, so no specific conclusions can be made.
  • Asia-Pacific: Advancements in endoscopic surgery, coupled with lower complication rates, have made the minimally invasive approach a preferred approach in Asia. Several studies (22-25) have demonstrated the value and efficacy of this approach, which appears to be the preferred treatment over conservative options.

Clinical Application & Conclusions:

Given the high prevalence of IAT, the development of new conservative treatments is paramount. Continued identification of effective surgical techniques is also important, with special attention paid to minimally-invasive options. Regenerative treatments represent a promising area for tendinopathy and small tears. Continued clinical experimentation – including the potential benefit of manual or soft tissue therapies – is needed.

Study Methods:

The authors provided a narrative review, based on research and evidence currently available in the literature.

Study Strengths / Weaknesses:

  • This was a comprehensive review, providing an excellent summary of available evidence. The focus was appropriately on diagnosis and management of IAT which is helpful for all clinicians.
  • Narrative nature of this review provided no opportunity for pooling of available data.
  • There is currently limited data informing us regarding the potential and efficacy of new therapies such as regenerative medicine.

Additional References:

  1. Chimenti RL, Cychosz CC, Hall MM, et al. Current concepts review update: insertional Achilles Tendinopathy. Foot Ankle Int 2017; 38: 1160–9.
  2. Kujala UM, Sarna S, Kaprio J. Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med 2005; 15: 133–5.
  3. Clain MR, Baxter DE. Achilles tendinitis. Foot Ankle 1992; 13: 482–7.
  4. Krishna Sayana M, Maffulli N. Insertional Achilles tendinopathy. Foot Ankle Clin 2005; 10: 309–20.
  5. Cheng Y, Zhang J, Cai Y. Utility of ultrasonography in assessing the effectiveness of extracorporeal shock wave therapy in insertional Achilles Tendinopathy. Biomed Res Int 2016; 2016: 1–5.
  6. Morris KL, Giacopelli JA, Granoff D. Classifications of radiopaque lesions of the tendo Achillis. J Foot Surg 1990; 29: 533–42.
  7. Frey C, Rosenberg Z, Shereff MJ, et al. The retrocalcaneal bursa: anatomy and bursography. Foot Ankle 1992; 13: 203–7.
  8. Caudell GM. Insertional Achilles Tendinopathy. Clin Podiatr Med Surg 2017; 34: 195–205.
  9. Jonsson P, Alfredson H, Sunding K, et al. New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. Br J Sports Med 2008; 42: 746–9.
  10. Kedia M, Williams M, Jain L, et al. The effects of conventional physical therapy and eccentric strengthening for insertional achilles tendinopathy. Int J Sports Phys Ther 2014; 9: 488–97.
  11. Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial. J Bone Joint Surg Am 2008; 90: 52–61.
  12. Wei M, Liu Y, Li Z, et al. Comparison of clinical efficacy among endoscopy-assisted radio-frequency ablation, extracorporeal shockwaves, and eccentric exercises in treatment of insertional Achilles Tendinosis. J Am Podiatr Med Assoc 2017; 107: 11–16.
  13. McCormack JR, Underwood FB, Slaven EJ, et al. Eccentric exercise versus eccentric exercise and soft tissue treatment (Astym) in the management of insertional Achilles Tendinopathy. Sports Health 2016; 8: 230–7.
  14. Hamilton B, Remedios D, Loosemore M, et al. Achilles tendon rupture in an elite athlete following multiple injection therapies. J Sci Med Sport 2008; 11: 566–8.
  15. Yelland MJ, Sweeting KR, Lyftogt JA, et al. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med 2011; 45: 421–8.
  16. Hunt KJ, Cohen BE, Davis WH, et al. Surgical treatment of insertional achilles tendinopathy with or without flexor hallucis longus tendon transfer: a prospective, randomized study. Foot Ankle Int 2015; 36: 998–1005.
  17. Greenhagen RM, Shinabarger AB, Pearson KT, et al. Intermediate and long-term outcomes of the suture bridge technique for the management of insertional achilles tendinopathy. Foot Ankle Spec 2013; 6: 185–90.
  18. Maffulli N, Del Buono A, Testa V, et al. Safety and outcome of surgical debridement of insertional Achilles tendinopathy using a transverse (Cincinnati) incision. J Bone Joint Surg Br 2011; 93: 1503–7.
  19. McGarvey WC, Palumbo RC, Baxter DE, et al. Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot Ankle Int 2002; 23: 19–25.
  20. Tallerico VK, Greenhagen RM, Lowery C. Isolated gastrocnemius recession for treatment of insertional achilles tendinopathy: a pilot study. Foot Ankle Spec 2015; 8: 260–5.
  21. Leitze Z, Sella EJ, Aversa JM. Endoscopic decompression of the retrocalcaneal space. J Bone Joint Surg Am 2003; 85-A: 1488–96.
  22. Lui TH. Endoscopic calcaneoplasty and achilles tendoscopy with the patient in supine position. Arthrosc Tech 2016; 5: e1475–9.
  23. Chan KB, Lui TH, Chan LK. Endoscopic-assisted repair of acute Achilles tendon rupture with Krackow suture: an anatomic study. Foot Ankle Surg 2009; 15: 183–6.
  24. Lui TH. Technique tip: reattachment of the Achilles tendon after endoscopic calcaneoplasty. Foot Ankle Int 2007; 28: 742–5.
  25. Park YH, Jeong SM, Choi GW, et al. How early must an acute Achilles tendon rupture be repaired? Injury 2017; 48: 776–80.