Definition
Insertional Achilles tendinopathy is a condition in which the lower section of the Achilles Tendon, adjacent to the calcaneum (heel bone) becomes thickened and painful. In many cases there is also a prominent spur of bone on the top of the heel bone (Haglund spur or Haglund exostosis) which can impinge upon the Achilles’ tendon or cause inflammation of the bursa between them. It is more common in men and in middle age. Many factors can contribute to the development of insertional Achilles tendinopathy such over-use, poor footwear, leg or foot deformity, and tightness of the gastrocnemius and soleus (calf muscles).
Diagnosis
The diagnosis can be made clinically from your history and by examining your ankle. X-rays can be useful to identify any Haglund bone spurs or calcium deposits that may be present in the tendon. MRI scans are a more sensitive way of looking for structural damage within the tendon itself and inflammation in the pre-Achilles bursa (fluid-filled sac that lies between the heel bone and the tendon).
Conservative Treatment
Insertional Achilles tendinopathy can improve with exercises to stretch the calf muscles and with modification to shoes.
Surgical Treatment
Surgery should be considered once conservative treatment has failed. It can take a number of different techniques which aim mostly to reduce the contact between the Achilles and the heel bone.
If there is significant impingement between the Haglund spur and the Achilles tendon but little structural damage within the tendon the spur can be burred away using an arthroscopic (keyhole) or open technique. If the gastrocnemius muscle is tight, it may be released at the same time.
If there is extensive damage within the Achilles itself, it may be better to perform open surgery to debride (remove) the damaged areas and repair the healthy ones. Sometimes this includes detaching the tendon from the heel bone, debriding and re-attaching it. If the tendon is found to be damaged beyond repair it may be removed and another tendon, usually FHL (flexor hallucis longus) diverted into the heel bone to take over its function.
Alternatively, an operation to cut and re-align the calcaneum (heel bone) so it no longer impinges on the Achilles, fixing it back together with one or more screws can be performed.
Most techniques require the patient to be kept non-weight bearing in a boot or plaster for approximately two weeks, with gradually increasing weightbearing and rehabilitation thereafter. Complete FHL tendon transfer and osteotomy (cutting and re-aligning) of the heel bone (calcaneum) usually require the patient to be non-weight bearing for between four and six weeks.
Outcomes
Published studies have shown good results with all of these techniques; which technique is most appropriate depends on the patient’s needs and the extent of tendon damage.