Insertional Achilles Tendonitis

The Achilles tendon is the largest tendon in the body. Insertional Achilles tendonitis is a degeneration of the Achilles tendon fibers where the tendon inserts into the heel bone. It may be associated with inflammation of a bursa or tendon sheath in the same area.

Causes

Insertional Achilles tendonitis primarily is caused by degeneration of the tendon over time. The average patient is in their 40s. Conditions associated with increased risk include psoriasis and Reiter’s syndrome, spondyloarthropathy (generalized inflammation of joints), gout, familial hyperlipidemia, sarcoidosis, and diffuse idiopathic skeletal hyperostosis as well as the use of medications such as steroids and fluoroquinolone antibiotics.

Symptoms

Most patients report a gradual onset of pain and swelling at the back of the heel bone without specific injury. At first, the pain may only be noticeable after activity, but it becomes more constant over time. The pain increases with jumping or running and especially with sports requiring short bursts of these activities. Patients experience tenderness over the back of the heel bone and the bone often becomes more prominent. It is painful to position the ankle above a 90 degree position.

Your foot and ankle orthopaedic surgeon will perform a clinical exam to determine if you have insertional Achilles tendinosis. They may order X-rays to look for calcification (bone) deposits within the tendon at its insertion into the heel. These deposits are present approximately 60 percent of the time and are associated with a more guarded success rate for non-surgical treatment and a much longer recovery time for surgical treatment. X-rays also may reveal a Haglund’s deformity.
MRIs may be used to determine the extent of tendon degeneration as well as other factors such as bursitis, which may contribute to heel pain.

Potential Treatments

Non-surgical treatments, including liberal use of nonsteroidal anti-inflammatory drugs, heel lifts, stretching, and switching to shoes that do not put pressure over this area, are effective for the majority of patients. If symptoms persist, your surgeon may recommend night splints, arch supports, physical therapy, or the use of a cast or brace. Nitroglycerin patches also may be of benefit to increase the blood supply to this area.

Surgery may be recommended if there is no improvement after several months of non-surgical treatment. During the procedure, your surgeon will make an incision over the back of the heel and remove the diseased portion of the tendon. A small amount of bone is removed from the back of the heel bone to create a healthy area for the tendon to attach. Your surgeon will reattach the tendon using special bone anchors that allow the tendon to be fixed to the bone.

Several different approaches and techniques, including endoscopy, may be used. There is no clear consensus regarding which technique is best. In older patients or those in whom more than 50% of the tendon is removed, one of the other tendons at the back of the ankle usually is transferred to the heel bone to assist the Achilles tendon with strength as well as provide a better blood supply to this area.

After surgery, you will be put into a cast or removable cast boot. If the tendon was not fully detached from the heel, the doctor may allow you walk around in the boot for 6-8 weeks and work on motion exercises with physical therapy.

If the tendon was totally detached or another tendon was used in the repair, a cast or boot may be used for three months. For the first six weeks, you should not place any weight on the foot, but in the second six weeks you can walk in the cast or boot.

After the cast or boot comes off, you can wear shoes with a small heel lift and begin physical therapy. The length of time needed to return to full activities and sports is determined by the strength of the repair and the speed of recovery with physical therapy. Full recovery can take 6-12 months. Some patients may require 1-2 years to recover.

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Complications with this surgery can include residual pain, infections, weakness or tightness, or rupture of the repair.