Operative management of insertional achilles tendinopathy
Insertional Achilles tendinopathy is a disorder involving the inflammation and degeneration of the distal Achilles tendon located at the tendinous insertion onto the posterior calcaneus. The incidence has been reported around 4% in the general population and up to 21% in running and jumping athletes. There are two distinct groups of patients who present with this condition: younger, athletic individuals and older, more comorbid individuals; the latter cohort is typically less responsive to conservative treatment. Insertional Achilles tendinopathy is primarily a clinical diagnosis presenting as posterior heel pain, swelling or fullness at the Achilles insertion, and exacerbation of pain following activity or with closed-back shoe wear. In general, the indication for surgical treatment is persisting pain and limitations in daily activities and/or sports activities despite exhausting conservative measures. The surgical technique must address all pathology that is producing the pain, and one should consider the degree and severity of tendon involvement and the presence and extent of intratendinous calcification or enthesophytes, a prominent posterosuperior calcaneus (Haglund's deformity), retrocalcaneal bursitis, or equinus deformity. The posterior midline transtendinous approach has become the most commonly utilized approach as it allows adequate access to perform all potential indicated procedures: retrocalcaneal bursectomy, calcaneal exostectomy to remove the Haglund's and enthesophytes, partial detachment of the Achilles tendon, debridement of all degenerative tendon and intratendinous calcification, and repair of the Achilles tendon back to the calcaneus. Other surgical considerations include a flexor hallucis longus transfer/augmentation, endoscopic bursectomy and calcaneoplasty, Zadek osteotomy, V-Y advancement, and gastrocnemius recession. Overall, patients with insertional Achilles tendinopathy refractory to conservative measures experience positive results following operative intervention with high patient-reported functional outcome scores and patient satisfaction.
