Insertional Achilles Tendinopathy

NewsBot · Jun 24, 2021

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Insertional Achilles Tendinopathy

NewsBot · Jun 24, 2021

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NewsBot · Jul 3, 2022

Insertional tendinopathy of the Achilles tendon.
Treatment from start to finish
C. Álvarez Gómez, C. Gamba
Rev Esp Artrosc Cir Articul En. 2022;29(1):68-80

Insertional tendinopathy of the calcaneal tendon is a common
disorder associated with advancing age and recurrent microtraumatisms due to overuse of the tendon in patients with predisposing factors. The presence of lesions in the bursae, the formation of calcifications, and damage to the tendon structure itself
are common findings.
Most studies in the literature suggest that patients with insertional tendinopathy should initially be managed on a conservative basis during a period of 3-6 months, including guided exercise programs, high-energy extracorporeal shock wave therapy,
and physiotherapy.
The surgical treatment options in turn include debridement and
resection of inflamed bursae, hypertrophic synovial tissue, insertional calcifications and intratendinous degenerative tissue,
the resection of prominences of the posterior tuberosity, and reinsertion of the Achilles tendon. Postoperative complications are
not infrequent, with wound healing problems being one of the
most frequent complications. Surgical treatment of insertional
tendinopathy of the Achilles tendon often resolves the pain and
improves function. Complete rehabilitation may be reached up
to one year after the operation.
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NewsBot · Aug 11, 2022

Endoscopic Treatment of Insertional Achilles Tendinopathy
A.I.M.Ghonim, H.H.Ahmed and E.M.Mohamady
Benha Journal of Applied Sciences (BJAS)

Background: Achilles tendinopathy is a common hindfoot disorder which affects both the active and non-active
population. It can be classified as insertional and non- insertional tendinopathy. Insertinal acilles tendinopathy presents 20% to
25% of total Achilles tendon related disorders. Operative treatment in cases of failure of conservative treatment for 6 months in
the form of open surgery and minimally invasive endoscopic treatment. The aim of this study was to evaluate the outcome of
endoscopic treatment of insertional Achilles tendinopathy. Methods: In our study we had 15 patients with endoscopic
treatment of insertional achilles tendinopathy with mean Pre-operative AOFAS hindfoot scale was 58.2 (36-80) and mean postoperative AOFAS hindfoot scale after 6 months was 86.53 (67-97) with P value.001 which showed significant improvement.
Results: In our study there were two cases showed non improvement of pain and function postoperatively which maybe due
to high BMI (35.05 and 33.44), they were have triple pathology in the form of (haglund deformity, retrocalcaneal bursitis and
retrocalcaneal exostosis) and more Achilles tendon degeneration. There were no postoperative complications in the form of
deep venous thrombosis, sural nerve injury, Achilles tendon rupture and wound infection but only 3 cases have postoperative
scar tenderness. Conclusion: Endoscopic technique for treatment of insertional achilles tendinopathy seemed to be a safe and
efficient as the open technique and has the advantage of small incisions with better cosmetic scar, early wightbearing which
decrease the risk of deep venous thrombosis, less risk to weaken the Achilles tendon insertion that can cause tendon rupture,
and also fewer wound complications such as dehiscence, painful or ugly scars, nerve entrapment within the scar and
hypoesthesia.
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NewsBot · Oct 2, 2022

Treatment of Insertional Achilles Tendinosis With Polyurethane Urea-Based Matrix Augmentation
Daniel J Cuttica et al
Foot Ankle Spec. 2022 Sep 30

Introduction: Surgical treatment for insertional Achilles tendinosis (IAT) sometimes requires tendon repair augmentation. The purpose of this study is to evaluate the efficacy of polycaprolactone-based polyurethane urea (PUUR) matrix augmentation in the treatment of IAT.

Methods: A retrospective review was performed in surgically treated IAT. Repairs were augmented with a PUUR matrix. Factors evaluated included date of full weightbearing, patient satisfaction, Visual Analog Scale (VAS) pain score, strength, and ankle motion. The Wilcoxon signed-rank test was used to compare baseline and final follow-up VAS scores.

Results: A total of 18 cases were included in the study. The mean patient age was 54.61 ± 8.25 (40-75) years with a mean follow-up of 163.61 ± 57.81 (92-314) days. Patient satisfaction was obtained on 15 of 18 patients, with 14 patients satisfied with their outcome. Mean VAS for pain significantly decreased from 6.19 ± 1.97 (2.5-9) to 0.83 ± 1.54 (0-5) postoperatively, which was statistically significant (P < .01).

Conclusion: Achilles tendon augmentation with the PUUR matrix is a viable option in the treatment of IAT. Its use in this condition has minimal morbidity and can be an alternative to other forms of augmentation.
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NewsBot · Oct 18, 2022

Differences at the Achilles Insertion Between Adults with Insertional and Midportion Achilles Tendinopathy as Observed Using Ultrasound
Nabeel Hamdan Alghamdi et al
Muscles Ligaments Tendons J. 2022 Apr-Jun;12(2):115-121

Background: The purpose of this study was to determine structural and pathological differences of Achilles tendon insertion between insertional Achilles tendinopathy (IAT) and midportion Achilles tendinopathy (MidAT) in both injured and uninjured sides.

Methods: Patients (n=34; 58.8% male) with unilateral Achilles tendinopathy (50% with IAT; 50% with MidAT) were recruited. Median age 52 years and Victorian Institute of Sport Assessment - Achilles (VISA-A) score mean 59, and 17 (12 male) had MidAT, median(range) age of 58(48)years, and VISA-A score mean(SD) 59.1(19.7). Ultrasound imaging was used to evaluate structural measurements at the insertion (insertional length, bone-to-insertion length, and tendon insertion angle), tendon length (calcaneus to soleus), tendon thickness at the calcaneal edge, and the presence of pathological changes (boney deformity and/or calcification). A 2×2 mixed Analysis of Variance (group by side) was used to compare IAT and MidAT groups and injured and uninjured sides.

Results: Tendon thickness at the calcaneus on the injured side was significantly greater than the uninjured side in the IAT group but not in the MidAT group (P=.001). VISA-A score was 59.9(18.7) in IAT group and 59.1(19.7) for MidAT group (P=.909). There were no significant group-by-side interactions for structural measurements at insertion site.

Conclusion: Calcaneal edge tendon thickness was the only significant structural difference observed between involved and uninvolved sides in IAT, although this was not found in in MidAT.
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NewsBot · Nov 9, 2022

Surgical treatment of calcifying insertional Achilles tendinopathy via a lateral approach
Michael H Amlang et al
Oper Orthop Traumatol. 2022 Nov 7

Objective: Reduction of pain and swelling over the Achilles tendon insertion while maintaining function.

Indications: Strong, intolerable pain over the Achilles tendon insertion with chronic, calcifying insertional tendinopathy that does not respond to non-operative treatment over a minimum of 6 months.

Contraindications: Chronic wounds or severe circulatory deficits at the foot or ankle, irradiating or projected pain, complex regional pain syndrome (CRPS).

Surgical technique: The intratendinous heel spur is resected via a lateral approach. The superior surface of the calcaneal tuberosity is trimmed by resection of the dorsal heel spur with the oscillating saw. A second osteotomy at the medial edge of the tuberosity extends to the insertion of the plantaris tendon. With the third osteotomy, the Haglund deformity is resected. At the resulting area with cancellous bone, the Achilles tendon is reinserted with a suture anchor.

Postoperative management: A ventral plastic splint in 20° plantar flexion is worn for a week. Full weight-bearing is allowed in a walking boot with 4 cm heel lift for 6 weeks. The heel lift is then gradually reduced for another 2 weeks. After 8 weeks only an elastic wedge of 1 cm is worn. Physical therapy (isometric exercises) starts in the boot and is intensified after removal of the boot.

Results: Seven of 12 patients treated with that technique for calcifying insertional Achilles tendinopathy (58%) stated being pain free according to the Likert scale, while the remaining 5 patients (42%) reported a "substantial improvement". The VISA‑A score averaged 84 of 100 points. Postoperative complications have not been observed.

Keywords: Achilles tendinopathy; Haglund deformity; H
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NewsBot · Feb 8, 2023

Comparative short-term effectiveness of non-surgical treatments for insertional Achilles tendinopathy: a systematic review and network meta-analysis
Violet Man-Chi Ko et al
BMC Musculoskelet Disord. 2023 Feb 7;24(1):102

Background: The incidence of Achilles tendinopathy has risen over the past decades. Insertional Achilles tendinopathy is characterised by tissue degeneration of the Achilles tendon from its insertion in the calcaneus to up to 2 cm proximally. This clinical condition is accompanied by pain, loss of function and diminished exercise tolerance. Numerous conservative treatment modalities are available to participants with insertional Achilles tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, laser therapy, cryotherapy, therapeutic ultrasound, and orthotics. Eccentric exercise and extracorporeal shockwave therapy may reduce pain in participants with non-calcified insertional Achilles tendinopathy. However, no specific treatment is recommended over another due to the low methodological quality of trials. Given the lack of standard or preferred non-surgical treatment and the potential risks of surgical treatment, there is an imminent need to reassess different non-surgical treatments based on the newest evidence. Thus, this systematic review aims to evaluate the clinical effectiveness of the various non-surgical treatments for insertional Achilles tendinopathy.

Methods: AMED EBSCOhost, CINAHL, EBSCOhost, EMBASE, PEDro, PubMed, Web of Science, and Clinicaltrials.gov were searched from 1992 to 14th October 2022, randomised controlled trials of adults with insertional Achilles tendinopathy investigating non-surgical treatments compared with each other or no treatment, placebo/sham control. Two reviewers independently screened and extracted the data. Random effects of network meta-analysis immediately after treatments were used to report comparative treatment effects. The surface under the cumulative ranking probabilities was calculated to assess the relative ranking of treatments.

Results: Nine trials (total n = 464 participants) were included. This review recommended the combination of eccentric exercise and soft tissue therapy to manage insertional Achilles tendinopathy. With the highest SUCRA values of 84.8, and the best mean rank of 1.9, Eccentric exercise plus soft tissue treatment ranked as the most effective treatment for short-term pain.

Conclusions: This is the first NMA of non-surgical treatment focusing on short-term pain control for IAT which eccentric exercise plus soft-tissue therapy was found to be the most effective treatment combination. However, the overall confidence in non-surgical treatments from all included trials was very low. No recommendation of the best treatment option can be made from this review.
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NewsBot · May 29, 2023

Association of Haglund Deformity Size and Insertional Achilles Tendinopathy
Wonyong Lee et al
Source

Background:
We aimed to investigate the effect of Haglund deformity size on insertional Achilles tendinopathy (IAT) using a new measurement system and identify independent risk factors of IAT with Haglund deformity.
Methods:
We reviewed medical records of patients with IAT and age/sex-matched patients with diagnoses other than Achilles tendinopathy. Radiographs were reviewed to identify posterior heel spur, plantar heel spur, and intra–Achilles tendon calcification, and to measure Fowler-Philip angle, calcaneal pitch angle, and Haglund deformity angle and height. We introduced a new measurement system for Haglund deformity angle and height and evaluated its intraobserver and interobserver reliability. Multivariate logistic regression analysis was performed to identify independent risk factors of IAT with Haglund deformity.
Results:
Fifty patients (55 feet) were enrolled in the study group, equaling the size of the age/sex-matched control group. The new Haglund deformity measurement system showed excellent intraobserver and interobserver reliability. No significant differences between the 2 groups were noted in Haglund deformity angle and height: 6.0 degrees in both groups, and 3.3 mm vs 3.2 mm in the study and control group, respectively. The study group had significantly higher calcaneal pitch angle, incidence of posterior heel spur, plantar heel spur, and intra–Achilles tendon calcification: 5.2 vs 23.1 degrees (P = .044), 81.8% vs 36.4% (P < .001), 76.4% vs 34.5% (P = .003), and 67.3% vs 5.5% (P < .001), respectively. Multivariate logistic regression analysis identified independent risk factors of IAT: posterior heel spur (OR = 3.650, 95% CI = 1.063, 12.532), intra–Achilles tendon calcification (OR = 55.671, 95% CI = 11.233, 275.905), and increased calcaneal pitch angle (OR = 6.317).
Conclusion:
Based on our results, the actual size of Haglund deformity as we have reliably measured was not associated with IAT, suggesting a routine Haglund deformity resection may be unnecessary in the surgical treatment of IAT. If patients with Haglund deformity have posterior heel spur, intra–Achilles tendon calcification, or increased calcaneal pitch angle, a higher chance of IAT can be predicted.
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NewsBot · Jul 6, 2023

Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review
Kenichiro Nakajima
World J Orthop. 2023 Jun 18;14(6):369-378

Studies of minimally invasive surgery for insertional Achilles tendinopathy are limited. To establish this surgery, the following techniques must be minimally invasive: Exostosis resection at the Achilles tendon insertion, debridement of degenerated Achilles tendon, reattachment using anchors or augmentation using flexor hallucis longus (FHL) tendon transfer, and excision of the posterosuperior calcaneal prominence. Studies on these four perspectives were reviewed to establish minimally invasive surgery for insertional Achilles tendinopathy. Techniques for exostosis resection were demonstrated in one case study, where blunt dissection around the exostosis was performed, and the exostosis was resected using an abrasion burr under fluoroscopic guidance. Techniques for debridement of degenerated Achilles tendon were demonstrated in the same case study, where the space left after resection of the exostosis was used as an endoscopic working space, and the degenerated Achilles tendon and intra-tendinous calcification were debrided endoscopically. Achilles tendon reattachment techniques using suture anchors have been demonstrated in several studies. However, there are no studies on FHL tendon transfer techniques for Achilles tendon reattachment. In contrast, endoscopic posterosuperior calcaneal prominence resection is already established. Additionally, studies on ultrasound-guided surgeries and percutaneous dorsal wedge calcaneal osteotomy as minimally invasive surgery were reviewed.
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NewsBot · Jul 27, 2023

Two-Year Clinical and Radiologic Outcomes Following Surgical Treatment of Insertional Achilles Tendinopathy Using a Central Tendon-Splitting Approach
Adriel You Wei Tay et al
Source

Background:
If conservative treatment of insertional Achilles tendinopathy (IAT) fails, surgery is often considered. Various surgical approaches have been used including the central Achilles tendon splitting approach. This study aimed to report the 2-year clinical and radiologic outcomes after surgical treatment of IAT with a central tendon-splitting approach.
Methods:
Seventy-five cases of IAT treated surgically via the open central tendon-splitting approach were analyzed. Clinical outcomes included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, visual analog scale (VAS), 36-Item Short Form Health Survey (SF-36) physical (PCS) and mental (MCS) component summary scores, all measured at baseline and 6 and 24 months postoperatively. Radiologic parameters measured included the Fowler-Philip angle (FPA) and parallel pitch lines (PPL).
Results:
Three patients had clinically significant wound issues but healed completely by 3 weeks. Mean AOFAS score improved from 45.63 preoperatively to 94.71 at 24 months. Mean VAS score improved from 6.73 preoperatively to 0.55, mean SF-36 PCS from 35.98 to 48.74, and mean SF-36 MCS from 53.04 to 55.43 at 24 months. Satisfaction at 2 years was 94.3%. Mean FPA decreased from 62.0 degrees preoperatively to 34.0 degrees postoperatively. PPL was positive in 82.7% (62 of 75) of cases preoperatively, decreasing to 1.3% (1 of 75) postoperatively. Increasing age and higher preoperative VAS and SF-36 MCS scores were significantly associated with improvements in postoperative AOFAS, SF-36 PCS, and MCS scores.
Conclusion:
Surgical treatment of IAT via the central tendon-splitting approach achieved substantial improvements in all patient-reported outcome measures measured. These excellent clinical outcomes continued to show improvement 2 years postoperatively.
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NewsBot · Aug 16, 2023

Risk Factors for Failure of Conservative Management of Insertional Achilles Tendinosis
Bryce F. Kunkle et al
Source

Introduction:
While many patients benefit from nonoperative treatment of insertional Achilles tendinopathy (IAT), some elect for surgical debridement and reconstruction. The purpose of this study is to determine the relationship of patient demographic characteristics, comorbidity profiles, and radiological parameters with failure of conservative management of IAT.
Methods:
A retrospective chart review was performed to identify patients who received either surgical or nonsurgical treatment of IAT at an academic institution from September 2015 to June 2019 (N = 226). Demographic and comorbidity data, and the presence and magnitude of relevant radiological parameters were collected and compared between the surgically (n = 48) and nonsurgically (n = 178) treated groups.
Results:
No significant differences could be detected between groups regarding demographic factors or previous procedures. The surgery group was significantly more likely to have evidence of Haglund’s deformity on clinical exam (83% vs 69%, P = .005), lower SF-12 physical scores (25.5 vs 35.5, P < .001), higher VAS pain scores (6.3 vs 5.3, P = .033), any mental illness (33% vs 20%, P = .044), and depression (27% vs 12%, P = .012).
Discussion:
Patients who received surgery for IAT were significantly more likely to have evidence of Haglund’s deformity on clinical exam, depression, higher VAS pain scores, and lower SF-12 physical scores. Both patients and surgeons should be aware of the higher rates of failure of conservative treatment in these patients.
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NewsBot · Sep 6, 2023

Insertional Achilles Tendinopathy: Occupational Outcomes in the Military
Greg E. Lausé, MD, Rachel A. Egbert, MD, and Paul M. Ryan, MD
SOurce

A retrospective review of consecutive patients diagnosed with insertional Achilles tendinopathy (IAT) was performed. Outcomes included Visual Analog Scale (VAS) pain scores, return to run rates, and return to military duty rates. Our data analysis included 113 patients; 58 (55%) patients required surgery. Mean duration of follow-up was 42 months (range, 12-143). Mean age at the time of surgery was 37.2 years (range, 21-54). VAS scores significantly improved from 5.4 at the preoperative visit to 2.9 at 24 months. There was no significant improvement in VAS scores after the 3-month postoperative visit. Mean return to run time was 9 months (range, 4.5-16). At 1 year, 80% (46/58) of patients returned to military duty. Complications requiring return to the operating room were observed in 6 patients (9%). The high rate of return to duty and significant improvement in pain scores demonstrate that the surgical management of IAT is a viable treatment option for patients who could not otherwise remain on active duty. With that said, the complication rate of 27% is high. Patients and providers should consider the risks, benefits, and duration of therapy during their shared decision-making process.
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NewsBot · Dec 24, 2023

Recurrence rates for surgically treated insertional Achilles tendinopathy
Hubert Hörterer et al
Arch Orthop Trauma Surg. 2023 Dec 12

Introduction: Insertional Achilles tendinopathy (IAT) is a challenge for every orthopedic surgeon. Although surgical intervention is difficult to avoid after frustrating conservative therapy, little is known about recurrence of this disorder. Therefore the aim of the study was to assess the recurrence rate after primary IAT surgery.

Materials and methods: The authors previous published cohort on primary IAT surgery was reanalyzed. Patients with a follow-up Foot and Function Index (FFI) at one year and final follow-up were included. IAT recurrence was defined as a FFI worsening between one year and final follow-up of > 6.5 points. General demographics, surgical details, complications, and the patient reported outcome (PROM) were assessed.

Results: Out of 58 included patients (51 ± 14 years), 8 patients (14%) suffered IAT recurrence after an average of 50 ± 25 months. None of the assessed factors was predictive for an IAT recurrence.
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NewsBot · Jan 14, 2024

Impact of BMI on the Surgical Management of Chronic Insertional Achilles Tendinopathy
Nathaniel A Ptak , Ryan B Rigby
J Foot Ankle Surg. 2023 Dec 25

Posterior heel pain secondary to insertional Achilles tendinopathy is a common condition that often times requires surgical management. Typically, this involves reflecting a portion of the Achilles tendon from its insertion in order to adequately debride devitalized or thickened tendon as well as any osseous prominence and then reattached into the calcaneus via suture anchors. Oftentimes, it is suggested that patients with an increased body mass index (BMI) have a higher risk of complications. However, there is no published evidence to support this claim. The present study is a retrospective review of 78 patients that underwent detachment/reattachment of the Achilles tendon for chronic insertional Achilles tendinopathy. Patients were separated into three groups based on BMI: normal, obese, and morbidly obese. The mean BMI of all patients included was 35.6 kg/m2 (range: 21.8-54.9, SD: 6.9). We compared complication rates between the groups and found no significant difference (p = 0.541). Patients in all groups also demonstrated statistically significant improvements in both American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle scores (Normal BMI: p = 0.002; Obese: p = <0.001; Morbidly obese: p = <0.001) and Patient-Recorded Outcomes Measurement Information System (PROMIS) scores (Normal BMI: p = 0.003; Obese: p = <0.001; Morbidly obese: p = 0.001). In conclusion, the results of our study demonstrate that detachment/reattachment of the Achilles insertion in the management of insertional Achilles tendinopathy in obese and morbidly obese patients may be safe and effective without the risk for increased complications
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