Outcomes for Insertional Achilles Tendinopathy

NewsBot · Jun 21, 2021

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Functional Outcomes of Insertional Achilles Tendinopathy Treatment
A Systematic Review
Jarin, Ian J. MBS et al
JBJS Reviews: June 2021 - Volume 9 - Issue 6 - e20.00110

Background:
Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional, and effective treatment of each type can vary. We sought to investigate the current evidence on different treatment methods for insertional Achilles tendinopathy with a focus on functional outcomes.

Methods:
We performed a systematic review of the available literature using the PubMed/MEDLINE and Cochrane Central Register of Controlled Trials databases. Data from included studies were categorized according to treatment method and reported with respect to functional outcomes and complications.

Results:
A total of 1,457 abstracts were reviewed; 54 studies with 2,177 patients met the inclusion criteria. Among the 54 studies, 6 operative techniques and 6 nonoperative treatments were evaluated.

Conclusions:
Eccentric exercises and low-energy extracorporeal shockwave therapy (ESWT) have the greatest evidence for the initial management of insertional Achilles tendinopathy. ESWT has been increasingly studied in recent years, but more high-quality evidence is needed. Operative treatment with tenotomy, debridement, retrocalcaneal bursectomy, and calcaneal exostectomy is effective. Flexor hallucis longus tendon transfer may benefit cases of more severe disease. Minimally invasive procedures have a potential role in the treatment algorithm and require more rigorous study.
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NewsBot · Oct 25, 2021

Insertional Achilles Tendinopathy: Occupational Outcomes in the Military
Greg E. Lausé, MD, Rachel A. Egbert, MD, Paul M. Ryan, MD
Foot & Ankle Specialist October 23, 2021

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 · Jan 18, 2022

Review of Achilles Tendon Reattachment Using Double-Row Knotted and Knotless Techniques in the Management of Insertional Achilles Tendinopathy
Aaron T Scott et al
J Foot Ankle Surg. 2021 Dec 12;S1067-2516(21)00506-8

Insertional Achilles tendinopathy represents a chronic degenerative condition affecting the insertion of the Achilles. Surgery is indicated in recalcitrant cases and often involves extensive debridement followed by subsequent repair of the insertion. In the present study, we evaluate the results of knotted and knotless double-row suture systems for Achilles reattachment. Despite the popularity of double-row repairs, there is a relative paucity of clinic data regarding efficacy of the available implants. In a retrospective cohort study, 38 patients (40 Achilles tendons) who received double-row repairs between November 2012 and December 2016 were evaluated. In addition to demographic information, preoperative pain scores and symptom duration were recorded. Perioperative and postoperative records were reviewed, and telephone interviews were conducted to assess patient satisfaction, functional status, postoperative pain, and information regarding surgical complications. At a mean follow-up of 32.5 months, 35 (92.1%) patients reported satisfaction with the outcome. Decreased pain levels were reported in 38 (95%) ankles, with 21 (52.5%) ankles being rated pain-free postoperatively. Of the patients working prior to surgery, 20 (95.2%) were able to return to normal work duties, and all 11 (100%) patients who engaged in sports preoperatively were able to return to the same level of activity. Two patients developed postoperative infections, one of which required operative debridement. No Achilles avulsions were encountered. No significant differences were noted between the 2 operative techniques. Considering the available biomechanical data, along with high patient satisfaction rates and low rate of complications, double-row repair offers a viable option for recalcitrant insertional Achilles tendinopathy.
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NewsBot · Jan 19, 2022

Review of Achilles Tendon Reattachment Using Double-Row Knotted and Knotless Techniques in the Management of Insertional Achilles Tendinopathy
Aaron T. Scott, MD et al
December 11, 2021

Insertional Achilles tendinopathy represents a chronic degenerative condition affecting the insertion of the Achilles. Surgery is indicated in recalcitrant cases and often involves extensive debridement followed by subsequent repair of the insertion. In the present study, we evaluate the results of knotted and knotless double-row suture systems for Achilles reattachment. Despite the popularity of double-row repairs, there is a relative paucity of clinic data regarding efficacy of the available implants. In a retrospective cohort study, 38 patients (40 Achilles tendons) who received double-row repairs between November 2012 and December 2016 were evaluated. In addition to demographic information, preoperative pain scores and symptom duration were recorded. Perioperative and postoperative records were reviewed, and telephone interviews were conducted to assess patient satisfaction, functional status, postoperative pain, and information regarding surgical complications. At a mean follow-up of 32.5 months, 35 (92.1%) patients reported satisfaction with the outcome. Decreased pain levels were reported in 38 (95%) ankles, with 21 (52.5%) ankles being rated pain-free postoperatively. Of the patients working prior to surgery, 20 (95.2%) were able to return to normal work duties, and all 11 (100%) patients who engaged in sports preoperatively were able to return to the same level of activity. Two patients developed postoperative infections, one of which required operative debridement. No Achilles avulsions were encountered. No significant differences were noted between the 2 operative techniques. Considering the available biomechanical data, along with high patient satisfaction rates and low rate of complications, double-row repair offers a viable option for recalcitrant insertional Achilles tendinopathy.
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NewsBot · Jan 26, 2022

Shock Wave Therapy Associated with Eccentric Strengthening vs Isolated Eccentric Strengthening for Achilles Insertional Tendinopathy Treatment: A Double Blinded Randomized Clinical Trial
Nacime S. Mansur, MD, Oreste L. Carrazzone, Fabio Teruo Matsunaga, MD, PhD, ...
Foot & Ankle Orthopaedics January 21, 2022

Introduction/Purpose:
Lack of consensus inhibits Achilles insertional tendinopathy (AIT) management. The condition is usually treated with eccentric exercises (EE), despite its absence of satisfactory and standing results. Shock wave therapy (SWT) was presented as an alternative, but it is still supported by a paucity of studies that shows moderate outcomes. The purpose of this study is to determine if the association of shock wave therapy (SWT) with the eccentric exercises (EE) protocol improve rates of pain and function in patients with AIT.

Methods:
This was a single-centre, double blind, placebo-controlled, in parallel groups, randomized clinical trial. 119 patients diagnosed with AIT, were evaluated, and enrolled in the study from February 2017 to February 2019. They were divided in two treatment groups, SWT associated to EE (SWT group) and EE associated to sham (CON group). Three sessions of radial shockwaves (or sham) separated by 2 weeks and eccentric training for three months were applied. The primary outcome was the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) at 24 weeks. Secondary outcomes included the Visual Analogue Scale (VAS), Algometry, the Foot and Ankle Outcome Score (FAOS) and the 12 Item Short Form Health Survey (SF-12).

Results:
Both groups showed significant improvement with the corresponding treatment in the study period. However, there were no between-group differences (all ps > 0.05) in any of the outcomes. At the 24th week evaluation, the SWT group exhibited a mean VISA-A of 63.2 (CI 8.0) and the CON group of 62.3 (CI 6.9), p=0.876. Failures were higher in the SWT (38.3% to 11.5%, p=0.002) and recurrences were superior in the CON side (34.6% to 17.0%, p=0.047). There were no complications.

Conclusion:
Extracorporeal shockwave therapy does not potentialize the effects of eccentric strengthening in the management of Achilles insertional tendinopathy.
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NewsBot · Jan 28, 2022

Impingement in Insertional Achilles Tendinopathy Occurs Across a Larger Range of Ankle Angles and Is Associated With Increased Tendon Thickness
Anthony N Aggouras et al
Foot Ankle Int. 2022 Jan 27

Background: Insertional Achilles tendinopathy (IAT) is characterized by tendon degeneration and thickening near the tendon-bone insertion.11 Calcaneal impingement is believed to contribute to the pathogenesis of IAT.5 However, it is unclear how increased tendon thickness in individuals with IAT influences impingement. This study aimed to compare Achilles tendon impingement in individuals with and without IAT.

Methods: Eight healthy adults and 12 adults with clinically diagnosed symptomatic IAT performed a passive flexion exercise during which ankle flexion angle, anterior-posterior (A-P) thickness, and an ultrasonographic image sequence of the Achilles tendon insertion were acquired. The angle of ankle plantarflexion at which the calcaneus first impinges the Achilles tendon, defined as the impingement onset angle, was identified by (1) a anonymized observer (visual inspection method) and (2) a computational image deformation-based approach (curvature method).

Results: Although the 2 methods provided different impingement onset angles, the measurements were strongly correlated (R2 = 0.751, P < .05). The impingement onset angle and the thickness of the Achilles tendon insertion were greater in subjects with clinically diagnosed IAT (P = .0048, P = .0047). Furthermore, impingement onset angle proved to have a moderate correlation with anterior-posterior thickness (R2 = 0.454, P < .05).

Conclusion: Our findings demonstrated that increased tendon thickness in IAT patients is associated with larger impingement onset angles, raising the range of ankle angles over which the tendon is exposed to impingement.

Clinical relevance: Increased susceptibility to impingement may exacerbate or perpetuate the pathology, highlighting the need for clinical strategies to reduce impingement in IAT patients.
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NewsBot · Mar 15, 2022

Management of Insertional Achilles Tendinopathy
Jie Chen, Cory Frederick Janney, Mohammed Asad Khalid, Vinod Kumar Panchbhavi
J Am Acad Orthop Surg. 2022 Mar 10

Insertional Achilles tendinopathy is a common condition that can lead to chronic, debilitating heel pain in athletes and nonathletes alike. Conservative treatment options include activity and shoe wear modification, physical therapy, injections, and extracorporeal shock wave therapy. When nonsurgical treatment fails, surgical treatment is recommended. Although there are options aimed at preserving the tendon and débriding the retrocalcaneal bursa and excess bone formation, others are aimed at detaching the Achilles tendon to perform a thorough débridement and subsequent reattachment. Additional or alternate procedures may include a calcaneal closing wedge osteotomy, gastrocnemius lengthening, and flexor hallucis longus tendon transfer. Recent advances in suture anchor techniques further add to the complexity of available options. This review discusses the relevant anatomy, biomechanics, and pathophysiology as well as the recent available evidence for nonsurgical and surgical management of this condition to guide surgeons in selecting the most appropriate treatment for their patients.
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NewsBot · Apr 10, 2022

Management of Insertional Achilles Tendinopathy
Chen, Jie MD, MPH; Janney, Cory Frederick MD; Khalid, Mohammed Asad MD; Panchbhavi, Vinod Kumar MD, FACS
Journal of the American Academy of Orthopaedic Surgeons: March 10, 2022

Insertional Achilles tendinopathy is a common condition that can lead to chronic, debilitating heel pain in athletes and nonathletes alike. Conservative treatment options include activity and shoe wear modification, physical therapy, injections, and extracorporeal shock wave therapy. When nonsurgical treatment fails, surgical treatment is recommended. Although there are options aimed at preserving the tendon and débriding the retrocalcaneal bursa and excess bone formation, others are aimed at detaching the Achilles tendon to perform a thorough débridement and subsequent reattachment. Additional or alternate procedures may include a calcaneal closing wedge osteotomy, gastrocnemius lengthening, and flexor hallucis longus tendon transfer. Recent advances in suture anchor techniques further add to the complexity of available options. This review discusses the relevant anatomy, biomechanics, and pathophysiology as well as the recent available evidence for nonsurgical and surgical management of this condition to guide surgeons in selecting the most appropriate treatment for their patients.
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NewsBot · May 4, 2022

Clinical outcomes following surgical management of insertional Achilles tendinopathy using a double-row suture bridge technique with mean two-year follow-up
T L Lewis et al
Eur J Orthop Surg Traumatol. 2022 May 4

Background: The clinical outcomes following surgical management of insertional Achilles tendinopathy (IAT) vary depending on the surgical technique used to reattach the Achilles tendon following debridement. The aim of this study was to investigate the clinical outcomes of patients with IAT who underwent surgical management with a double-row suture bridge technique used to reattach the Achilles tendon.

Methods: A retrospective review of consecutive patients diagnosed with IAT, who underwent surgical management utilising a double-row suture bridge technique (Arthex Speedbridge), and a minimum of 3-month follow-up were included. The primary outcome was the Manchester-Oxford Foot Questionnaire (MOXFQ) Index score which is a patient reported outcome measure (PROM). Secondary outcomes included EuroQol EQ-5D-5L health-related quality of life PROM and complication rates.

Results: Between July 2013 and June 2020, 50 consecutive patients (23 male; 27 female) were included. The mean age (± standard deviation) was 52.3 ± 11.3 (range 29.0-84.3). Pre- and post-operative PROM data were available for all cases. The mean follow-up was 2.4 ± 1.9 years. The MOXFQ Index score improved from 48.5 to 12.4 (p < 0.01), EQ-5D-5L improved from 2.7 ± 0.46 to 1.2 ± 0.37 (p < 0.01), and EQ-VAS improved from 48.0 ± 18.4 to 84.1 ± 12.6 (p < 0.01). Four patients had complications which were of minimal clinical relevance and caused no deviation from routine recovery. There were no cases of tendon rupture.

Conclusion: This study has demonstrated that surgical management of IAT is safe and effective with clinical improvement in both clinical and general health-related quality of life outcome PROMs.
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NewsBot · May 22, 2022

Risk Factors for Failure of Conservative Management of Insertional Achilles Tendinosis
Bryce F Kunkle et al
Foot Ankle Spec. 2022 May 18

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 · Jul 3, 2022

Chronic insertional Achilles tendinopathy secondary to congenital os Achilles: A case report
Frederic J.Washburn et al
International Journal of Surgery Case Reports Volume 96, July 2022, 107355

Highlights
•Insertional Achilles tendinopathy is multifactorial, but mostly an overuse disorder.
•This is a unique case of a successfully treated IAT due to congenital os Achilles.
•Consideration of congenital os Achilles is valuable in evaluating chronic IAT.
•More studies will help guide future recognition and management for this condition.
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Introduction
Insertional Achilles tendinopathy is a common overuse disorder affecting the foot and ankle that can lead to the development of a Haglund's deformity with chronicity, a retrocalcaneal exostosis that forms at the Achilles insertion site, further increasing pain and dysfunction.

Presentation of case
We report a case of a healthy, 35–40-year-old male with chronic left-sided insertional Achilles pain beginning in early adolescence. Physical exam demonstrated bilateral prominences on the posterior aspect of both heels, exquisitely tender on the left and without range of motion deficits. Imaging demonstrated a large calcific ossicle clearly within the tendinous insertion of the Achilles onto the left calcaneus. He underwent surgical intervention to provide pain relief and restore function. He exhibited full recovery post-operatively and has now returned to full functional activities.

Discussion
Given his symptom pathogenesis and progression, this patient may likely have suffered from chronic insertional Achilles tendinopathy due to an accessory ossicle that we believe was congenital. Current literature describes an additional secondary ossification center that appears over the dorsal, posterosuperior surface of the calcaneus. We suspect that there was a lapse in fusion at this additional ossification center that contributed to his pathological condition.

Conclusion
This case report presents a unique occurrence of Achilles tendinopathy likely due to an accessory ossicle of congenital etiology. This highlights the importance of investigating the prevalence of this condition in those with chronic insertional Achilles tendinopathy, thus providing meaningful insight in considering effective treatment modalities in the management of these patients.
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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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