Treatment options for Achilles Insertional Calcific Tendinopathy

podesh · Mar 3, 2011

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Hi I'm looking for help and treatment strategies for the above. I have a 45 yr old woman with the largest bony spurs?? calcified achilles insertion?? I have ever seen. She's had this condition for approx 2yrs and is suffering greatly. There is a large amount of swelling and pain, she finds it difficult to wear shoes.

I have just started in private practice after many years in the public sector, specialising in wounds!! so feeling slightly out of my depth. I sent her away with heel lifts, taping. I also suggested very gentle calf stretches as she also has very tight gast and soleus. But to my horror, I read that you shouldn't get the patient to stretch. She's coming back in today, I'm looking forward to seeing how she is going.

We did talk about surgery as a last resort, but she's really not keen, any more ideas on what I should be suggesting would be much appreciated.

Many Thanks
Esher

Kevin Kirby · Mar 3, 2011

podesh said: ↑

Hi I'm looking for help and treatment strategies for the above. I have a 45 yr old woman with the largest bony spurs?? calcified achilles insertion?? I have ever seen. She's had this condition for approx 2yrs and is suffering greatly. There is a large amount of swelling and pain, she finds it difficult to wear shoes.

I have just started in private practice after many years in the public sector, specialising in wounds!! so feeling slightly out of my depth. I sent her away with heel lifts, taping. I also suggested very gentle calf stretches as she also has very tight gast and soleus. But to my horror, I read that you shouldn't get the patient to stretch. She's coming back in today, I'm looking forward to seeing how she is going.

We did talk about surgery as a last resort, but she's really not keen, any more ideas on what I should be suggesting would be much appreciated.

Many Thanks
Esher
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Esher:

Try open back clogs or clog style Z-coil shoes, icing therapy 20 minutes twice a day, avoidance of wearing enclosed-heel shoes or barefoot, and topical Voltaren Gel three times a day. If these conservative measures don't relieve the pain sufficiently, then surgical removal of the posterior spurs does work well for these patients.

G Flanagan · Mar 3, 2011

Two recent articles from PodToday have covered Calcific Tendinosis and insertional pain of the Tendo Achilles.

http://www.podiatrytoday.com/how-conquer-achilles-insertional-calcific-tendinosis

http://www.podiatrytoday.com/keys-d...tional-pain-and-retrocalcaneal-exostosis-pain

lucycool · Mar 3, 2011

thank you very much!! I was just about to ask about this as a pt came in yesterday with a similar problem!!

NewsBot · Dec 22, 2015

Use of a Central Splitting Approach and Near Complete Detachment for Insertional Calcific Achilles Tendinopathy Repaired With an Achilles Bridging Suture
Craig T. Gillis, DO, Jason S. Lin, MD
JFAS; Article in Press

After 3 to 6 months of conservative management for insertional calcific Achilles tendinopathy, operative intervention might be warranted. Despite a success rate of 75% to 100% with surgery, no consensus has been reached on the amount of acceptable detachment of the Achilles tendon. The present case series reports on the results of a central splitting approach with 80% to 90% detachment of the Achilles insertion repaired with a double-row bridging suture device. A total of 14 patients (16 heels) for whom nonoperative management for insertional calcific Achilles tendinopathy had previously failed were enrolled in the present study they had undergone surgical management. The patients were followed up for a mean of 18 (range 11 to 25) months postoperatively and were evaluated using the American Orthopaedic Foot and Ankle Society Hind Foot scoring system, 36-item Short Form Health Survey questionnaire, and pre- and postoperative visual analog pain scale. The mean visual analog pain scale core had decreased 5.84 (range 1 to 9) points postoperatively (p < .001). The mean postoperative American Orthopaedic Foot and Ankle Society Hind Foot score was 87 ? 19.7 (range 52 to 105) points. One patient reported moderate pain with no limitation of activities. The mean 36-item Short-Form Health Survey score for physical functioning was 77.7 (range 30 to 100) points postoperatively in 11 patients. No patient reported incisional discomfort. All 14 patients (16 heels) reported being satisfied and had returned to their previous functional status. Thus, the central splitting Achilles approach with anchoring of the Achilles insertion using the double-row suture device is a safe and reasonable option in the operative treatment of insertional calcific Achilles tendinopathy.
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NewsBot · Jan 9, 2019

Calcific Insertional Achilles Tendinopathy-Achilles Repair With Flexor Hallucis Longus Tendon Transfer: Case Series and Surgical Technique.
Howell MA et al
J Foot Ankle Surg. 2019 Jan 3

Calcific insertional Achilles tendinopathy (CIAT) is a relatively common musculoskeletal entity that results in significant pain and disability, as well as posterior muscle group weakness. There is a lack of evidence criteria to support the timing of operative intervention, choice of procedures, or whether equinus requires treatment. The purpose of this study was to retrospectively review 45 patients (48 feet) who have undergone surgical management of CIAT with concomitant posterior muscle group weakness with the single heel rise testing. All patients underwent debridement and repair of the Achilles tendon with reattachment of the Achilles tendon to the calcaneus, ostectomy of the calcaneus, and flexor hallucis longus tendon transfer. Those patients with equinus also underwent gastrocnemius recession. The focus includes patient-reported satisfaction, time to return to normal shoe gear, and the incidence of revision surgery. The overall average of time to weightbearing was 4.3 weeks. After surgery, 73.3% (n = 33) of the 45 patients responded to the following question: "Would you have this surgery done again?" Of these patients, 93.9% (n = 31) responded "Yes" and 6.1% (n = 2) responded "Unsure." Of the same 33 patients, 84.8% (n = 28) responded that they were "Very Satisfied" with the procedure and 15.2% (n = 5) responded that they were "Satisfied." Twelve patients (26.7%) did not respond to either question. One of the 12 patients (8.3%) who did not respond had bilateral procedures. None of the patients experienced tendon rupture, deep vein thrombosis, or the need for revision surgery. Four patients (8%) experienced a superficial infection, whereas 1 patient (2%) had development of a deep infection. No correlations were found when looking at the relationship between body mass index and return to weightbearing/normal shoe gear with Spearman analysis.
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NewsBot · Oct 4, 2020

Insertional Calcific Tendinopathy of the Achilles Tendon and Dysmetabolic Diseases
An Epidemiological Survey
Giai Via, Alessio MD et al
Clinical Journal of Sport Medicine: September 24, 2020

Objective:
This study reports the incidence of insertional calcific tendinopathy (ICT) of the Achilles tendon in the general population and the percentage of symptomatic patients. The secondary aim is to ascertain whether ICT is associated with diabetes mellitus, thyroid disorders, obesity, and hypercholesterolemia. We hypothesized that metabolic diseases increase the risk of ICT of the Achilles tendon.

Design:
Prospective observational study (level III study).

Setting:
Orthopedic Outpatients Clinic and Emergency Department of Tor Vergata University Hospital, Rome, Italy.

Participants:
Four hundred thirty-three subjects who met the inclusion criteria.

Intervention Methods:
We collected the plain radiographs of the foot and ankle of patients who attended the hospital. Personal data were recorded [age, sex, and body mass index (BMI)], and comorbidities investigated (diabetes mellitus, hypothyroidism, hyperthyroidism, obesity, and hypercholesterolemia). Multivariate regression analyses were performed to study the predictors of the occurrence of Achilles ICT.

Results:
A total of 101 patients (23.3%) showed radiographic evidence of ICT, and 3% (13 patients) were symptomatic. Age [odds ratio (OR) 1.05], diabetes (OR 2.95), hypercholesterolemia (OR 2.27), and hypothyroidism (OR 3.32) were significantly associated with the presence of ICT of the Achilles tendon. Independent predictors of ICT were age, diabetes, hypercholesterolemia, and hypothyroidism. A BMI >30 was associated with a higher incidence of calcifications, and patients with 2 or more comorbidities had more than 10 times higher risk to develop ICT.

Conclusion:
Insertional calcific tendinopathy of the Achilles tendon is common, but few patients are symptomatic. The incidence of ICT increases with age and is significantly higher in patients with diabetes mellitus and hypothyroidism.
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NewsBot · Dec 6, 2022

Treatment of Achilles insertional calcific tendinosis using a longitudinal midline incision approach/central tendon splitting approach
Dariusch Arbab et al
Oper Orthop Traumatol. 2022 Dec 5

Objective: Treatment of Achilles insertional calcific tendinosis through a longitudinal midline incision approach with optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity).

Indications: Calcific Achilles tendinosis, dorsal heel spur, insertional tendinosis.

Contraindications: General medical contraindications to surgical interventions. Fracture, infection.

Surgical technique: Longitudinal skin incision medial of the Achilles tendon. Exposure and midline incision of the Achilles tendon with plantar detachment from the insertion site preserving medial and lateral attachment. Resection of a dorsal heel spur and intratendinous calcifications. Optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity).

Postoperative management: Partial weight bearing 20 kg in 30° plantar flexion in a long walker boot for 2 weeks. Afterwards 2 weeks of progressively weight bearing in 15° plantar flexion and another 2 weeks in neutral ankle joint position in a long walker boot.

Results: A total of 26 feet of 26 patients with calcific Achilles tendinosis were treated with midline incision of the tendon. In all feet calcific tendon parts were resected. In 10 (38%) feet, a prominent dorsal spur was resected, in 12 feet (38%) retrocalcaneal bursa, and in 24 (92%) feet a calcaneal tuberosity. Mean follow-up was 34.5 months (range 2-64 months). Preoperative Manchester-Oxford Foot Questionnaire (MOXFQ) score was 58.2 (±8.1) and postoperatively the score was 22.75 (±6.0). In all, 7 (26.9%) patients stated delayed wound healing; 1 suffered from deep vein thrombosis. Shoe problems were reported by 50% of patients, and 23.1% suffered from par- or dysesthesia. No revision surgery was required.
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NewsBot · Mar 30, 2023

Treatment of Calcific Insertional Achilles Tendinopathy: Knotless Internal Brace versus Knot-Tying Suture Bridge
Xiaodong Zhao et al
J Pers Med. 2023 Feb 24;13(3):404

Background: This study aimed to compare the knotless internal brace technique and the knot-tying suture bridge technique via the medial approach in the treatment of calcific Achilles tendinopathy.

Methods: The clinical data of 25 cases of calcific Achilles tendinopathy in which nonoperative treatments had failed were retrospectively collected. All the patients received Achilles tendon debridement and Haglund deformity excision through a medial approach, followed by repair using the knotless internal brace technique or the knot-tying suture bridge technique. Pain was evaluated by using the visual analog scale (VAS). The American Orthopedic Foot and Ankle Score (AOFAS) questionnaire was administered preoperatively and postoperatively.

Results: The mean follow-up time was 2.6 (range 2-3.5) years. There were no wound complications and no Achilles tendon ruptures. At 1 year postoperatively, the internal brace group was superior to the suture bridge group in terms of the VAS scores (p = 0.003). However, no differences were noticed between the two groups in either the VAS or the AOFAS scores at 2 years postoperatively.

Conclusions: The medial approach in combination with the suture bridge technique was effective in treating calcific Achilles tendinopathy. The knotless internal brace technique involved less pain compared to the knot-tying suture bridge technique only at the early postoperative stage.
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