Insertional Achilles tendonitis is a degeneration of the fibers of the Achilles tendon directly at its insertion into the heel bone. It may be associated with inflammation of a (retrocalcaneal) bursa or tendon sheath in the same area.
Nonsurgical Treatment Options
Conservative nonsurgical treatment remains effective in the majority of patients with liberal use of nonsteroidal anti-inflammatory drugs, heel lifts, stretching and shoes, which do not provide pressure over this area. If symptoms persist, then night splints, arch supports and physical therapy may be of benefit. If this fails, then application of a cast or brace with gradual return to activity is indicated. Nitroglycerin patches may also be of benefit in an attempt to increase the blood supply to this area.
Surgical Treatment Options
Surgical treatment is indicated if there is failure of several months of nonsurgical treatment. Surgery removes the degenerative portions of the tendon, any bone which is irritating the tendon, as well as any inflamed bursa tissue. If the tendon is short, then lengthening may also be necessary. The tendon attachment to the heel bone may need to be strengthened with sutures which attach directly into the bone.
Several different approaches and techniques, including endoscopy, are used to achieve these goals without a clear consensus regarding which is best in terms of both success as well as complications. 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 is usually 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, a splint is worn for 2 weeks in a toe down position to allow wound healing. Once the wound begins to heal, weight-bearing in a cast or brace in a toe down position as well as range of motion exercises are started. Actual physical therapy is started at 4-6 weeks. Return to athletic activities usually occurs between 8 to 12 weeks, depending on the amount of detachment of the tendon at the time of surgery. If another tendon is transferred, then recovery may take longer. Some patients may require 1-2 years to recover following both surgical and non-surgical treatment.
Good to excellent results after surgery are about 75%.
Because of the poor blood supply to the skin and tendon in this area, the greatest risk following surgery is that of wound complications, infection, and tendon detachment
Frequently Asked Questions
Would a cortisone injection help?
Cortisone injections are not recommended for the treatment of these types of problems of the Achilles tendon because it can lead to death of the tendon and make it much easier to rupture.
*Source: American Orthopaedic Foot & Ankle Society® http://www.aofas.org
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