Achilles tendinopathy (also described as tendonitis, tendinosis, and paratendonitis) is a condition in which the Achilles tendon degenerates or breaks down over time. The Achilles tendon is the cord-like structure along the back of your leg that connects your calf muscle to your heel bone (calcaneus). Insertional Achilles tendinopathy involves the part of the tendon that attaches to the heel bone.
Most patients report a gradual onset of pain and swelling at the back of their heel bone without a specific injury. At first, the pain may only be noticeable after activity, but it can get worse over time. In some cases, the pain may appear to come out of nowhere. The pain is often worse with activities such as jumping, running, or walking uphill. The heel area may get larger or swell, which can cause painful rubbing in shoes. It is often painful to stretch the tendon. Touching the area may be painful as well.
Insertional Achilles tendinopathy is caused by repetitive activity over a long period of time that results in damage to the tendon at its insertion. It is often seen in runners. Contributing factors can include older age, diabetes, being overweight, steroid use, changes in training, or shoes.
The foot of a patient with insertional Achilles tendinopathy. Note the swelling on the back of the heel.
Your foot and ankle orthopaedic surgeon will perform a clinical exam to determine if you have insertional Achilles tendinosis. They may order X-rays to look for calcium deposits within the tendon or heel spurs.
MRIs may be used to see how severely the tendon is damaged, but are not required for the diagnosis.
X-ray image of a heel spur associated with insertional Achilles tendinopathy.
Non-surgical treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), heel lifts, and switching to shoes that do not put pressure on the area. Exercise-based treatments such as physical therapy are an effective first-line treatment for the majority of patients. This treatment often includes exercises to strengthen the tendon. Stretching can sometimes make the pain worse! Eccentric strengthening exercises help many patients—it is best to work with a physical therapist to determine the best exercises for your injury.
Other options that may help include night splints, extracorporeal shock wave therapy (ESWT), or the use of a temporary brace or boot for patients who have difficulty walking. Shock wave therapy involves the use of a probe that delivers waves of energy to the tendon to help it heal. It is typically not covered by insurance.
Steroid/cortisone injections and sclerosing agents near the Achilles are not recommended due to the risk of tendon tear.
Other injections such as platelet-rich plasma (PRP) are low risk, but the effectiveness of these injections remains unknown. Platelet-rich plasma involves the use of blood taken from you and separating a part of it that has growth factors or substances that can help your tendon to heal. These growth factors are then directly injected into the area of pain.
Surgery is usually recommended for patients who do not see improvement after 3-6 months of non-surgical treatment. In the most common procedure, your surgeon will make an incision over the back of the heel and remove the diseased portion of the tendon. In some cases this can be performed with smaller incisions, using a camera and special tools to help remove the damaged tendon. Prominent bone and bone spurs are removed from the back of the heel bone. If the tendon has to be detached, your surgeon will then reattach the tendon using special bone anchors.
Sometimes the Achilles is so badly damaged that a tendon transfer is required to replace the Achilles. The tendon to the big toe (flexor hallucis longus or FHL) is often used in these cases. Most patients do not notice any loss of big toe strength, although some patients may feel a little weaker in their big toe.
After surgery, your foot will be put into a splint or removable cast boot. Your surgeon will determine when you can put weight on your foot after the surgery, but most patients are limited for 6-8 weeks. Full recovery can take 9 months or longer.
All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves, bleeding, and blood clots. The most common complication of this surgery is continued pain in the same area.
Yes. After the appropriate repair, physical therapy, and healing time, the goal is for you to be able to return to all the activities you want to do. Residual pain may limit but not prevent you from some activities. Running is the most difficult activity to resume, and not all patients will be able to return to running without pain.
Although they can look pointed and sharp, bone spurs do not cause tendon damage. Patients who are successfully treated without surgery will still have bone spurs on X-rays but will no longer have pain. If you do end up having surgery for this problem, however, the bone spur is typically removed during the procedure.
Contributors/Reviewers: Sudheer Reddy, MD; David Lee, MD; Paul Ryan, MD; Elizabeth Cody, MD
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