What Is Insertional Achilles Tendinitis?

Insertional Achilles tendinitis 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 bursa or tendon sheath in the same area. 


Most patients report the gradual onset of pain and swelling at the Achilles tendon insertion into the back of the heel bone without specific injury. At first, the pain is noted after activity alone, but becomes more constant over time. The pain is made worse by jumping or running and especially with sports requiring short bursts of these activities. There is tenderness directly over the back of the heel bone and often there is a bone prominence at this area. Positioning the ankle above a 90 degree position is limited by pain. 


Insertional Achilles tendinitis primarily is caused by degeneration of the tendon. The average patient is in their 40s. Conditions associated with increased risk include psoriasis and Reiter’s syndrome, spondyloarthropathy (generalized inflammation of joints), gout, familial hyperlipidemia, sarcoidosis and diffuse idiopathic skeletal hyperostosis as well as the use of medications such as steroids and fluoroquinolone antibiotics. 


The Achilles tendon is the largest tendon in the body. It is formed by the merging the upper calf muscles and functions to bend the knee, point the toes down, and slightly roll the heel to the big toe side of the foot. It inserts into the back of the heel bone. There may be a shelf extending off the back of the heel bone at the insertion site as well as a prominence of the heel bone in this area referred to as a Haglund's deformity, which can cause mechanical irritation of the Achilles tendon. Just as nose sizes and shapes vary, there can be variations in the size and shape of these bones. 


This remains primarily a clinical diagnosis. X-rays show calcification (bone) deposits within the tendon at its insertion into the heel approximately 60 percent of the time. Their presence is associated with a more guarded success rate for non-surgical treatment and a much longer recovery time if surgery is performed. X-rays also may reveal a Haglund's deformity. MRIs are the imaging option of choice because they can determine the extent of tendon degeneration as well as other factors such as bursitis, which may contribute to posterior heel pain.


Non-surgical treatment is effective in the majority of patients with liberal use of nonsteroidal anti-inflammatory drugs, heel lifts, stretching, and shoes that 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, use of a cast or brace with gradual return to activity is indicated. Nitroglycerin patches also may be of benefit to increase the blood supply to this area.  

Surgical treatment is indicated if there is failure after several months of non-surgical treatment. During this surgery, an incision is made over the back of the heel. The diseased portion of the tendon is removed. A small amount of bone is removed from the back of the heel bone to create a healthy area for the tendon to attach. The tendon is reattached using special bone anchors that allow the tendon to be fixed to the bone.

Several different approaches and techniques, including endoscopy, are used to achieve these goals. There is no clear consensus regarding which is best in terms of both success and avoiding complications. In older patients or those in whom more than 50 percent of the tendon is removed, one of the other tendons at the back of the ankle usually is 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, you will be put into a cast or removable cast boot. If the tendon was not fully detached from the heel, the doctor may allow you walk around in the boot for 6-8 weeks and work on motion exercises with physical therapy.

If the tendon was totally detached or another tendon was used in the repair, a cast or boot may be used for three months. For the first six weeks, you should not place any weight on the foot, but in the second six weeks you can walk in the cast or boot. 

After the cast or boot comes off, you can wear shoes with a small heel lift and begin physical therapy. The length of time needed to return to full activities and sports is determined by the strength of the repair and the speed of recovery with physical therapy. Full recovery can take 6-12 months. Some patients may require one to two years to recover following both surgical and non-surgical treatment. 

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.Complications with this surgery can include residual pain, infections, weakness or tightness, or rupture of the repair. 


Would a cortisone injection help? 
Cortisone injections are not recommended to treat these types of problems of the Achilles tendon because they can weaken the tendon, leading to possible rupture.

After surgery, can I return to all the activities I want to do?
Yes. After the appropriate repair, physical therapy and healing time, the goal is for you to be able to return to activities you want to do. Residual pain may limit but not prevent you from doing some activities.


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