Insertional Achilles tendinopathy, also known as tendonitis, tendinosis, or paratendonitis, is a condition characterized by the degeneration or breakdown of the Achilles tendon over time. This tendon, which connects the calf muscle to the heel bone (calcaneus) along the back of the leg, is affected at its attachment point to the heel bone.

Symptoms

Patients typically experience a gradual onset of pain and swelling at the back of the heel bone without a specific injury. Initially, the pain may only manifest after activity but can worsen with time. Sometimes, the pain seems to arise suddenly. Activities such as jumping, running, or uphill walking exacerbate the discomfort. Swelling or enlargement of the heel area may occur, leading to painful friction within shoes. Tendon stretching is often painful, and the affected area may be tender to touch.

Causes

Insertional Achilles tendinopathy results from repetitive activity over an extended period, leading to tendon damage at its insertion point. It is frequently observed in runners. Contributing factors may include advanced age, diabetes, obesity, steroid usage, alterations in training, or inappropriate footwear.

Diagnosis

Dr. Kamel conducts a clinical examination to diagnose insertional Achilles tendinosis. X-rays may be ordered to detect calcium deposits within the tendon or heel spurs. While MRIs can assess the severity of tendon damage, they are not mandatory for diagnosis.

Treatments

Non-surgical Treatment

Non-surgical options encompass nonsteroidal anti-inflammatory drugs (NSAIDs), heel lifts, and switching to footwear that alleviates pressure on the affected area. Physical therapy, focusing on tendon-strengthening exercises, is often the primary treatment. However, some stretching exercises may exacerbate pain, hence consultation with a physical therapist is advised. Additional aids such as night splints, extracorporeal shock wave therapy (ESWT), or temporary braces may benefit patients experiencing difficulty walking. Steroid/cortisone injections are discouraged due to the risk of tendon tears. Platelet-rich plasma (PRP) Injections remain of uncertain effectiveness but pose low risk. 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. 

Surgical Treatment

Surgery is recommended for patients who fail to respond to non-surgical interventions after 3-6 months. The most common surgical procedure involves removing the diseased portion of the tendon through an incision at the back of the heel. In severe cases, a tendon transfer may be necessary. Post-surgery, patients typically wear a splint or cast boot, with weight-bearing restrictions for 6-8 weeks. Full recovery may take 9 months or longer.

Risks and Complications

Potential complications of surgery include those associated with anesthesia, infection, nerve damage, bleeding, and blood clots. Continued pain in the operated area is the most common complication.