Achilles insertional tendinopathy

Definition

Presentations and conditions are more often combined  and intricated, mixing bone impingement, bursitis , degenerative changing's in the distal end of the Achilles tendon.

Causes
This area, which is normally very thin and almost virtual, gets swollen and inflamed because of increased friction.

Pes cavus, morphology of the calcaneus itself (prominence of the posterosuperior aspect of the calcaneus, so-called « Haglund’ deformity »), tightening of the triceps surae, leads to impingement between the calcaneus and the distal end of the Achilles tendon, bursitis, spurs on the heel bone….

Symptoms
The pain can be found just above the place where the tendon inserts into the bone and slightly to the sides.
Repetitive impingements, started with shoe-wearing, sports , increase the volume and the inflammatory aspect of the heel  .

Diagnosis
Plain X-rays with weight-bearing
Ultrasonography, MRI for the insertion status of the Achilles tendon


Medical treatment

A raising of the heel allows the tendon to be somewhat removed from the bone and thus to reduce the friction between them. The combination with physiotherapy heals patients in most cases from “Haglund disease”.

Elongation exercises may decrease the over tension in the calf. Insoles to correct hindfoot deformity are suitable. The injection of cortisone or one of its derivatives may weaken the area and sometimes cause a rupture.

The main problem is the evolution to a progressive degenerative rupture of the Achilles tendon at its insertion.


Surgical treatment

So, surgery must be considered,, with different goals :

a.    ensuring that no conflict occurs between the tendons itself and the bone: the removal of the excessive bone growth is made through arthroscopy or open surgery.

b.    regarding  anatomical morphology of the calcaneus, this technique remains insufficient :by  taking out a piece of bone from the heel bone through an osteotomy, the impingement is treated. However, this requires a longer rehabilitation, since the two bone fragments, fixed with a screw or a plate, will only fuse again after a 6 weeks minimum. During that period, the patient cannot lean on the ankle and often a plaster is needed.

c.     additional procedures are proposed on request such as :

  • the removal of calcifications with open surgery. Depending on its size, one must sometimes re-attach the tendon to the bone with a bone anchor.
  • elongation of the Triceps surae

d.    When the distal end of the Achilles tendon is severely damaged, the Achilles tendon becomes totally insufficient. It must be reinforced  by the transplantation of the flexor tendon of the big toe .