Insertional Achilles tendinopathy
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Insertional Achilles tendinopathy (with or without Haglund’s deformity)
The Achilles tendon is the combination of tendons of the soleus and gastrocnemius muscles and connects these muscles to the back of the heel. Insertional Achilles tendinopathy (IAT) – with or without Haglund’s deformity – is an acute or chronic painful disorder of the Achilles tendon at its insertion onto the calcaneus. Several terms have been used to describe this condition including tendinosis, tendinitis and peritendinitis.

However, histologic examination of biopsy specimens from patients undergoing surgery for chronic symptoms has shown that chronic IAT is associated with degenerative changes in the tendon. Accordingly, the disease is better characterized as tendinopathy than tendinitis or tendinosis.

Diagnosis is based on the clinical features of the disease, with the location of the pain as an important discriminating factor. The spot of maximum pain in IAT is located at the tendon-bone junction, whereas in case of noninsertional Achilles tendinopathy, the spot of maximum pain is 2 to 6 cm proximal to the insertion. Symptoms can be exacerbated by running on hard surfaces and climbing stairs. Diagnostic imaging should be considered to rule out other causes of Achilles tendon pain and heel pain, or to establish the diagnosis of IAT when in doubt.

The etiology of IAT is likely multifactorial and may include advanced age, obesity, hypertension, diabetes, hyperpronation and steroid use, to mention only a few. Particularly in athletes the onset of IAT may also be influenced by poor training habits including excessive training, training on hard or sloping surfaces, and abrupt changes in scheduling.

It has been hypothesized that healing of injuries of the Achilles tendon as a result of overuse involves the penetration of small blood vessels into the tendon in order to increase healing by providing improved blood flow. However, these small blood vessels are accompanied by small nerve fibers with high concentrations of nociceptive substances including glutamate, substance P, and calcitonin gene-related peptide (CGRP). These small nerve fibers are considered the cause of pain in chronic IAT.

Runners comprise the largest group of patients with chronic pain in the Achilles tendon. The annual incidence of IAT among athletes is approximately 8%. However, individuals of all activity levels and all ages present with similar complaints.

The treatment of IAT should start with conservative treatment modalities including rest, icing, physiotherapy, stretching (eccentric loading), exercises, orthoses, heel lifts and non-steroidal anti-inflammatory drugs. In certain cases braces and immobilization with a cast or a pneumatic walking boot may improve the situation. Patients not responding to conservative treatment for six months shall then be subjected to radial shock wave therapy (RSWT). Surgery should be considered for recalcitrant cases of IAS, with different surgical strategies described in the literature. Prevention of recurrence should focus on appropriate exercise habits, wearing low-heeled shoes and eccentric strengthening exercises.