What is the diagnosis for a patient with Achilles enthesopathy at the insertion on the posterior calcaneus, presenting with a 6.5 mm enthesophyte and suspected thickening of the distal Achilles tendon?

From the Guidelines

The patient should begin with conservative measures including rest, ice application, and over-the-counter anti-inflammatory medications like ibuprofen or naproxen for 1-2 weeks to reduce pain and inflammation, as recommended by the most recent and highest quality study 1. The findings indicate Achilles enthesopathy, which is inflammation and irritation where the Achilles tendon attaches to the heel bone.

Key Points to Consider

• Gentle stretching exercises for the calf muscles and Achilles tendon should be performed 2-3 times daily, holding each stretch for 30 seconds.
• Physical therapy may be beneficial to address biomechanical issues.
• Wearing supportive shoes with a slight heel lift can reduce tension on the Achilles tendon.
• Night splints may help maintain tendon flexibility during sleep.
• If symptoms persist beyond 4-6 weeks of conservative treatment, consider seeking further evaluation for possible corticosteroid injections or, in severe cases, surgical intervention. This condition results from repetitive stress or overuse causing microtears at the tendon-bone junction, leading to inflammation and calcium deposit formation (the 6.5mm enthesophyte noted in the findings), as discussed in 1 and 1.

Treatment Options

• Eccentric strength training is a particularly popular and effective option, as noted in 1.
• Anatomic misalignment can be treated with shoe orthotics to correct overpronation or pes planus problems, as mentioned in 1.
• Many patients will benefit from heel lift orthotics to unload the tendon for pain relief, as discussed in 1. It is essential to prioritize conservative measures and avoid unnecessary interventions, as recommended by 1 and 1.

From the Research

Diagnosis and Treatment of Achilles Enthesopathy

• The diagnosis of Achilles enthesopathy is based on the presence of symptoms such as pain and swelling at the Achilles tendon insertion on the posterior calcaneus, as well as imaging findings like enthesophytes and thickening of the distal Achilles tendon 2.
• Conservative treatment options for Achilles enthesopathy include reduction of activity levels, administration of non-steroidal anti-inflammatory drugs (NSAID), adaptation of footwear, heel wedges and orthoses or immobilization, and eccentric stretching exercises 2, 3.
• Eccentric stretching exercises have been shown to achieve a 40% reduction in pain and are considered a gold standard treatment for Achilles tendinopathy 3.
• Other conservative treatment options include extracorporeal shock wave therapy, which has been shown to reduce pain by 60% with a patient satisfaction of 80% 2.

Role of NSAIDs in Treatment

• The use of NSAIDs in the treatment of Achilles tendinopathy has been investigated, and studies have shown that short-term ibuprofen treatment has no effect on gene expression in human chronic tendinopathic tendon or leads to any clear changes in tendon pain or function 4.
• However, NSAIDs may still be used to reduce pain and inflammation in the short term, although their long-term effectiveness is unclear 2, 4.

Indications for Surgical Referral

• Surgical referral may be indicated after 6 months of unsuccessful conservative therapy, and operative therapy options include open debridement and reattachment of the Achilles tendon if detached by >50% 2.
• Tendoscopy is a promising treatment option for isolated retrocalcaneal bursitis and has shown similar success rates to open debridement with significantly lower complication rates 2.