What are the treatment options for left plantar, calcaneal spur, and calcific tendinosis of the left Achilles tendon insertion?

Treatment of Insertional Calcific Achilles Tendinosis and Plantar Calcaneal Spur

Begin with conservative management for 6-8 weeks, including eccentric strengthening exercises, activity modification, NSAIDs, heel lifts, and open-backed shoes; if symptoms persist after this period, surgical debridement with central tendon splitting is indicated. 1

Initial Conservative Treatment (First-Line for 6-8 Weeks)

Activity and Footwear Modifications

• Reduce activities that cause pain while continuing activities that don't worsen symptoms to prevent ongoing tendon damage 1
• Switch to open-backed shoes to reduce direct pressure on the inflamed Achilles insertion and calcaneal spur 2, 1
• Use heel lifts or orthotic modifications to unload tension on the Achilles tendon insertion 2, 1
• Temporarily decrease weight-bearing activities until symptoms improve 2

Exercise Therapy (Gold Standard Conservative Treatment)

• Eccentric strengthening exercises are the most effective conservative option and should be the cornerstone of treatment, as they stimulate collagen production and guide normal alignment of newly formed collagen fibers 1
• These exercises can achieve approximately 40% reduction in pain 3
• Perform gastrocnemius-soleus complex stretching to improve flexibility and reduce tension on the tendon 1
• Deep transverse friction massage may reduce pain in the affected tendon 2

Pain Management

• NSAIDs (oral or topical) are effective for short-term pain relief, with topical formulations having fewer systemic side effects 1
• Cryotherapy (ice application) provides short-term pain relief by reducing tissue metabolism and blunting inflammatory response 2, 1

Critical Pitfall to Avoid

• Never inject corticosteroids into or near the Achilles tendon, as they inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 1

Advanced Conservative Options (If Partial Response at 6-8 Weeks)

• Extracorporeal shock wave therapy (ESWT) has demonstrated 60% pain reduction with 80% patient satisfaction and can be considered before surgery 3
• Immobilization with a cast or fixed-ankle walker may be necessary if symptoms persist despite other conservative measures 2
• Injections with platelet-rich plasma, dextrose, or polidocanol cannot currently be recommended due to limited evidence 3

Surgical Management (After 6 Months of Failed Conservative Treatment)

Indications for Surgery

• Persistent symptoms after 6 months of conservative therapy warrant surgical intervention 3
• Referral to a podiatric foot and ankle surgeon or orthopedic specialist should occur if no improvement after 6-8 weeks of conservative treatment 2, 1

Surgical Technique

• Central tendon splitting approach is the preferred technique for insertional calcific Achilles tendinosis, providing excellent pain relief with improved function and avoiding painful postoperative scars 4, 5
• The procedure involves:
  • Longitudinal midline incision of the Achilles tendon with plantar detachment while preserving medial and lateral attachments 5
  • Resection of intratendinous calcifications and dorsal heel spur 5
  • Optional resection of retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity) if present 5
  • Suture anchor augmentation should be routinely used to reinforce the tendon insertion after debridement 4

Surgical Outcomes

• Open debridement achieves success rates over 70%, with significant improvement in pain scores (from 7 to 33 points) and function scores (from 36 to 46 points) 4
• The suture bridge technique using 4 suture anchors provides greater tendon compression and stability, allowing earlier return to weight-bearing 6
• If more than 50% of the Achilles tendon diameter requires debridement, consider flexor hallucis longus (FHL) tendon transfer for augmentation, though this is frequently applied based on surgeon judgment rather than validated data 3

Postoperative Protocol

• Partial weight bearing (20 kg) in 30° plantar flexion in a long walker boot for 2 weeks 5
• Progress to weight bearing in 15° plantar flexion for 2 weeks 5
• Advance to neutral ankle position in walker boot for another 2 weeks 5

Surgical Complications to Anticipate

• Delayed wound healing occurs in approximately 27% of patients 5
• Shoe problems affect 50% of patients postoperatively 5
• Paresthesia or dysesthesia occurs in 23% of patients 5
• Overall complication rates can reach up to 40% with open procedures 3

Alternative Surgical Approach

• Endoscopic calcaneoplasty and tendoscopy is a promising option for isolated retrocalcaneal bursitis, showing similar success rates to open debridement with significantly lower complication rates, less morbidity, and faster recovery 3, 7