What is the diagnosis and treatment for a 56-year-old male with tenderness and pain at the Achilles tendon's insertion at the heel after doing Bulgarian split squats with weights?

Diagnosis and Treatment of Insertional Achilles Tendinopathy

Diagnosis

This is insertional Achilles tendinopathy, a degenerative overuse condition affecting the tendon's attachment to the calcaneus, triggered by the eccentric loading from Bulgarian split squats. 1

Key Diagnostic Features

The clinical presentation strongly indicates insertional Achilles tendinopathy based on:

• Pain and tenderness localized at the Achilles insertion on the heel (not 2-6 cm proximal, which would suggest non-insertional tendinopathy) 1
• Gradual onset following eccentric loading exercise (Bulgarian split squats involve significant eccentric stress on the Achilles tendon) 2
• Pain limiting ambulation and worsening with activity 1
• Transient relief with stretching (characteristic of tendinopathy) 2

Important Diagnostic Pitfall

At age 56, you must rule out Achilles tendon rupture, though the gradual onset makes this less likely. Check for: negative Thompson test, normal plantar flexion strength, absence of palpable gap, and normal passive dorsiflexion range. If two or more of these tests are abnormal, rupture is present and requires different management. 1

Imaging Considerations

Plain radiographs can identify spurring or erosion at the insertion site, which is common in insertional tendinopathy. 1 However, imaging is not required for diagnosis when clinical findings are clear. 2

Treatment Algorithm

The cornerstone of treatment is eccentric strengthening exercises combined with relative rest, ice, and activity modification—this approach achieves full recovery in approximately 80% of patients within 3-6 months. 2, 3

First-Line Conservative Treatment (Weeks 0-8)

Eccentric strengthening exercises are the gold standard and most effective conservative treatment, as they stimulate collagen production and guide normal alignment of newly formed collagen fibers. 3 These should be initiated immediately and continued throughout treatment.

Activity modification: Reduce or eliminate activities causing pain (like weighted Bulgarian split squats), but continue activities that don't worsen symptoms. 3

Gastrocnemius-soleus stretching exercises improve flexibility and reduce tension on the tendon. 3

Cryotherapy (ice) provides short-term pain relief by reducing tissue metabolism and blunting inflammatory response. 3

Footwear modifications:

• Open-backed shoes reduce pressure on the insertion site 3
• Heel lifts or orthoses unload the tendon 3
• Pain relief when walking barefoot is characteristic of insertional tendinopathy 1

Pain Management

NSAIDs (oral or topical) for short-term pain relief only: 3

• Naproxen 500 mg initially, then 500 mg every 12 hours or 250 mg every 6-8 hours for acute tendonitis, with initial daily dose not exceeding 1250 mg and subsequent days not exceeding 1000 mg 4
• Topical NSAIDs have fewer systemic side effects 3
• Critical caveat: NSAIDs provide acute pain relief but cannot be recommended over other analgesics for long-term management, as they don't address the underlying degenerative pathology 2

Critical Treatment Pitfall to Avoid

NEVER inject corticosteroids into or near the Achilles tendon insertion. Corticosteroid injections may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture. 3 This is particularly dangerous in insertional tendinopathy where the tendon attachment is already compromised.

Treatment Duration and Progression

Continue this conservative regimen for 6-8 weeks before considering more aggressive interventions. 3 If improvement occurs, continue treatments until symptoms completely resolve. 3

Second-Line Options (After 6-8 Weeks Without Improvement)

If no improvement after 6-8 weeks of conservative treatment, consider:

• Shock wave therapy (has high evidence-based effectiveness) 5
• Glyceryl trinitrate patches 5
• Specialist referral for consideration of advanced interventions 3

Surgical Consideration

Surgery should be reserved only for patients who have failed 3-6 months of conservative therapy. 2, 6 Surgical management involves Achilles tendon debridement, calcaneal exostectomy, and retrocalcaneal bursa excision with possible tendon reattachment. 6

Biomechanical Assessment

Evaluate for anatomic deformities such as forefoot varus, heel varus, excessive pes planus, or foot pronation, as these biomechanical factors contribute to development and persistence of symptoms and must be addressed for successful treatment. 3

Prognosis

With appropriate conservative treatment, approximately 80% of patients achieve full recovery within 3-6 months. 2 The key is early initiation of eccentric exercises and strict avoidance of pain-provoking activities during the healing phase.