Treatment Recommendations for Bone Spurs Near Achilles Tendinopathy
Begin with 6-8 weeks of conservative management centered on eccentric strengthening exercises, activity modification, and footwear adjustments—this approach achieves full recovery in approximately 80% of patients with insertional Achilles tendinopathy, which commonly presents with bone spurs at the calcaneal insertion. 1
Understanding the Condition
Insertional Achilles tendinopathy affects the tendon's attachment to the calcaneus and frequently involves bone spur formation (Haglund's deformity or calcaneal enthesophytes) at the insertion site. 1 The condition represents a failed healing response with degenerative changes rather than acute inflammation, characterized by pain and tenderness localized at the Achilles insertion on the heel. 1, 2
First-Line Conservative Treatment Algorithm
Core Treatment Components (Implement All Simultaneously)
Eccentric strengthening exercises are the gold standard and most effective conservative treatment, stimulating collagen production and guiding normal alignment of newly formed collagen fibers. 1, 3 These exercises should be performed consistently as they have the strongest evidence base for tendinopathy management. 1
Activity modification requires reducing or eliminating activities causing pain (particularly eccentric loading exercises like Bulgarian split squats) while continuing activities that don't worsen symptoms. 1, 4 This is relative rest, not complete immobilization—avoid complete rest as it causes muscular atrophy and deconditioning. 5
Footwear modifications are critical for insertional tendinopathy with bone spurs:
- Open-backed shoes reduce direct pressure on the insertion site and bone spur 1, 4
- Heel lifts unload the tendon by reducing the stretch at the insertion 1, 4
- Custom orthoses may be needed if biomechanical abnormalities (forefoot/heel varus, excessive pes planus, or foot pronation) are present 4
Gastrocnemius-soleus stretching improves flexibility and reduces tension on the tendon, providing complementary benefit to eccentric exercises. 1, 4
Cryotherapy (ice through a wet towel for 10-minute periods) provides short-term pain relief by reducing tissue metabolism and blunting inflammatory response. 1, 4
Pain Management
NSAIDs (oral or topical) can be used for short-term pain relief but should not be recommended for long-term management. 1 Topical NSAIDs are preferable as they have fewer systemic side effects than oral formulations. 1
Treatment Duration and Progression
Continue this conservative regimen for 6-8 weeks before considering more aggressive interventions. 1, 4 If improvement occurs, continue treatments until symptoms completely resolve. 1 Approximately 80% of patients achieve full recovery within 3-6 months with appropriate conservative treatment, with early initiation of eccentric exercises and strict avoidance of pain-provoking activities being key. 1
Critical Pitfalls to Avoid
Never inject corticosteroids into or near the Achilles tendon—they inhibit healing, reduce tensile strength, and predispose to spontaneous rupture. 4, 2 This is particularly dangerous in the presence of bone spurs where the tendon may already be compromised.
Second-Line Conservative Options (If 6-8 Weeks Fail)
If initial conservative management fails after 6-8 weeks, consider:
Extracorporeal shock wave therapy (ESWT) has demonstrated effectiveness for insertional Achilles tendinopathy, with patient satisfaction >70% at 6 months. 6 The protocol typically involves 3 sessions of 2400 impulses at 0.17-0.25 mJ/mm² per session. 6
Platelet-rich plasma (PRP) injections (peritendinous, not intratendinous) show similar effectiveness to ESWT, with 2 injections over two weeks being a standard protocol. 6 These should be injected at the interface between the Achilles tendon and Kager's triangle, not into the tendon substance. 2
Surgical Consideration
Surgery is justified only after 6 months of well-managed conservative treatment has failed. 2, 7 Surgical options for insertional tendinopathy with bone spurs typically involve excision of the bone spur, debridement of degenerative tendon tissue, and reattachment of the tendon if necessary. 2 Referral to an orthopedic or foot and ankle specialist should occur if no improvement is seen after 6-8 weeks of conservative treatment or if symptoms significantly limit function. 4
Key Success Factors
The presence of bone spurs does not change the fundamental treatment approach—conservative management remains first-line. 1 However, footwear modifications become even more critical to reduce direct pressure on the bony prominence. 1, 4 Address any underlying biomechanical abnormalities with appropriate orthoses, as these contribute to both the development and persistence of the condition. 4