From the Guidelines
Insertional Achilles tendinopathy should be treated with conservative measures, including relative rest, activity modification, and eccentric strengthening exercises, as these methods have been shown to promote healing and pain relief. The condition is characterized by inflammation and degeneration of the Achilles tendon at its insertion point on the heel bone, often caused by repetitive microtrauma, and treatment should aim to reduce inflammation, promote healing, and address biomechanical factors 1.
Key Recommendations
- Relative rest and reduced activity to prevent further damage and promote healing and pain relief 1
- Eccentric strengthening exercises, starting with 3 sets of 15 repetitions and gradually increasing as tolerated, to reverse degenerative changes 1
- Anti-inflammatory medications like ibuprofen (400-600mg three times daily with food for 1-2 weeks) to manage pain and inflammation 1
- Ice application for 15-20 minutes several times daily, particularly after activity, to reduce pain and swelling 1
- Physical therapy focusing on eccentric strengthening, stretching, and manual therapy for 6-8 weeks 1
- Consideration of a night splint to maintain ankle dorsiflexion during sleep for persistent cases 1
- Extracorporeal shock wave therapy as a safe, noninvasive, and effective means of pain relief for chronic cases 1
- Surgery reserved for cases that fail to respond to 6 months of conservative treatment 1
Important Considerations
- Anatomic misalignment, such as forefoot and heel varus and excessive pes planus or foot pronation, should be addressed with shoe orthotics to correct overpronation or pes planus problems 1
- Heel lift orthotics can be used to unload the tendon and provide pain relief 1
- Cryotherapy, including repeated applications of melting ice water through a wet towel for 10-minute periods, can provide acute relief of tendinopathy pain 1
From the Research
Insertional Achilles Tendinopathy Treatment Options
- Conservative treatment is the first line of therapy, including reduction of activity levels, administration of non-steroidal anti-inflammatory drugs (NSAID), adaptation of footwear, heel wedges and orthoses or immobilization 2
- Eccentric stretching exercises are a key component of physiotherapy and can achieve a 40% reduction in pain 2
- Extracorporeal shock wave therapy has been shown to reduce pain by 60% with a patient satisfaction of 80% 2
- Injections with platelet-rich plasma (PRP), dextrose (prolotherapy) or polidocanol (sclerotherapy) are not currently recommended due to limited evidence 2
Surgical Treatment Options
- Operative therapy is indicated after 6 months of unsuccessful conservative therapy 2
- Open debridement allows all pathologies to be addressed, including osseous abnormalities and intratendinous necrosis, with a success rate of over 70% 2
- The Achilles tendon should be reattached if detached by >50% 2
- Tendoscopy is a promising treatment option for isolated retrocalcaneal bursitis, with similar success rates to open debridement and lower complication rates 2
Current Evidence and Recommendations
- The overall level of evidence for insertional Achilles tendinopathy treatment is limited, with most studies being case series evaluations or having a low level of evidence 3, 4
- Exercise has the highest level of evidence supporting its ability to reduce insertional Achilles tendinopathy pain 4
- Extracorporeal shock wave therapy is a recommended nonoperative treatment option after exercise has been unsuccessful 4
- Surgical treatment is recommended when nonsurgical treatment fails, with various options available including débridement, tendon reattachment, and tendon transfer 5