What is the treatment for right Achilles insertional tendinosis and enthesopathy with a possible punctate intrasubstance partial thickness tear?

From the Guidelines

For right Achilles insertional tendinosis with possible partial tear, I recommend a conservative treatment approach prioritizing eccentric strength training, as it is a particularly popular and effective option, according to 1. Begin with rest and activity modification to reduce stress on the tendon. Apply ice for 15-20 minutes several times daily to reduce inflammation. Take NSAIDs like ibuprofen (400-600mg three times daily with food) or naproxen (500mg twice daily) for 1-2 weeks to manage pain and inflammation. Some key considerations for treatment include:

• Eccentric heel drop exercises: stand on a step with heels hanging off, rise on both feet, then slowly lower with the affected foot only, 3 sets of 15 repetitions twice daily for at least 12 weeks.
• Use a heel lift (0.5-1cm) in both shoes to reduce tension on the Achilles, as anatomic misalignment can be treated with shoe orthotics to correct overpronation or pes planus problems, as noted in 1.
• Physical therapy is crucial for guided rehabilitation, including ultrasound therapy, manual techniques, and progressive strengthening.
• Night splints can help maintain tendon flexibility. For persistent pain, consider a walking boot for 2-4 weeks or a corticosteroid injection (though this carries risks of tendon weakening). Surgery, as discussed in 1, is typically reserved for cases that don't respond to 6+ months of conservative treatment, and may include excision of abnormal tendon tissue and performance of longitudinal tenotomies to release areas of scarring and fibrosis. This multi-modal approach addresses inflammation while promoting healing and preventing recurrence by gradually strengthening the tendon.

From the Research

Treatment Options for Right Achilles Insertional Tendinosis and Enthesopathy

• Conservative treatment is the first line of therapy, which includes:
  • 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, which can achieve a 40% reduction in pain 2
  • Extracorporeal shock wave therapy, which has been shown to reduce pain by 60% with a patient satisfaction of 80% 2
• Surgical treatment is indicated after 6 months of unsuccessful conservative therapy, which may include:
  • Open debridement to address all pathologies, including osseous abnormalities and intratendinous necrosis 2
  • Reattachment of the Achilles tendon if detached by >50% 2
  • Flexor hallucis longus transfer to augment the repair, considered in older, heavier patients or if more than 50% of the tendon was debrided 3
  • Tendoscopy, a promising treatment option for isolated retrocalcaneal bursitis, with similar success rates to open debridement and significantly lower complication rates 2
• Other treatment options that may be considered include:
  • Calcaneal closing wedge osteotomy
  • Gastrocnemius lengthening
  • Suture anchor techniques 4
  • Physical therapy with eccentric training and other modalities 3, 4
  • Injections and extracorporeal shock wave therapy 4, 5

Considerations for Treatment

• The treatment approach should be individualized based on the patient's specific condition and needs 4
• A thorough diagnosis and early conservative management can improve patient quality of life and reduce unnecessary surgical consultations 5
• Surgical treatment should be considered when nonsurgical treatment fails, and the patient's condition warrants further intervention 3, 4