Achilles Insertional Tendonitis

Pain is often present with the associated inflammation. At the bony insertion site, a bump may develop called a Haglund’s deformity. This may become so large it can cause difficulty with fitting shoe wear, rubbing of the heel and even exquisite tenderness.

• Weight-bearing X-rays are required
• MRI scan may be required

• Topical anti-inflammatory creams
• Pain medications e.g. NSAIDS such as Mobic or Panadol Osteo
• Shoe wear modification e.g. open back shoes or heel lift
• Orthotic with medial arch support to help any overpronation of the foot
• Activity modification
  • improve fitness and strength via non axial loading exercises e.g. cycling or swimming. Avoid axial loading exercises e.g. running
  • avoid activities which overstretch the Achilles tendon
• Physiotherapy
  • eccentric strengthening program
  • avoid aggressive stretching programs as these often exacerbate symptoms
• Weight loss management
• Extracorporeal shockwave therapy may be of benefit but this has not been proven
• Corticosteroid injections must be avoided – there is a risk of tendon rupture
• Eccentric strengthening
  • stand on the balls of your feet on the edge of a stair with legs straight
  • gently drop both heels down to below the level of the stair
  • hold for 10 seconds

Surgery is considered if symptoms are progressing and function is decreasing after a trial on non-surgical treatment.

Surgical options may include:

• Open Achilles tendon debridement with removal of any calcific tissue and excision of the bony Haglunds deformity
  • An augment may be required e.g. FHL tendon

• Reconstruction of the insertion of the Achilles tendon with anchors into the bone

All surgery has risks involved, however every effort is made to reduce these risks. Risks include but are not limited to:

• Infection: superficial wounds or deep infections
• Clots: DVT (deep venous thrombosis) or PE (pulmonary embolus)
• Nerve damage: tingling, numbness or burning
• Ongoing pain
• General or anaesthetic risks including to the heart and lung
• Drug reactions/allergy
• Scarring or tethering of the skin
• Calf weakness
• Revision surgery

There are increased risks of surgery in diabetics, smokers, significant peripheral vascular disease, severe neuropathy, previous or current infection which may preclude a patient from surgery.

• Pain and stiffness along the Achilles tendon in the morning
• Pain along the tendon or back of the heel that worsens with activity
• Severe pain the day after exercising
• Thickening of the tendon
• Swelling that is present all the time and gets worse throughout the day or with activity
• Pain on the back of the heal when you wear shoes

• Weight-bearing X-rays are required
• MRI scan may be required

A walking CAM (controlled ankle motion) boot or moon boot may help reduce the inflammation. Occasionally a PRP (platelet rich plasma) injection may be offered. This can help promote reduction in inflammation and healing of the tendon. Application of glyceryl trinitrate patch has been shown to be effective.

Surgery is considered if non-operative treatment is unsuccessful after more than 6 months.

It may consist of:

• Arthroscopic debridement
• Open debridement of the unhealthy tendon and augmentation of the main Achilles tendon

All surgery has risks involved, however every effort is made to reduce these risks. Risks include but are not limited to:

• Infection: superficial wounds or deep infections
• Clots: DVT (deep venous thrombosis) or PE (pulmonary embolus)
• Nerve damage: tingling, numbness or burning
• Ongoing pain
• General or anaesthetic risks including to the heart and lung
• Drug reactions/allergy
• Scarring or tethering of the skin
• Calf weakness
• Revision surgery

There are increased risks of surgery in diabetics, smokers, significant peripheral vascular disease, severe neuropathy, previous or current infection which may preclude a patient from surgery.

View FootForward for Diabetes (run by Diabetes Australia) for more information on foot care.