Summary

Proposed management protocol for insertional Achilles Tendinitis

Abstract

Introduction

Insertional Achilles Tendinopathy (IAT) accounts for up to 25% of Achilles problems. Factors such as age, obesity, hypertension, diabetes, gender and certain medication can all predispose to the condition. IAT can be a challenging condition to treat, with no clear management protocol published to date. In this article we reviewed the various management options for IAT and report on a novel protocol that we use in our practice.

Methods

We performed a PubMed literature search for articles relating to the management of IAT. Our exclusion criteria included papers that reported on Achilles tendon ruptures and studies that were centred on pain in an area other than the Achilles tendon insertion.

Results

Conservative options for IAT include exercise programs, splinting, shockwave therapy and various injection therapies. Of these, only studies on heavy-slow eccentric exercises and shockwave therapy show significant improvements in outcomes in patients with IAT. With failure to respond to conservative measures, clinicians can focus on surgical targets. Debridement, with or without augmentation, can be performed in advanced disease with evidence suggesting that the Achilles tendon can be debrided up to 50% prior to it requiring augmentation. Both Gastrocnemius recession and dorsal wedge osteotomies have a role in disease specific IAT, however both have a low level of evidence supporting their use. Currently the effects of Hyaluronic acid injections and Plantaris syndrome on IAT are still being evaluated.

Conclusion

There remains a paucity of high-level evidence for the various treatment options in IAT with a need for more level 1 studies. We have reviewed the published literature and describe a protocol that can be a useful management aid for clinicians treating patients with IAT.