Insertional Achilles Tendonopathy

Condition

The Achilles tendon inserts into the back of the heel bone (the calcaneus) and this is termed the Achilles tendon insertion. If there is excessive pull at the attachment, the area can become painful and this is called insertional Achilles tendonopathy. In some instances a bone spur can form at the back of the heel.

There is a small fluid filled sack called a bursa which sits between the Achilles tendon (just above the insertion) and the heel bone. This can become inflamed and painful and is termed Achilles bursitis.

The bone itself can become inflamed and be prominent. When this is present, it is termed a Haglund’s deformity. It is possible to have either 1, 2 or all 3 of these conditions.

What causes Insertional Achilles tendonopathy?

Generally this occurs with over use, particularly in sport. However, bone spurs can take many years to form without being painful.

Poor biomechanical function can contribute to over use and increased pull at the insertion, pre-disposing to symptoms.

In some patients, new blood vessels form as part of the healing process (neovascularisation) and it is has been postulated that these bring nerves with them which contribute to the pain. However, this process has been called into question more recently.

Will it get worse?

Left un-treated, most musculoskeletal problems deteriorate, eventually causing reduced activity. However, this is one condition that can settle with rest.

What are the common symptoms?

• Pain directly over the bone at the back of the heel.
• If there is a bone spur, the back of the heel may be prominent
• Stretching the Achilles tendon may cause symptoms.
• It may be painful first thing in the morning or on getting up from a chair after a rest.
• If the bursa is inflamed, it may be swollen and painful just behind the Achilles tendon directly above the bony insertion.

How is it recognised?

• Clinical examination and a detailed history allow diagnosis.
• X-rays will identify if there is any spur or if the bone is prominent as in a Haglund’s deformity.
• A detailed 3D gait analysis can help to diagnose the contributing factors.
• When necessary and ultrasound scan or MRI scan can help diagnosis.

What can I do to reduce the pain?

There are several things that you can do to try and relieve your symptoms:

• Rest
• Ice
• Heel raises can help
• An Achilles heel protector can be of benefit
• See a podiatrist

What will Premier Podiatry do?

If simple measures do not reduce your symptoms, there are other options:

• Confirm the diagnosis / arrange any necessary investigations
• Perform a detail 3D gait analysis to diagnose the under lying factors that may contribute to injury if necessary.
• Advise appropriate shoes
• Advise exercises – an eccentric exercise programme can be beneficial
• In our experience, orthotics are rarely beneficial for this condition.
• Perform shockwave therapy which has been shown to be effective for this condition.
• A steroid injection targeted to the area of symptoms can be helpful. Our experience has been that the results are improved if it is followed by a 2-4 week period of immobilisation in a removable walking boot.

Will this cure the problem?

This can be a very difficult condition to treat and can take several months to settle. Whilst the treatment options can be of benefit, they will not reduce any bone spur.

What will happen if I leave this alone?

If you continue to exercise, it is likely to get worse. It can settle with rest / reduced activity..

How can I cure the deformity?

In severe cases, surgery is an option, particularly if there is a bone spur. However, this involves cutting through the Achilles tendon, removing the back of the heel bone and re-attaching the tendon, usually with a bone anchor. Whilst this can be very effective in reducing symptoms, it often involves a long recovery (6-12 months).