Insertional Achilles tendinopathy: A guide for patients

Haglund’s prominence:
Bony outgrowth from the heel, with associated calcification of the tendon.

Insertional Achilles tendinopathy is an acute or chronic condition affecting the Achilles tendon and its surrounding structures.

The condition is painful and leads to reduced mobility and swelling. The pain is often made worse by activity and can be aggravated by pressure from footwear.

Insertional Achilles tendinopathy is often associated with a bony prominence, known as Haglund’s prominence. This can aggravate the tendon, as well giving a bony outgrowth around the insertion of the Achilles tendon and calcification - bone formation - in the tendon itself.

The bony outgrowth around the heel causes a number of problems with footwear and can be rather disabling.

Treatment options

Treatment can be broadly divided into conservative and surgical management.

Conservative care

Footwear alteration

A more accommodating shoe, with a wider heel area, can help reduce friction to the area.

Eccentric stretching exercises

These exercises place a stretch on to the tendon and encourage tendon healing. They are different from the exercises for non-insertional Achilles tendinopathy and will be discussed with you by the podiatric surgeon.

Extra corporeal shock wave therapy

This treatment is a combination of ultrasound and a pulse wave, which helps reduce the pain associated with the condition and encourages tendon healing. It will not reduce the size of the bony outgrowths.

Heel raise

A heel lift can reduce the compression of the tendon and reduce the overall tension of the tendon, so it reduces pain. A heel raise should be worn in both shoes and can be bought at a pharmacy.

Surgical care

Surgical management consists of removing the Haglund’s prominence, as well as the bony growths in the tendon and any degenerative tendon. This procedure involves detaching the Achilles tendon from the heel bone and then re-attaching it to the heel through bone anchors. The bone anchors are good at holding the tendon back to the bone, but need a period of non-weight-bearing in a below knee cast and then partial weight- bearing in an aircast boot. You will be in the cast and boot for six to eight weeks. After this, you will be placed in a running trainer with a heel lift and a course of mobilisation and rehabilitation will begin. Depending on the type of work that you do, you should be able to return at around eight to 10 weeks. This is longer for a more manual job.

Frequent or serious risks

All operations carry a small risk of complications. In foot surgery, complications are uncommon and most resolve without permanent disability or pain. General and specific complications of this procedure include:

• Infection (two in 100)
• Delayed healing of the skin (eight in 100)
• Non-compliance of patients (four in 100)
• Prolonged swelling post operatively (four in 100)
• Thick or sensitive scar formation (four in 100)
• Blood clot deep vein thrombosis (DVT)
• Rupture of the tendon from the bone anchors and no improvement.

Complications following foot surgery are rare, but can happen. If there are complications, you will be need to visit the hospital more frequently and there could be a significant impact on the time it takes you to recover and return to work. Foot surgery should be avoided if it is only for cosmetic gain.