Current Concepts Review: Insertional Achilles Tendinopathy

Abstract

Pathology of the Achilles tendon is a common source of posterior ankle and heel pain. A variety of terms have been used to describe similar but clinically distinct conditions involving this tendon including tendinosis, tendinitis, paratenonitis, and peritendinitis. The latter are misleading because their suffixes imply an inflammatory process. However, inflammatory cells are rarely present in biopsies from involved tendons.3 The most common histopathologic finding is a degenerative process characterized by disorganized collagen, abnormal neovascularization, necrosis and mucoid degeneration.34,58 Based on these findings, Maffulli and colleagues advocated for the term tendinopathy to describe the syndrome characterized by pain, swelling and impaired performance.39 While runners comprise the largest group of patients with chronic pain in the Achilles tendon, individuals of all activity levels and ages present with similar complaints. The location of the pain is an important discriminating factor, as insertional (tendon-bone junction) pain is often treated differently than noninsertional (2 to 6 cm proximal to the insertion) pain. This review will focus on insertional tendinopathy and will discuss related disorders including retrocalcaneal bursitis and Haglund’s deformity. Recently, much has been learned regarding the pathophysiology of Achilles tendinopathy and this knowledge has lead to the development of new treatment options. However, the evidence to support these innovative approaches has not been appraised. This current concepts review will present the etiology, pathophysiology, and evaluate the merits of