Insertional Achilles Tendinopathy Research Articles

Patterns of movement-evoked pain during tendon loading and stretching tasks in Achilles tendinopathy: A secondary analysis of a randomized controlled trial

BackgroundThis study aimed to characterize movement-evoked pain during tendon loading and stretching tasks in individuals with Achilles tendinopathy, and to examine the association between movement-evoked pain with the Achilles tendinopathy type (insertional and midportion), biomechanical, and psychological variables. MethodsIn this laboratory-based, cross-sectional study, 37 individuals with chronic Achilles tendinopathy participated. Movement-evoked pain intensity (Numeric Rating Scale: 0 to 10) and sagittal-plane ankle biomechanics were collected simultaneously during standing, fast walking, single-leg heel raises, and weight-bearing calf stretch. Description of symptoms, including location of Achilles tendon pain and duration of tendon morning stiffness, as well as pain-related psychological measures, including the Tampa Scale of Kinesiophobia were collected. Linear mixed effects models were built around two paradigms of movement-evoked pain (tendon loading and stretching tasks) with each model anchored with pain at rest. FindingsMovement-evoked pain intensity increased as task demand increased in both models. Lower peak dorsiflexion with walking (β = −0.187, 95% CI: −0.305, −0.069), higher fear of movement (β = 0.082, 95% CI: 0.018, 0.145), and longer duration of tendon morning stiffness (β = 0.183, 95% CI: 0.07, 0.296) were associated with greater pain across tendon loading tasks (R2 = 0.47). Lower peak dorsiflexion with walking (β = −0.27, 95% CI: −0.41, −0.14), higher dorsiflexion with the calf stretch (β = 0.095, 95% CI: 0.02, 0.16), and insertional Achilles tendinopathy (β = −0.93, 95% CI: −1.65, −0.21) were associated with higher pain across tendon stretching tasks (R2 = 0.53). InterpretationIn addition to exercise, the ideal management of Achilles tendinopathy may require adjunct treatments to address the multifactorial aspects of movement-evoked pain.

Paper 68: Outcomes following Extracorporeal Shockwave Therapy for chronic Achilles tendinopathy at short to mid-term follow-up

Objectives: The purpose of this retrospective clinical study was to evaluate outcomes following extracorporeal shockwave therapy (ESWT) for the treatment of Achilles tendinopathy. Subgroup analysis was conducted to identify predictors of poor outcomes. Methods: This retrospective cohort study included existing clinical data from 74 patients from a single academic institution. Patients greater than 16 years of old who underwent ESWT for Achilles tendinopathy in the office setting between 3/3/2017 to 8/2/2022 were included. Data collected included: patient demographics, co-morbidities, treatment characteristics, Victorian institute of sports assessment – Achilles (VISA-A) scoring tool, visual analog scale (VAS), magnetic resonance imaging data, return to play (RTP) data and failures were recorded. Failure was defined as no improvement in VISA-A nor VAS scores or surgical intervention. For these data, mean and standard deviation were calculated, and paired samples T-tests and Welch’s T-tests were performed on clinical outcome scores. Results: In total, 74 patients (91 heels) with a mean age of 54.1 ± 14.0 years and BMI of 27.3 ± 4.5 kg/m2 underwent ESWT for Achilles tendinopathy at a mean follow-up of 25.7 ± 15.0 months. Eighteen patients were in the non-insertional Achilles tendinopathy (NAT) cohort and 56 patients were in the insertional Achilles tendinopathy (IAT) cohort. Both NAT and IAT cohorts had a similar improvement in VISA-A score (p=0.365) and VAS scores (p=0.65). A shorter return to play time was found in the NAT cohort (1.1 ± 0.9 months) compared to the IAT cohort (2.6 ± 5.7 months) but this was not statistically significant (p=0.34). There was a higher failure rate in the the IAT cohort (50.0%) than the NAT cohort (38.9%). Patients who received platelet-rich plasma (PRP) had a higher failure rate (61.2%) than those who did not receive PRP (39.6%). In the NAT cohort, the failure rate in females was 0.0%. In the IAT cohort, the failure rate in females was 61.9%. Linear regression analysis found that elevated BMI and MRI severity were associated with worse post-ESWT outcomes. Conclusions: This retrospective study demonstrated a high failure rate at short-term follow-up in patients who underwent ESWT for Achilles tendinopathy. Higher failure rates were found in patients with IAT and those who received intratendinous PRP. Predictors of poor outcomes included elevated BMI and MRI severity. Further studies with larger patient cohorts and a longer follow-up are necessary to determine the role of ESWT in the treatment of Achilles tendinopathy.

Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy and Haglund Deformity: A Technique Tip.

Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy and Haglund Deformity: A Technique Tip.

A comparison of characteristics and outcomes of operative treatment for Achilles tendon sleeve avulsion in older versus younger patients.

Achilles tendon sleeve avulsion (ATSA) is a rare injury that often results from pre-existing insertional Achilles tendinopathy and occurs when a tendon avulses from the insertion as a continuous sleeve. To date, outcomes of operative treatment for ATSA in older patients have not been reported. Therefore, this study aims to compare the characteristics and outcomes of Achilles tendon (AT) reattachment with or without tendon lengthening for ATSA between older and younger patients. This study enrolled 25 consecutive patients who underwent operative treatment following a diagnosis of ATSA between January 2006 and June 2020. The inclusion criterion was a minimum follow-up duration of one year. The enrolled patients were divided into two groups according to their age at operation: ≥ 65years (group 1, 13 patients) and < 65years (group 2, 12 patients). AT reattachment was performed in all patients using two 5.0-mm suture anchors after an inflamed distal stump resection in the 30° plantar-flexed ankle position. The degree of active dorsiflexion and plantar flexion, mean visual analog scale score, and Victorian Institute of Sports Assessment-Achilles scores at the final follow-up were not significantly different between the two groups (P > 0.05 each). The rate of satisfactory clinical outcomes (defined as fair or greater) was 84.6% and 91.7% in groups 1 and 2, respectively. We observed that comparable clinical outcomes could be achieved after AT reattachment with or without lengthening for ATSA between older and younger patients.

Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review.

Studies of minimally invasive surgery for insertional Achilles tendinopathy are limited. To establish this surgery, the following techniques must be minimally invasive: Exostosis resection at the Achilles tendon insertion, debridement of degenerated Achilles tendon, reattachment using anchors or augmentation using flexor hallucis longus (FHL) tendon transfer, and excision of the posterosuperior calcaneal prominence. Studies on these four perspectives were reviewed to establish minimally invasive surgery for insertional Achilles tendinopathy. Techniques for exostosis resection were demonstrated in one case study, where blunt dissection around the exostosis was performed, and the exostosis was resected using an abrasion burr under fluoroscopic guidance. Techniques for debridement of degenerated Achilles tendon were demonstrated in the same case study, where the space left after resection of the exostosis was used as an endoscopic working space, and the degenerated Achilles tendon and intra-tendinous calcification were debrided endoscopically. Achilles tendon reattachment techniques using suture anchors have been demonstrated in several studies. However, there are no studies on FHL tendon transfer techniques for Achilles tendon reattachment. In contrast, endoscopic posterosuperior calcaneal prominence resection is already established. Additionally, studies on ultrasound-guided surgeries and percutaneous dorsal wedge calcaneal osteotomy as minimally invasive surgery were reviewed.

Two-Year Clinical and Radiologic Outcomes Following Surgical Treatment of Insertional Achilles Tendinopathy Using a Central Tendon-Splitting Approach.

If conservative treatment of insertional Achilles tendinopathy (IAT) fails, surgery is often considered. Various surgical approaches have been used including the central Achilles tendon splitting approach. This study aimed to report the 2-year clinical and radiologic outcomes after surgical treatment of IAT with a central tendon-splitting approach. Seventy-five cases of IAT treated surgically via the open central tendon-splitting approach were analyzed. Clinical outcomes included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, visual analog scale (VAS), 36-Item Short Form Health Survey (SF-36) physical (PCS) and mental (MCS) component summary scores, all measured at baseline and 6 and 24 months postoperatively. Radiologic parameters measured included the Fowler-Philip angle (FPA) and parallel pitch lines (PPL). Three patients had clinically significant wound issues but healed completely by 3 weeks. Mean AOFAS score improved from 45.63 preoperatively to 94.71 at 24 months. Mean VAS score improved from 6.73 preoperatively to 0.55, mean SF-36 PCS from 35.98 to 48.74, and mean SF-36 MCS from 53.04 to 55.43 at 24 months. Satisfaction at 2 years was 94.3%. Mean FPA decreased from 62.0 degrees preoperatively to 34.0 degrees postoperatively. PPL was positive in 82.7% (62 of 75) of cases preoperatively, decreasing to 1.3% (1 of 75) postoperatively. Increasing age and higher preoperative VAS and SF-36 MCS scores were significantly associated with improvements in postoperative AOFAS, SF-36 PCS, and MCS scores. Surgical treatment of IAT via the central tendon-splitting approach achieved substantial improvements in all patient-reported outcome measures measured. These excellent clinical outcomes continued to show improvement 2 years postoperatively. Level III, retrospective cohort study.

Association of Haglund Deformity Size and Insertional Achilles Tendinopathy.

We aimed to investigate the effect of Haglund deformity size on insertional Achilles tendinopathy (IAT) using a new measurement system and identify independent risk factors of IAT with Haglund deformity. We reviewed medical records of patients with IAT and age/sex-matched patients with diagnoses other than Achilles tendinopathy. Radiographs were reviewed to identify posterior heel spur, plantar heel spur, and intra-Achilles tendon calcification, and to measure Fowler-Philip angle, calcaneal pitch angle, and Haglund deformity angle and height. We introduced a new measurement system for Haglund deformity angle and height and evaluated its intraobserver and interobserver reliability. Multivariate logistic regression analysis was performed to identify independent risk factors of IAT with Haglund deformity. Fifty patients (55 feet) were enrolled in the study group, equaling the size of the age/sex-matched control group. The new Haglund deformity measurement system showed excellent intraobserver and interobserver reliability. No significant differences between the 2 groups were noted in Haglund deformity angle and height: 6.0 degrees in both groups, and 3.3 mm vs 3.2 mm in the study and control group, respectively. The study group had significantly higher calcaneal pitch angle, incidence of posterior heel spur, plantar heel spur, and intra-Achilles tendon calcification: 5.2 vs 23.1 degrees (P = .044), 81.8% vs 36.4% (P < .001), 76.4% vs 34.5% (P = .003), and 67.3% vs 5.5% (P < .001), respectively. Multivariate logistic regression analysis identified independent risk factors of IAT: posterior heel spur (OR = 3.650, 95% CI = 1.063, 12.532), intra-Achilles tendon calcification (OR = 55.671, 95% CI = 11.233, 275.905), and increased calcaneal pitch angle (OR = 6.317). Based on our results, the actual size of Haglund deformity as we have reliably measured was not associated with IAT, suggesting a routine Haglund deformity resection may be unnecessary in the surgical treatment of IAT. If patients with Haglund deformity have posterior heel spur, intra-Achilles tendon calcification, or increased calcaneal pitch angle, a higher chance of IAT can be predicted. Level III, retrospective cohort study.

Fluoroscopic and Endoscopic Calcaneal Exostosis Resection and Achilles Tendon Debridement for Insertional Achilles Tendinopathy: Surgical Techniques

This Technical Note describes the minimally invasive surgical techniques for insertional Achilles tendinopathy: fluoroscopic and endoscopic calcaneal exostosis resection and Achilles tendon debridement. First, two portals are placed 1 cm proximal and distal to the exostosis on the lateral heel. Next, blunt dissection around the exostosis and exostosis resection is performed under fluoroscopic guidance. The remaining space after the exostosis resection is used as the working space for endoscopy. Finally, the degenerated Achilles tendon is debrided endoscopically.

Comparison of efficacy of platelet-rich plasma and extracorporeal shock wave for the treatment of chronic insertional Achilles tendinopathy

To compare clinical efficacy of platelet-rich plasma (PRP) and extracorporeal shock wave in treating chronic insertional Achilles tendinopathy. From February 2019 to August 2021, 42 patients with chronic insertional Achilles tendinopathy were selected and divided into PRP group(20 patients, 28 feet) and shock wave group (22 patients, 29 feet). In PRP group, there were 12 males and 8 females, aged 47.00(28.00, 50.75) years old, and the courses of disease ranged 7.00(6.00, 7.00) months;PRP injection was performed in the Achilles tendon stop area of the affected side. In shock wave group, there were 16 males and 6 females, aged 42.00(35.75, 47.25) years old;and the courses of disease was 7.00(6.00, 8.00) months;shock wave was performed in Achilles tendon stop area of the affected side and triceps surae area. Visual analogue scale (VAS) and Victorian Institute of Sport Assessment-Achilles (VISA-A) were applied to evaluate clnical effect before treatment, 1, 3 and 6 months after treatment, and satisfaction of patients was investigated. VAS and VISA-A score in both groups were significantly improved at 1, 3 and 6 months after treatment than before treatment (P<0.05), VAS and VISA-A score in PRP group at 6 months after treatment were significantly higher than those at 1 and 3 months after treatment, and VAS and VISA-A score in shock wave group were lower than those at 1 and 3 months after treatment (P<0.05). There was no significant difference in VAS and VISA-A score between two groups before treatment, 1 and 3 months after treatment(P>0.05), while VAS and VISA-A score in PRP group were better than those in shock wave group at 6 months after treatment(P<0.05), and the satisfaction survey in PRP group was better than that in shock wave group(P<0.05). PRP injection has a good clinical effect on chronic insertional Achilles tendinopathy with high patient satisfaction, and medium-and long-term effect of PRP injection for the treatment of chronic insertional Achilles tendinopathy is better than that of extracorporeal divergent shock wave.

Treatment of Achilles insertional tendinopathy: our surgical procedure and medium-term results.

Achilles insertional tendinopathy (AIT) is a common injury and its pathogenesis is still not entirely clear. It manifests with worsening pain and functional limitations. When conservative treatment fails, surgical treatment is indicated. The purpose of our research is to evaluate the outcome after one year in patients affected by AIT (calcific and non-calcific AIT) who were treated at our centre. Between 2014 and 2021, 42 patients suffering from AIT - a total of 47 feet - underwent surgery at our centre. The patients filled in the VISA-A and AOFAS questionnaires at the pre-operative consultation and at the clinical check-up after one year of follow up. Of the 47 feet treated, 28 were calcific AITs treated by medial access and tendon reinsertion using a knotless double suture anchor system (Achilles Suture Bridge™) and 19 were non-calcific tendinopathies treated using a lateral paratendinous approach. The one-year clinical results show an increase in VISA-A scores of 48.6 and AOFAS scores of 44.1 and the absence of complications. Only one patient reported a recurrence of certain symptoms and none of the patients were hospitalized for recurrence. The literature is unable to establish a gold standard of treatment for AIT. The method we have used has shown excellent short- and medium-term results without any complications. Further studies are needed to prove its effectiveness in the long term.

Factors Associated With Poor Patient-Reported Outcomes in Isolated Gastrocnemius Recession for Heel Pain.

Gastrocnemius recession is commonly performed for a variety of pathologies of the foot and ankle, yet studies characterizing risk factors associated with patient-reported outcomes are limited. In this cohort study, patient outcomes were compared against the general population for PROMIS scores with correlation analysis comparing demographics and comorbidities. Our primary goal in this study is to identify risk factors associated with poor patient-reported outcomes following isolated gastrocnemius recession for patients with plantar fasciitis or insertional Achilles tendinopathy. A total of 189 patients met inclusion criteria. The open Strayer method was preferred. However, if the myotendinous junction could not be adequately visualized without expanding the excision, then a Baumann procedure was performed. The decision between the two did not depend on preoperative contracture. Patient demographics and visual analog scale (VAS) scores were obtained via the electronic medical record. Telephone interviews were completed to collect postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) and Foot Function Index (FFI) scores. The data were analyzed using the type 3 SS analysis of variance test to identify individual patient factors associated with reduced PROMIS, FFI, and VAS scores. No demographic variables were found to be significantly associated with postoperative complications. Patients who reported tobacco use at the time of surgery had significantly decreased postoperative PROMIS physical function (P = .01), PROMIS pain interference (P < .05), total FFI scores (P < .0001), and each individual FFI component score. Patients undergoing their first foot and ankle surgeries reported numerous significant postoperative outcomes, including decreased PROMIS pain interference (P = .03), higher PROMIS depression (P = .04), and lower FFI pain scores (P = .04). Hypertension was significantly associated with an increased FFI disability score (P = .03) and, along with body mass index (BMI) >30 (P < .05) and peripheral neuropathy (P = .03), significantly higher FFI activity limitation scores (P = .01). Pre- and postoperative VAS scores demonstrated improvement in patient-reported pain from a mean of 5.53 to 2.11, respectively (P < .001). We found in this cohort that numerous patient factors were independently associated with differences in patient-reported outcomes following a Strayer gastrocnemius recession performed for plantar fasciitis or insertional Achilles tendinopathy. These factors include, but are not limited to, tobacco use, prior foot and ankle surgeries, and BMI. This study strengthens previous reports demonstrating the efficacy of isolated gastrocnemius recession and elucidates variables that may affect patient-reported outcomes. Level III, retrospective cohort study.

Epidemiology of insertional and midportion Achilles tendinopathy in runners: A prospective cohort study

BackgroundAchilles tendinopathy (AT) is a common problem among runners. There is only limited evidence for risk factors for AT, and most studies have not defined the AT subcategories. No study has compared the incidence and risk factors between insertional AT and midportion AT, though they are considered distinct. This study aimed to assess incidence and risk factors of AT based on data from a large prospective cohort. The secondary aim was to explore differences in risk factors between insertional and midportion AT. MethodsParticipants were recruited from among registered runners at registration for running events. Questionnaires were completed at baseline, 1 month before the event, 1 week before the event, and 1 month after the event. Information concerning demographics, training load, registered events, and running-related injuries were collected at baseline. The follow-up questionnaires collected information about new injuries. A pain map was used to diagnose midportion and insertional AT. The primary outcome was the incidence of AT. Multivariable logistic regression analysis was applied to identify risk factors for the onset. ResultsWe included 3379 participants with a mean follow-up of 20.4 weeks. The incidence of AT was 4.2%. The proportion of insertional AT was 27.7% and of midportion AT was 63.8%; the remaining proportion was a combined type of insertional and midportion AT. Men had a significantly higher incidence (5%, 95% confidence interval (95%CI): 4.1%–6.0%) than women (2.8%, 95%CI: 2.0%–3.8%). AT in the past 12 months was the most predominant risk factor for new-onset AT (odds ratio (OR) = 6.47, 95%CI: 4.27 –9.81). This was similar for both subcategories of AT (insertional: OR = 5.45, 95%CI: 2.51–11.81; midportion: OR = 6.96, 95%CI: 4.24–11.40). Participants registering for an event with a distance of 10/10.55 km were less likely to develop a new-onset AT (OR = 0.59, 95%CI: 0.36–0.97) or midportion AT (OR = 0.47, 95%CI: 0.23 –0.93). Higher age had a significant negative association with insertional AT (OR = 0.97, 95%CI: 0.94–1.00). ConclusionThe incidence of new-onset AT among recreational runners was 4.2%. The proportion of insertional and midportion AT was 27.7% and 63.8%, respectively. AT in the past 12 months was the predominant risk factor for the onset of AT. Risk factors varied between insertional and midportion AT, but we could not identify clinically relevant differences between the 2 subtypes.

Treatment of Insertional Achilles Tendinopathy Using Adjunct Electroacupuncture Therapy: A Randomized Controlled Trial.

Achilles tendinopathy is a common musculoskeletal condition associated with decreased functionality. The insertional variant (<2cm from the calcaneus) is less responsive to eccentric-exercise therapy. This study looked at the effect of electroacupuncture (EA) + eccentric exercise for treating insertional Achilles tendinopathy. Fifty-two active duty and Department of Defense beneficiaries older than 18 years of age with insertional Achilles tendinopathy were randomized to treatment with either eccentric exercise or eccentric exercise with EA. They were evaluated at 0, 2, 4, 6, and 12 weeks. The treatment group received EA treatment in the first 4 visits. The Victorian Institute of Sports Assessment-Achilles Questionnaire (VISA-A; scored 0-100; higher score = increased function) was used to assess the patients and patient-reported pain (0-10, increasing pain with score) pre- and post-demonstration of the exercises during each visit. Both the treatment group (53.6% reduction; confidence interval [CI]: 2.1, 3.9; P < 0.001) and the control group (37.5% reduction; CI: 0.4, 2.9; P = 0.023) reported decreased pain between the first and last visit. The treatment group had reduced pain (mean difference [MD] = 1.0; P < 0.01) between pre- and post-eccentric-exercise performance at each visit, while the control group did not (MD = -0.3; P = 0.065). VISA-A scores did not show a difference in functional improvement between the groups (P = 0.296). EA as an adjunct to eccentric therapy significantly improves short-term pain control for insertional Achilles tendinopathy.

Haglund Excision and Suture Bridge Repair

Background: Haglund deformity and insertional Achilles tendinopathy involve a degenerative process demonstrating disorganized collagen and mucoid degenerative material causing pain and swelling. Indications: Operative management through a distally based midline incision should be explored if symptoms are refractory to nonoperative management (activity and shoewear modifications, heel lifts, physical therapy, and heel sleeves). Direct lateral approach with small longitudinal split and removal of lateral prominence “pump bump” is performed when a patient has pain isolated solely to the prominence. We feel that endoscopic removal does not allow for appropriate evaluative of degenerative tissue. Techniques: Through a distally based incision, we dissect to the level of the paratenon and make one smooth cut through paratenon and tendon. We then excise the mucoid, degenerative tissue. Removal of Haglund deformity and exostosis is carefully accomplished with a saw. We then utilize a rongeur to smooth Haglund deformity and any remaining medial/lateral calcaneal prominences. We then complete a dual-row speed bridge with 4 suture anchors (horizontal mattress) and a modified Mason-Allen technique. A Thompson test is then repeated and the longitudinal split is repaired. Postoperatively, we have patients weight bear as tolerated in a boot for with suture removal and transition to shoewear at the 2-week mark. We begin range of motion and activity once the wound has healed. We expect return to sport beginning at 3 months with full return by 6 months. Results: The current body of literature shows significant patient satisfaction and minimal risk of complication. Some authors have shown significant improvement in American Orthopaedic Foot and Ankle Score (AOFAS) scores, with only 1 patient requiring a flexor hallucis longus (FHL) transfer and no complications. Further studies identify early weight-bearing in Achilles suture bridge technique to have some promise with improvement in visual analog scale (VAS)/AOFAS scores, though there is risk of wound breakdown. Discussion/Conclusion: An Achilles suture bridge technique with early weight-bearing is a viable option for patients with Haglund deformity, and insertional Achilles tendinopathy who have failed conservative management. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Treatment of Calcific Insertional Achilles Tendinopathy: Knotless Internal Brace versus Knot-Tying Suture Bridge.

This study aimed to compare the knotless internal brace technique and the knot-tying suture bridge technique via the medial approach in the treatment of calcific Achilles tendinopathy. The clinical data of 25 cases of calcific Achilles tendinopathy in which nonoperative treatments had failed were retrospectively collected. All the patients received Achilles tendon debridement and Haglund deformity excision through a medial approach, followed by repair using the knotless internal brace technique or the knot-tying suture bridge technique. Pain was evaluated by using the visual analog scale (VAS). The American Orthopedic Foot and Ankle Score (AOFAS) questionnaire was administered preoperatively and postoperatively. The mean follow-up time was 2.6 (range 2-3.5) years. There were no wound complications and no Achilles tendon ruptures. At 1 year postoperatively, the internal brace group was superior to the suture bridge group in terms of the VAS scores (p = 0.003). However, no differences were noticed between the two groups in either the VAS or the AOFAS scores at 2 years postoperatively. The medial approach in combination with the suture bridge technique was effective in treating calcific Achilles tendinopathy. The knotless internal brace technique involved less pain compared to the knot-tying suture bridge technique only at the early postoperative stage.

Comparative short-term effectiveness of non-surgical treatments for insertional Achilles tendinopathy: a systematic review and network meta-analysis

BackgroundThe incidence of Achilles tendinopathy has risen over the past decades. Insertional Achilles tendinopathy is characterised by tissue degeneration of the Achilles tendon from its insertion in the calcaneus to up to 2 cm proximally. This clinical condition is accompanied by pain, loss of function and diminished exercise tolerance. Numerous conservative treatment modalities are available to participants with insertional Achilles tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, laser therapy, cryotherapy, therapeutic ultrasound, and orthotics. Eccentric exercise and extracorporeal shockwave therapy may reduce pain in participants with non-calcified insertional Achilles tendinopathy. However, no specific treatment is recommended over another due to the low methodological quality of trials. Given the lack of standard or preferred non-surgical treatment and the potential risks of surgical treatment, there is an imminent need to reassess different non-surgical treatments based on the newest evidence. Thus, this systematic review aims to evaluate the clinical effectiveness of the various non-surgical treatments for insertional Achilles tendinopathy.MethodsAMED EBSCOhost, CINAHL, EBSCOhost, EMBASE, PEDro, PubMed, Web of Science, and Clinicaltrials.gov were searched from 1992 to 14th October 2022, randomised controlled trials of adults with insertional Achilles tendinopathy investigating non-surgical treatments compared with each other or no treatment, placebo/sham control. Two reviewers independently screened and extracted the data. Random effects of network meta-analysis immediately after treatments were used to report comparative treatment effects. The surface under the cumulative ranking probabilities was calculated to assess the relative ranking of treatments.ResultsNine trials (total n = 464 participants) were included. This review recommended the combination of eccentric exercise and soft tissue therapy to manage insertional Achilles tendinopathy. With the highest SUCRA values of 84.8, and the best mean rank of 1.9, Eccentric exercise plus soft tissue treatment ranked as the most effective treatment for short-term pain.ConclusionsThis is the first NMA of non-surgical treatment focusing on short-term pain control for IAT which eccentric exercise plus soft-tissue therapy was found to be the most effective treatment combination. However, the overall confidence in non-surgical treatments from all included trials was very low. No recommendation of the best treatment option can be made from this review.

Evaluation of Flexor hallucis tendon transfer in chronic insertional Achilles tendinopathy in over 50-year-old population using validated ankle scores

PurposeChronic insertional Achilles tendinopathy is a common pathology in the over 50 years old population. Patients not relieved with conservative treatment had to undergo surgical intervention for the management. This study evaluates the clinical outcome of FHL transfer in such patients using validated ankle functional scores. MethodIt is a retrospective study including 20 patients of either gender managed with debridement of the distal degenerative remnant Achilles tendon fibers either at the insertion site or the distal end of the torn tendon, resection of Haglund deformity with FHL transfer, and reattachment of Achilles tendon. The average age of the patients was 56.55 + 11 years (50–77 years) followed by over 35.6 months (Range 22–48months). The preoperative FAAM, FADI, SF 36, VAS, and AOFAS scores were calculated and followed every 6 months. The plantarflexion and dorsiflexion of the ankle were also recorded preoperatively and at follow-up visits. ResultsAll the patients were operated on by a single surgeon (MS) with the same surgical technique, implant, and rehabilitation protocol. All the patients were followed for an average of 35.6 months (Range 22–48 months). All the ankle scores, FAAM, FADI, SF36, VAS, and AOFAS improved in follow-ups. The mean plantarflexion and dorsiflexion were 39.300+ 4.90 and 12.50+ 4.70 respectively. Three patients had minor wound complications. All the patients returned to activities of daily living. ConclusionFHL transfer in elderly patients with insertional Achilles tendinopathy improves the validated ankle functional scores and decreases pain significantly. Furthermore, randomized studies with a larger study population and longer follow-ups may ascertain the beneficial effects.

Endoscopic calcaneoplasty with gastrocnemius recession for Haglund's syndrome: Is it safe and effective? Results from a retrospective case series

BackgroundEndoscopic calcaneoplasty (ECP) and gastrocnemius recession (GR) are procedures that have been described to effectively treat Haglund’s deformity and insertional Achilles tendinopathy respectively. The purpose of our manuscript is to evaluate the efficacy and safety of ECP and GR with immediate weightbearing for the treatment of Haglund’s deformity with mild to moderate insertional Achilles tendinopathy. MethodsWe performed ECP coupled with GR on 14 patients with an average age of 52 years. All patients demonstrated < 50% tendinous degeneration on MRI. All were allowed weightbearing as tolerated in a CAM boot within the first post-operative week. AOFAS scores and plain film radiographic findings were collected pre-operatively and post-operatively. ResultsThe radiographic exam of the Fowler-Philip angle significantly improved from an average 60.1–40.7° (p < 0.001). The AOFAS ankle/hindfoot score significantly improved from an average 54.7–91.4 (p < 0.001). The average return to work was 7.5 weeks. There were two cases of temporary sural nerve paresthesia, and two cases of delayed wound healing. ConclusionsThis is the first mid-term study evaluating the outcomes of ECP with GR. The results of our study suggest that ECP with GR followed by immediate weightbearing is a safe and effective procedure for the treatment of Haglund’s deformity and mild to moderate insertional Achilles tendinopathy.

Does radiofrequency application improve function and reduce pain in patients with insertional Achilles tendinopathy? A retrospective study with a minimum 2-year follow-up

ABSTRACT This case series study aimed to investigate patients with insertional Achilles tendinopathy (IAT) who underwent radiofrequency (RF), how much do their patient-reported outcomes scores improve and what percentage return to sport, and what patient-related factors are associated with improved scores and increased odds of return to sport, at a minimum of 2-year follow-up. Between 2012 and 2018, 41 patients were followed up. The median Victorian Institute of Sports Assessment-Achilles (VISA-A) score increased from 20 (range, 3–62) to 97 (range, 53–100), the median 11-point visual analogue scale (VAS) reduced from 8 (range, 1–10) to 0 (range, 0–3) and the median Tenger score increased from 1 (range, 0–1) to 3 (range, 2–8). Thirty-eight (92.7%) patients returned to sports with a mean time of 11 ± 4.8 months. In linear regression analysis, age was significantly associated with return-to-sports outcome (b = -0.07, 95% CI = -0.13 to -0.02, p = 0.02), while in logistic regression, symptoms duration revealed a significant impact on pain presence (OR = 1.07, 95% CI = 1.01 to 1.14, p = 0.02). In summary, RF for IAT had a 68.7 ± 14.5 VISA-A improvement at 5.4 years of follow-up regarding reliable functional restoration and pain reduction; however, the current evidence remains insufficient to support RF as an effective treatment for IAT.

Ultrasonography- and Doppler-Guided Surgical Treatment for Insertional Achilles Tendinopathy: Results From a Case Series in a Southern Sweden County Hospital.

Treatment with ultrasonography (US)- and color Doppler (CD)-guided mini surgery for insertional Achilles tendinopathy has shown good clinical results in a sports medicine setting. The aim in this study was to introduce this new methodology at a county hospital and study the clinical results on a traditional orthopaedic population. Twenty-six consecutive patients (12 men, mean age 61 years; 14 women, mean age 56 years) with a long duration (>12 months) of pain symptoms from insertional Achilles tendinopathy (a combination of bursae, bone, and tendon pathology) were included. US- and CD-guided surgical removal of bursae, bone, and tendon pathology, performed with local anaesthesia, was used. After surgery, there was immediate weightbearing loading without immobilization, followed by a structured rehabilitation protocol for 12 weeks. The VISA-A and SEFAS scores plus a questionnaire evaluating satisfaction with treatment and activity level was used for evaluation. At the 1-year follow-up, there were 3 dropouts. Twenty-one patients were satisfied. Their VISA-A score had increased significantly from 26 to 81 (P < .001), and the SEFAS score from 17 to 38 (P < .001). Two patients were not satisfied. There were 3 complications, 2 superficial skin infections, and 1 wound rupture. For patients with chronic painful insertional Achilles tendinopathy, the US- and CD-guided surgical treatment method followed by immediate weightbearing loading showed a high satisfaction rate and improved functional scores at the 1-year follow-up in a majority of the patients. There are advantages using this method compared to other more tendon invasive surgical methods in use for this condition. Level IV, case series.