Insertional Achilles Tendinopathy

  • Gian Luigi CanataEmail author
  • Valentina Casale


The term Achilles tendinopathy entails various debilitating pathologies which can be distinguished in insertional (at the calcaneus-Achilles tendon junction), pre-insertional, and non-insertional (2–6 cm proximal to the calcaneus-Achilles tendon junction).

Insertional Achilles tendinopathy is an overuse injury which affects the active population, especially running athletes. The problem results from repetitive stress to the tendon, but the predisposing factors can be intrinsic (i.e., foot hyperpronation, pes cavus, leg length discrepancy, limited mobility of the subtalar joint, age, obesity, use of steroids and estrogens) or extrinsic (i.e., changes in training pattern, running on not appropriate surfaces).

Conservative options including rest or immobilization, stretching exercises, extracorporeal shock wave therapy, the use of non-steroidal anti-inflammatory drugs, and orthotics may provide pain relief. However, surgical treatment is advisable if patients do not respond to conservative management and must address the specific pathology.


Insertional Achilles Tendinopathy Achilles tendon disorders Haglund’s syndrome Tendinous calcifications Achilles tendon debridement 


  1. 1.
    Karjalainen PT, Soila K, Aronen HJ, et al. MR imaging of overuse injuries of the Achilles tendon. AJR Am J Roentgenol. 2000;175(1):251–60.CrossRefGoogle Scholar
  2. 2.
    Irwin TA. Current concepts review: insertional Achilles tendinopathy. Foot Ankle Int. 2010;31(10):933–9.CrossRefGoogle Scholar
  3. 3.
    Van Dijk CN, van Sterkenburg MN, Wiegerink JL, et al. Terminology for Achilles tendon related disorders. Knee Surg Sports Traumatol Arthrosc. 2011;19(5):835–41.CrossRefGoogle Scholar
  4. 4.
    Li HY, Hua YH. Achilles tendinopathy: current concepts about the basic science and clinical treatments. Biomed Res Int. 2016;2016:6492597.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Calder J, Karlsson J, Maffulli N, et al., editors. Disorders of the Achilles tendon insertions – current concepts in orthopaedics. Guildford, UK: DJO Pubblications; 2012.Google Scholar
  6. 6.
    Kvist M. Achilles tendon injuries in athletes. Sports Med. 1994;18(3):173–210.Google Scholar
  7. 7.
    Mansur NS, Faloppa F, Belloti JC, et al. Shock wave therapy associated with eccentric strengthening versus isolated eccentric strengthening for Achilles insertional tendinopathy treatment: a double-blinded randomised clinical trial protocol. BMJ Open. 2017;7(1):e013332.CrossRefGoogle Scholar
  8. 8.
    Schepsis AA, Jones H, Haas AL. Achilles tendon disorder in athletes. Am J Sports Med. 2002;30(2):287–305.CrossRefGoogle Scholar
  9. 9.
    Bah I, Kwak ST, Chimenti RL, et al. Mechanical changes in the Achilles tendon due to insertional Achilles tendinopathy. J Mech Behav Biomed Mater. 2016;53:320–8.CrossRefGoogle Scholar
  10. 10.
    DeOrio M, Easley ME. Surgical strategies: insertional Achilles tendinopathy. Foot Ankle Int. 2008;29(5):542–50.CrossRefGoogle Scholar
  11. 11.
    Den Hartog BD. Insertional Achilles tendinosis: pathogenesis and treatment. Foot Ankle Int. 2009;14(4):639–50.CrossRefGoogle Scholar
  12. 12.
    Weinfeld SB. Achilles tendon disorders. Med Clin North Am. 2014;98(2):331–8.CrossRefGoogle Scholar
  13. 13.
    Furia JP. High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy. Am J Sports Med. 2006;34(5):733–40.CrossRefGoogle Scholar
  14. 14.
    Myerson MS, McGarvey W. Disorders of the Achilles tendon insertion and Achilles tendinitis. Instr Course Lect. 1999;48:211–8.PubMedGoogle Scholar
  15. 15.
    Clement DB, Taunton JE, Smart GW. Achilles tendinitis and paratendinitis: etiology and treatment. Am J Sports Med. 1984;12(3):179–84.CrossRefGoogle Scholar
  16. 16.
    Holmes GB, Lin J. Etiologic factors associated with symptomatic Achilles tendinopathy. Foot Ankle Int. 2006;27(11):952–9.CrossRefGoogle Scholar
  17. 17.
    Selvanetti ACM, Cipolla M, Puddu G. Overuse tendon injuries: basic science and classification. Oper Tech Sports Med. 1997;5(3):110–7.CrossRefGoogle Scholar
  18. 18.
    Maganaris CN, Narici MV, Maffulli N. Biomechanics of the Achilles tendon. Disabil Rehabil. 2008;30(20–22):1542–7.CrossRefGoogle Scholar
  19. 19.
    Berkowitz MJ (2016) Insertional Achilles tendinopathy. In: Instructional course lectures of the 2016 AAOS Annual Meeting, Orlando, FL, 1–5 March 2016.Google Scholar
  20. 20.
    Rufai A, Ralphs JR, Benjamin M. Structure and histopathology of the insertional region of the human Achilles tendon. J Orthop Res. 1995;13(4):585–93.CrossRefGoogle Scholar
  21. 21.
    Benjamin M, Rufai A, Ralphs JR. The mechanism of formation of bony spurs (enthesophytes) in the Achilles tendon. Arthritis Rheum. 2000;43(3):576–83.CrossRefGoogle Scholar
  22. 22.
    Williams JGP. Achilles tendon lesions in sport. Sports Med. 1993;16(3):216–20.CrossRefGoogle Scholar
  23. 23.
    Kirchgesner T, Larbi A, Omoumi P, et al. Drug-induced tendinopathy: from physiology to clinical applications. Joint Bone Spine. 2014;81(6):485–92.CrossRefGoogle Scholar
  24. 24.
    Knobloch K. The role of tendon microcirculation in Achilles a patellar tendinopathy. J Orthop Surg Res. 2008;30(3):18.CrossRefGoogle Scholar
  25. 25.
    Cook JL, Rio E, Purdam CR, et al. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med. 2016;50(19):1187–91.CrossRefGoogle Scholar
  26. 26.
    Sharma P, Maffulli N. Biology of tendon injury: healing, modeling and remodeling. J Musculoskelet Neuronal Interact. 2006;6(2):181–90.PubMedGoogle Scholar
  27. 27.
    Andersson G, Forsgren S, Scott A, et al. Tenocyte hypercellularity and vascular proliferation in a rabbit model of tendinopathy: contralateral effects suggest the involvement of central neuronal mechanisms. Br J Sports Med. 2011;45(5):399–406.CrossRefGoogle Scholar
  28. 28.
    Witt BL, Hyer CF. Achilles tendon reattachment after surgical treatment of insertional tendinosis using the suture bridge technique: a case series. J Foot Ankle Surg. 2012;51(4):487–93.CrossRefGoogle Scholar
  29. 29.
    Soila K, Karjalainen PT, Aronen HJ, et al. High-resolution MR imaging of the asymptomatic Achilles tendon: new observations. AJR Am J Roentgenol. 1999;173(2):323–8.CrossRefGoogle Scholar
  30. 30.
    Khan KM, Tress BW, Hare WS, et al. Treat the patient, not the X-ray: advances in diagnostic imaging do not replace the need for clinical interpretation. Clin J Sport Med. 1998;8(1):1–4.CrossRefGoogle Scholar
  31. 31.
    Khan KM, Forster BB, Robinson J, et al. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med. 2003;37(2):149–53.CrossRefGoogle Scholar
  32. 32.
    Lin HA, Keen WC, Yeo W. Calcaneoplasty and reattachment of the Achilles tendon for insertional tendinopathy. J Orthop Surg (Hong Kong). 2014;22(1):56–9.CrossRefGoogle Scholar
  33. 33.
    Fahlstrom M, Jonsson P, Lorentzon R, et al. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc. 2003;11(5):327–33.CrossRefGoogle Scholar
  34. 34.
    Knobloch K, Kraemer R, Jagodzinski M, et al. Eccentric training decreases paratendon capillary blood flow and preserves paratendon oxygen saturation in chronic Achilles tendinopathy. J Orthop Sports Phys Ther. 2007;37(5):269–76.CrossRefGoogle Scholar
  35. 35.
    Wang CJ, Wang FS, Yang KD, et al. Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits. J Orthop Res. 2003;21(6):984–9.CrossRefGoogle Scholar
  36. 36.
    Ohtori S, Inoue G, Mannoji C, et al. Shock wave application to rat skin induces degeneration and reinnervation of sensory nerve fibers. Neurosci Lett. 2001;315(1-2):57–60.CrossRefGoogle Scholar
  37. 37.
    Gerdesmeyer L, Mittermayr R, Fuerst M, et al. Current evidence of extracorporeal shock wave therapy in chronic Achilles tendinopathy. Int J Surg. 2015;24(Pt B):154–9.CrossRefGoogle Scholar
  38. 38.
    Taylor J, Dunkerley S, Silver D, et al. Extracorporeal shockwave therapy (ESWT) for refractory Achilles tendinopathy: a prospective audit with 2-year follow up. Foot (Edinb). 2016;26:23–9.CrossRefGoogle Scholar
  39. 39.
    Best TM, Moore B, Jarit P, et al. Sustained acoustic medicine: wearable, long duration ultrasonic therapy for the treatment of tendinopathy. Phys Sportsmed. 2015;43(4):366–74.CrossRefGoogle Scholar
  40. 40.
    Wijesekera NT, Chew NS, Lee JC, et al. Ultrasound-guided treatments for chronic Achilles tendinopathy: an update and current status. Skelet Radiol. 2010;39(5):425–34.CrossRefGoogle Scholar
  41. 41.
    Rowe V, Hemmings S, Barton C, et al. Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning. Sports Med. 2012;42(11):941–67.CrossRefGoogle Scholar
  42. 42.
    Milano L, Rubin S. Treatment of calcific insertional Achilles tendonitis. In: Canata GL, Parker L, editors. EFOST surgical techniques in sports medicine—foot and ankle surgery. 1st ed. London: UK; 2015. p. 107–14.Google Scholar
  43. 43.
    Kleinman M, Gross AE. Achilles tendon rupture following steroid injection. Report of three cases. J Bone Joint Surg Am. 1983;65(9):1345–7.CrossRefGoogle Scholar
  44. 44.
    Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg. 2010;49(3 suppl):S1–S19.CrossRefGoogle Scholar
  45. 45.
    Wagner E, Gould JS, Kneidel M, et al. Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis. Foot Ankle Int. 2006;27(9):677–84.CrossRefGoogle Scholar
  46. 46.
    McGarvey WC, Palumbo RC Bacter DE, et al. Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot Ankle Int. 2002;23(1):19–25.CrossRefGoogle Scholar
  47. 47.
    Traina F, Perna F, Ruffilli A, et al. Surgical treatment of insertional Achilles tendinopathy: a systematic review. J Biol Regul Homeost Agents. 2016;30(4 Suppl 1):131–8.PubMedGoogle Scholar
  48. 48.
    Sundararajan PP, Wilde TS. Radiographic, clinical, and magnetic resonance imaging analysis of insertional Achilles tendinopathy. J Foot Ankle Surg. 2014;53(2):147–51.CrossRefGoogle Scholar
  49. 49.
    Wiegerinck JI, Kerkhoffs GM, van Sterkenburg MN, et al. Treatment for insertional Achilles tendinopathy: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1345–55.CrossRefGoogle Scholar
  50. 50.
    Watson AD, Anderson RB, Davis WH. Comparison of results of retrocalcaneal decompression for retrocalcaneal bursitis and insertional Achilles tendinosis with calcific spur. Foot Ankle Int. 2000;21(8):638–42.CrossRefGoogle Scholar
  51. 51.
    Hunt KJ, Cohen BE, Davis WH, et al. Surgical treatment of insertional Achilles tendinopathy with or without flexor halluces longus tendon transfer: a prospective, randomized study. Foot Ankle Int. 2015;36(9):998–1005.CrossRefGoogle Scholar
  52. 52.
    Den Hartog BD. Flexor halluces longus transfer for chronic Achilles tendinosis. Foot Ankle Int. 2003;24(3):233–7.CrossRefGoogle Scholar
  53. 53.
    Elias I, Raikin SM, Besser MP, et al. Outcomes of chronic insertional Achilles tendinosis using FHL autograft through single incision. Foot Ankle Int. 2009;30(3):197–204.CrossRefGoogle Scholar
  54. 54.
    Schon LC, Schores JL, Faro FD, et al. Flexor halluces longus tendon transfer in treatment of Achilles tendinosis. J Bone Joint Surg Am. 2013;95(1):54–60.CrossRefGoogle Scholar
  55. 55.
    McAlister JE, Hyer CF. Safety of Achilles detachment and reattachment using a standard midline approach to insertional enthesophytes. J Foot Ankle Surg. 2015;54(2):214–9.CrossRefGoogle Scholar
  56. 56.
    Maffulli N, Testa V, Capasso G, et al. Safety and outcome of surgical debridement of insertional Achilles tendinopathy using a transverse (Cincinnati) incision. J Bone Joint Surg Br. 2011;93-B:1503–7.CrossRefGoogle Scholar
  57. 57.
    Hegewald KW, Doyle MD, Todd NW. Minimally invasive approach to Achilles tendon pathology. J Foot Ankle Surg. 2016;55(1):166–8.CrossRefGoogle Scholar
  58. 58.
    Aktas S, Kocaoglu B. Open versus minimal invasive repair with Achillon device. Foot Ankle Int. 2009;30(5):391–7.CrossRefGoogle Scholar
  59. 59.
    Ceccarelli F, Berti L, Giuriati L, et al. Percutaneous and minimally invasive techniques of Achilles tendon repair. Clin Orthop Relat Res. 2007;458:188–93.PubMedGoogle Scholar
  60. 60.
    Webb JM, Bannister GC. Percutaneous repair of the ruptured tendon Achillis. J Bone Joint Surg Br. 1999;81(5):877–80.CrossRefGoogle Scholar
  61. 61.
    Chiu CH, Yeh WL, Tsai MC, et al. Endoscopy-assisted percutaneous repair of acute Achilles tendon tears. Foot Ankle Int. 2013;34(8):1168–76.CrossRefGoogle Scholar
  62. 62.
    Maffulli N, Longo U, Ronga M, et al. Favorable outcomes of percutaneous repair of Achilles tendon ruptures in the elderly. Clin Orthop Relat Res. 2010;468(4):1039–46.CrossRefGoogle Scholar
  63. 63.
    Carmont M, Rossi R, Scheffler S. Percutaneous and mini invasive Achilles tendon repair. Sports Med Arthrosc Rehabil Ther Technol. 2011;3:28.CrossRefGoogle Scholar
  64. 64.
    Johnson KW, Zalavras C, Thordarson DB. Surgical management of insertional calcific achilles tendinosis with a central tendon splitting approach. Foot Ankle Int. 2006;27(4):245–50.CrossRefGoogle Scholar
  65. 65.
    Nelen G, Martens M, Burssens A. Surgical treatment of chronic Achilles tendinitis. Am J Sports Med. 1989;17(6):754–9.CrossRefGoogle Scholar
  66. 66.
    Canata GL, Casale V. (2015) Haglund’s syndrome: comparing endoscopic and miniopen surgical techniques. Paper presented at the 17th EFORT congress, Prague, 27–29 May 2015.Google Scholar
  67. 67.
    van Dijk CN, van Dyk GE, Scholten PE, et al. Endoscopic calcaneoplasty. Am J Sports Med. 2001;29(2):185–9.CrossRefGoogle Scholar
  68. 68.
    Leitze Z, Sella EJ, Aversa JM. Endoscopic decompression of the retrocalcaneal space. J Bone Joint Surg Am. 2003;85-A(8):1488–96.CrossRefGoogle Scholar
  69. 69.
    Jerosch J. Endoscopic calcaneoplasty. Foot Ankle Clin. 2015;20(1):149–65.CrossRefGoogle Scholar
  70. 70.
    Syed TA, Pereira A. A proposed staging classification for minimally invasive management of Haglund’s syndrome with percutaneous and endoscopic surgery. Foot Ankle Clin. 2016;21(3):641–64.CrossRefGoogle Scholar
  71. 71.
    Canata GL. (1997) Surgical treatment of Haglund’s syndrome in local anaesthesia. Paper presented at the 1st ISAKOS Congress, Buenos Aires, 11–16 May 1997.Google Scholar
  72. 72.
    Canata GL, Casale V. (2017) Achilles insertional tendinopathies. Paper presented at the 11th ISAKOS Congress, Shanghai, 5–8 June 2017.Google Scholar

Copyright information

© ISAKOS 2019

Authors and Affiliations

  1. 1.Centre of Sports Traumatology, Koelliker HospitalTorinoItaly

Personalised recommendations