Insertional Achilles Tendinosis Surgery

What is insertional Achilles tendinosis?

Insertional Achilles tendinosis is a progressive condition that occurs where the Achilles tendon attaches to the heel bone. Some may call this tendinitis. Tendinosis develops when there is some degree of wear and tear.
Pain at the back of heel is usually what brings people to the doctor. Early on, there may be a non-painful lump. Pain at the

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Fig 1: X-ray showing bone spur where Achilles attaches to heel bone.

 start of activity or after may be present. Later, pain may occur even at rest. The pain may lessen by wearing a shoe with a higher heel or an open back. X-rays can sometimes show a spur where the Achilles tendon attaches to the heel bone (figure 1). 

What are the goals of surgery for insertional Achilles tendinosis?

The goal of surgery is to reduce pain and maintain function. A secondary goal may be to allow better fitting of shoes.

What signs indicate surgery may be needed?

Surgery may help with pain that cannot be improved with non-operative treatments. Sometimes an MRI or CT scan is used to help plan the surgery.

When should I avoid surgery?

If you have infections or open wounds, surgery is not recommended. Some other concerns are smoking, diabetes, previous steroid injections and skin problems in the area.

General Details of the Procedure

The main goal of the surgery is to remove the damaged portion of the Achilles tendon and maintain tendon attachment to the heel bone. Sometimes a small amount of tendon can be removed, leaving the remaining Achilles tendon attached to the heel bone.
In cases where the damage is more involved, the entire Achilles tendon may need to be removed from the heel bone and the remaining good tendon reattached. In more advanced cases, a large amount of Achilles tendon must be removed. In this situation another tendon may need to be used to bridge the gap between the good Achilles tendon and the heel bone.

Specific Techniques

An incision is usually made over the back of the heel. The diseased portion of the tendon is removed. A small amount of

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Figs 2-4: Surgical steps for treating a damaged Achilles tendon.

bone is removed from the back of the heel bone to create a healthy area for the tendon to attach to. The tendon is reattached by using special bone anchors that allow the tendon to be fixed to the bone (see figures 2-4).

What happens after surgery?

After surgery, you will be put into a cast or removable cast boot. If the tendon was not fully detached from the heel, the doctor may allow you walk around in the boot for six to eight weeks and work on motion exercises with physical therapy.
If the tendon was totally detached or another tendon was used in the repair, a cast/boot may be used for three months. For the first six weeks, you should not place any weight on the foot, but the second six weeks you can walk in the cast/boot.
After the cast/boot comes off, you can wear shoes with a small heel lift and begin physical therapy. The length of time needed to return to full activities and sports is determined by the strength of the repair and the speed of recovery with physical therapy. Full recovery can take six to 12 months.

Potential Complications

There are complications that relate to surgery in general. These include the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
Complications with this surgery can include residual pain, infections, weakness or tightness, or rupture of the repair.

Frequently Asked Questions

Can I return to all the activities I want to do?
Yes. After the appropriate repair, physical therapy and healing time, the goal is for you to be able to return to activities you want to do.  Residual pain may limit but not prevent you from doing some activities.
 
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