How To Conquer Achilles Insertional Calcific Tendinosis

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Author(s): 
Brent D. Haverstock, DPM, FACFAS

   Palpation in the retrocalcaneal region may also reproduce pain due to an inflamed bursal sac. When one palpates the mass and puts the foot through dorsiflexion and plantarflexion, the mass will move and this indicates that it resides within the Achilles tendon. Plain film radiographs will reveal a large single calcification or multiple smaller calcifications posterior to the calcaneus in the area of the Achilles tendon attachment. A solid spur may arise from the calcaneus.

   Magnetic resonance imaging (MRI) will reveal tendinosis with calcification within the tendon. Longitudinal tearing or separation of the tendon about calcification will also occur in chronic cases.

Pertinent Insights On Conservative Treatment

Initial conservative treatment of the condition consists of rest to decrease motion and irritation of the tendon. Avoiding impact or jumping activities is very important. For some patients, it may be beneficial to wear a removable walking cast while allowing gentle, non-weightbearing ankle joint dorsiflexion and plantarflexion to keep the tendon mobile in the initial phase of treatment.

   Injection therapy with a local anesthetic can reduce the pain. If one makes the injection between the paratenon and Achilles tendon, it will open up inflammatory adhesions. Further treatment will include physiotherapy, oral and topical nonsteroidal anti-inflammatory medication, heel lifts in shoes and footwear modifications.

   Eccentric exercises of the gastroc-soleus complex, although beneficial for mid-portion Achilles tendinopathy, are usually not as effective for insertional tendinopathy but may decrease pain in some patients.5 High energy extracorporeal shockwave therapy may also provide relief for this condition.

Emerging Insights On Surgical Repair

If patients fail to improve following six months of non-operative care, one should consider surgical management. Depending on the condition of the Achilles tendon, one may consider excision of the calcification or repair of the Achilles tendon with flexor tendon transfer for augmentation. In some cases, a calcaneal osteotomy may also be necessary to remove an osseous bump on the calcaneus.

   Johnson and colleagues evaluated the outcome of a central tendon splitting approach in the surgical management of 22 patients with insertional calcific Achilles tendinosis.6 Follow-up averaged 34 months and surgeons routinely used suture anchors to augment the tendon insertion following debridement. The investigators used the American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot score and evaluated shoe wear comfort and return to work.

   The authors found that pain significantly improved from 7 points preoperatively to 33 points postoperatively.6 Function improved significantly from 36 points to 46 points and the ankle-hindfoot score improved from 53 points to 89 points. Patient age older or younger than 50 did not affect the outcome. The researchers concluded that a central tendon splitting approach yielded good relief of pain with improved function, shoe wear and the ability to work without painful postoperative scars.

   European researchers also evaluated the surgical management of active patients with recalcitrant calcific insertional Achilles tendinopathy.7 Twenty-one patients (six women) (21 feet) (average age 46.9 ± 6.4 years) underwent surgical treatment with removal of the calcific deposit. Bone anchors facilitated the reinsertion of the Achilles tendon.

   At an average follow-up of 48.4 months, one patient necessitated a further operation.7 Eleven patients reported an excellent result and five had a good result. The remaining five patients could not return to their normal levels of sporting activity and kept fit by alternative means. The results of the VISA-A questionnaire markedly improved in all patients from a preoperative average of 62.4 percent to 88.1 percent postoperatively.

   The researchers recommended detachment of the Achilles tendon to excise the calcific deposit fully and reinsertion of the Achilles tendon in the calcaneus with suture anchors.7 No patient experienced a traumatic detachment of the reattached tendon.

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