Achilles Insertional Tendinopathy- Is There a Gold Standard?

Document Type : EDITORIAL


1 Rowan University School of Osteopathic Medicine, Stratford, NJ, USA

2 Rothman Orthopaedic Institute, Philadelphia, PA, USA


Achilles insertional tendinopathy (AIT) is inflammation and painful thickening of the Achilles tendon at its insertion on the posterior calcaneus. After a failed six month trial of non-operative management, the patient may elect to undergo operative management. Operative management involves a series of procedures including debridement of the diseased tendon, resection of the retrocalcaneal bursa, and excision of the calcaneal exostosis. Despite a variety of surgical techniques reported in the literature, there is no single gold standard. Previous studies has described complete detachment of the tendon at its insertion, partial detachment, as well as tendon sparing techniques, such as splitting of the tendon. Most studies show good to excellent results using these different techniques, however there are flaws with each. With there being no gold standard, management is most commonly based on individual surgeon preference. With over 30 years of experience, the senior author (JD) has felt that many of the reported techniques offer a variety of advantages and disadvantages with none being all encompassing. The senior author utilizes his own modification of an excisional debridement in which the most diseased central one-third portion of the Achilles tendon insertion is resected in an apex-superior triangle fashion. This is followed by a calcaneal exostectomy, FHL tendon transfer, and side to side repair of the tendon. The author believes this technique combines many of the best features of the wide variety of techniques that currently exist, while still minimizing complications.


1. Schepsis AA, Jones H, Haas A, et al. Achilles tendon
disorders in athletes. Am J Sports Med. 2002; 3(2):
2. DeOrio MJ, Easley ME. Surgical strategies: insertional
Achilles tendinopathy. Foot Ankle Int. 2008;
3. Hunt KJ, Cohen BE, Davis WH, Anderson RB, Jones
CP. Surgical Treatment of Insertional Achilles
tendinopathy with or without flexor hallucis longus
tendon transfer: A prospective, randomized study.
Foot Ankle Int. 2015; 36(9):998-1005.
4. El-Tantawy A, Azzam W. Flexor hallucis longus tendon
transfer in the reconstruction of extensive insertional
Achilles tendinopathy in elderly: an improved
technique. Eur J Orthop Surg Traumatol. 2015;
5. Martin RL, Manning CM, Carcia CR, Conti SF. An
outcome study of chronic Achilles tendinosis after
excision of the Achilles tendon and flexor hallucis
longus tendon transfer. Foot Ankle Int. 2005;
6. Wagner E, Gould JS, Kneidel M, Fleisig GS, Fowler R.
Technique and results of Achilles tendon detachment
and reconstruction for insertional Achilles tendinosis.
Foot Ankle Int. 2006; 27(9):677-84.
7. DeVries JG, Summerhays B, Guehlstorf DW. Surgical
correction of Haglund’s triad using complete
detachment and reattachment of the Achilles tendon.
J Foot Ankle Surg. 2009; 48(4):447-51.
8. Ettinger S, Razzaq R, Waizy H, et al. Operative
treatment of the insertional Achilles tendinopathy
through a transtendinous approach. Foot Ankle Int.
2016; 37(3):288-93.
9. McGarvey WC, Palumbo RC, Baxter DE, Leibman BD.
Insertional Achilles tendinosis: surgical treatment
through a central tendon splitting approach. Foot 
Ankle Int. 2002; 23(1):19-25.
10. Nunley JA, Ruskin G, Horst F. Long-term clinical
outcomes following the central incision technique
for insertional Achilles tendinopathy. Foot Ankle Int.
2011; 32(9):850-5.
11. Schepsis AA, Wagner C, Leach RE: Surgical
management of Achilles tendon overuse injuries: A
long-term follow-up study. Am J Sports Med. 1994;
22(5): 611–619.
12. McAlister JE, Hyer CF. Safety of Achilles detachment
and reattachment using a standard midline approach
to insertional enthesophytes. J Foot Ankle Surg. 2015;
13. Kolodziej P, Glisson RR, Nunley JA. Risk of avulsion
of the Achilles tendon after partial excision for
treatment of insertional tendonitis and Haglund’s
deformity: a biomechanical study. Foot Ankle Int.
1999; 20(7):433-437.
14. Michels F, Guillo S, King A, et al. Endoscopic
calcaneoplasty combined with Achilles tendon repair.
Knee Surgery, Sports Traumatology, Arthroscopy.
2008; 16(11), 1043-1046.
15. Wagner P, Wagner E, Ortiz C, et al. Achilles tendoscopy
for non insertional achilles tendinopathy. A case series
study. Foot and Ankle Surgery. 2020; 26(4): 421-424.
16. Vega J, Baduell A, Malagelada F, et al. Endoscopic
Achilles tendon augmentation with suture anchors
after calcaneal exostectomy in Haglund syndrome.
Foot & Ankle International. 2018; 39(5), 551–559.
17. Lui TH, Lo CY, Siu YC. Minimally invasive and
endoscopic treatment of Haglund syndrome. Foot and
Ankle Clinics. 2019; 24: 515-531.
18. Pfeffer G, Gonzalez T, Zapf M, et al. Achilles pullout
strength after open calcaneoplasty for Haglund’s
syndrome. Foot & Ankle International. 2019; 39(8):