Achilles tendonitis can be broken into three distinct types.
1. Body of the tendon – This form of tendonitis usually is a manifestation of a small micro tear of the tendon proximal to the insertion into the back of the heel. Fusiform swelling of the tendon surrounds the area of the tear (fusiform meaning a tubular swelling that encompasses the entire tendon).
2. Insertional tendonitis – Insertional Achilles tendonitis describes a form of tendonitis specific to the insertion of the tendon into the posterior heel (calcaneus).
3. Combined body/insertional Achilles tendonitis – This form represents both type 1&2 above.
Let’s focus this conversation on type 2 or what’s called insertional Achilles tendonitis.
Etiology – How and why do some folks develop insertional Achilles tendonitis? In a limited number of cases we’ll be able to relate a direct injury to the onset of the pain. But the majority of patients will relate no specific injury. Instead, a slow and gradual onset of pain is described. Pain may be associated with an increase in activity. Activity examples include that walk for the cure last Saturday or a new exercise program. For most patients, the primary reason for insertional Achilles tendonitis will be chronic tugging of the Achilles tendon on the posterior heel that cannot heal within a 24 hour period of time. Therefore, we could classify insertional Achilles tendonitis as a form of overuse syndrome.
Symptoms – Symptoms of insertional Achilles tendonitis include pain with the onset of activity. Examples of activities would include posterior heel pain when rising from bed or after a period of sitting. As the symptoms of insertional Achilles tendonitis increase over time, pain will be present for a longer period of time throughout the day. Hypertrophy (enlargement) of the posterior heel is common. Hypertrophy of the posterior heel is a response to traction (pulling) on the bone. The heel bone responds by calcifying the insertion of the Achilles resulting in a pronounced enlargement of the posterior heel.
Treatment – Unfortunately, treatment options for insertional Achilles tendonitis can be limited. Conservative care includes the use of a heel lift, calf stretches and anti-inflammatory medications. I’ve not found physical therapy or cast immobilization to be effective in cases of insertional Achilles tendonitis. Most case that do not respond to a heel lift and calf stretches will benefit from surgical correction of the problem. Surgical correction is performed on an out-patient basis and involves partial resection of the heel bone or what we previously called the hypertrophic heel. A partial lengthening of the Achilles tendon is often used.
The frustrating aspect of care for both patient and provider is the limited number of treatment options available. Either the conservative care works or we’re off to surgery. And that’s a tough set of choice knowing that surgical care is going to require 8 weeks in a hard, non-weight bearing cast. Surgery is successful, but the disability is quite a hit on the chin for patients.
Jeffrey A. Oster, DPM