Achilles Insertional Tendinopathy- Is There a Gold Standard?

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.