SLR - March 2022 - Thomas C. Arena
Reference: Jarin, I. , Bäcker, H. & Vosseller, J. (2021). Functional Outcomes of Insertional Achilles Tendinopathy Treatment. JBJS Reviews.Level of Evidence: Level IV
Scientific Literature Review
Reviewed By: Thomas C. Arena, DPM
Residency Program: Westside Regional Medical Center – Plantation, FL
Podiatric Relevance: Insertional achilles tendinopathy is a common pathology representing significant disability in up to 20 percent of all patients with achilles pathology. The pathogenesis of this degenerative condition is multifactorial with contributing factors including overuse, mechanical overload, weight, and age. In severe cases, conservative management alone may not resolve symptoms, thus it is important to understand the most efficacious methods to treat a common pathology from both conservative and surgical standpoints.
Methods: A review of all literature containing the terms “achilles, insertional, tendinopathy, and treatment” was performed using the PubMed/Medline and Cochrane databases. Of 1457 abstracts reviewed, 328 full-text articles were identified and assessed. Of these, 54 studies met inclusion criteria and 6 operative techniques and 6 nonoperative treatments were evaluated. There were 15 studies assessing non-operative management, 38 studies assessing operative treatment, and onestudy examining both treatment methods.
Results: Of all non-operative treatments examined, eccentric exercises and extracorporeal shockwave therapy (ESWT) received ‘B’ grade recommendations according to the literature. Cold air and high-energy laser therapy, platelet-rich plasma injection, and hyaluronic acid injections all received ‘insufficient’ grades meaning the literature evidence was insufficient or conflicting. Of all operative treatments, tenotomy/debridement/calcaneal exostectomy received the only ‘B’ grade recommendations. Flexor hallucis longus transfer received a ‘C’ grade recommendation. Gastrocnemius recession, autograft transfer, and minimally-invasive surgery all received ‘insufficient’ grades.
Conclusions: When considering conservative management, eccentric exercises and ESWT showed the greatest evidence of efficacy in initial treatment. However, more evidence is needed to further assess long-term benefit of ESWT. Of surgical treatment options, tenotomy/debridement along with retrocalcaneal bursectomy and exostectomy offer the highest-evidence of success. FHL tendon transfer may be beneficial as an augmentation in more severe cases. The role of MIS in treatment of insertional achilles tendinopathy requires further study.