Achilles tendinopathy is defined as a degenerative process of the Achilles tendon and can be categorized as insertional or noninsertional tendinopathy.1 Insertional Achilles tendinopathy frequently involves intratendinous calcification of the Achilles tendon insertion and a prominent superolateral calcaneus tuberosity known as a Haglund’s deformity. Haglund2 first described the superolateral calcaneus prominence in a case study. The incidence of insertional Achilles tendinopathy is up to 30%, affecting both recreational and elite athletes.3 The insertional footprint of the Achilles tendon is 1.4 mm wide and 10 mm long. At the calcaneal insertion, the retrocalcaneal bursa inserts onto the superior facet, the soleus inserts onto the medial-middle facet, and the gastrocnemius inserts onto the lateral-middle facet and inferior facet.4 There are intrinsic and extrinsic risk factors that play a role in developing insertional Achilles tendinopathy. Intrinsically, the Achilles tendon has poor vascularity, with the distal 2 to 6 cm of the tendon being relatively avascular.5 The poor vascularity leads to intrasubstance tendon degeneration (tendinosis), whereas the more vascular paratenon and retrocalcaneal fat are more susceptible to an inflammatory response. Other intrinsic risk factors include obesity, hypertension, diabetes, and steroid use.6 Extrinsic factors include overuse with repetitive running and jumping.1 Biomechanically, the Achilles tendon is subjected to large stresses during the stance phase and can be loaded up to 10 times one’s body weight. The combination of poor vascularity and microtrauma at the Achilles insertion leads to degeneration, pain, and dysfunction.
INDICATIONS AND CONTRAINDICATIONS
Conservative treatment for insertional Achilles tendinopathy includes nonsteroidal anti-inflammatory drugs, rest, wide shoe wear, heel lifts, gastrocnemius stretching, activity modification eccentric exercises, supination orthotics, and night splints.7 Nonoperative treatment should be continued until the patient is asymptomatic for 2 weeks. Overall, a significant number of patients with insertional Achilles tendinopathy continue to have symptoms despite conservative treatment. Verrall et al8 showed that a 6-week eccentric Achilles heel-drop protocol can lead to an 82% satisfaction rate in athletes with chronic Achilles tendinopathy. However, the subset of athletes with insertional Achilles tendinopathy, there was only a 50% satisfaction rate and 21% of athletes underwent surgical intervention within 14 months. Paavola and colleagues showed that during their 8-year observational study, 29% of patients with Achilles tendinopathy went on to undergo surgical treatment. Nichiolson et al9 demonstrated that patients with insertional Achilles tendinopathy with magnetic resonance imaging (MRI) evidence of extensive tendinosis had poorer outcomes after nonoperative treatment.
The indications for surgical treatment of insertional Achilles tendinopathy is appropriate when a patient’s symptoms are recalcitrant to nonoperative therapies. Contraindications for surgical treatment include patients with an active infection, overall poor health, vascular compromise, and poor skin integrity. Previous surgical approaches that have been described in the literature include the lateral,10 medial,11 medial-J incision,12 dual,1 and endoscopic.13 Significant wound complications are associated with these approaches. In 2002, McGarvey et al14 popularized the midline longitudinal incision, which is commonly used today. Insertional Achilles repair with double-row suture anchors has increasingly become more common among clinicians.15 Thus, we will describe our unique double-row repair technique for insertional Achilles tendinopathy.
Patients with insertional Achilles tendinopathy present clinically with posterior heel swelling, pain, and a prominent superolateral calcaneus tuberosity.16 Individuals will have a sensation of stiffness around their heel in the early mornings and posterior heel pain during the day. Restrictive shoe wear may also contribute to pain around the Haglund’s deformity. On examination, patients will have a palpable nodule along the Achilles tendon in patients with more extensive tendinopathy. There may also be pain along either side of the Achilles tendon, indicative of retrocalcaneal bursitis. The painful retrocalcaneal bursa should be removed at the time of surgery. An important clinical test is a Silfverskiöld test, which can detect a gastrocnemius or Achilles contracture. A gastrocnemius contracture is defined as having <5 degrees of passive ankle dorsiflexion with the knee in full extension. An Achilles contracture is defined as having <10 degrees of passive ankle dorsiflexion when the knee is in 90 degrees of flexion. A patient with a gastrocnemius or Achilles contracture may be contributing to their Achilles tendinopathy and can make adequate debridement more difficult. Prone examination of the affected limb will reveal a contiguous Achilles tendon without a palpable gap. The affected foot will have a normal resting tone and the Thompson test should be negative.
A weight-bearing plain radiograph of the lateral foot should be obtained to assess for intrasubstance calcification at the Achilles insertion (Fig. 1). Large amounts of tendon calcification denote marked tendon degeneration and may warrant advanced imaging to delineate the extent of Achilles tendon involvement. In addition, evaluation of a prominent Haglund’s deformity should also be noted. Individuals with a cavus foot may have an increased calcaneal pitch that may increase the impingement of the superolateral calcaneus tuberosity onto the Achilles insertion. MRI can be obtained to assess for intrasubstance delamination or degeneration.9 If extensive tendon involvement is seen on MRI, then either a proximal Achilles tendon debridement or flexor tendon transfer may be warranted intraoperatively.
Surgical Technique for Retrocalcaneal Spur Removal
The popliteal block anesthetic and general anesthesia are administered by the anesthesia team. The patient is then intubated by anesthesia. After this, the patient is then positioned onto the operative table in the prone position with their heels placed just distal to the edge of the operative table to allow for adequate ankle dorsiflexion during the case. After proper prepping and draping, a sterile 4-inch Esmarch tourniquet is wrapped up to the mid-calf to exsanguinate the limb. The Esmarch tourniquet is held in place with a Kelly clamp. It is also acceptable to use a thigh-high tourniquet. A 6-cm longitudinal midline skin incision is made using a #15 blade directly over the Haglund’s deformity with the ankle in maximal dorsiflexion (Fig. 2). The incision should be carried to the inferior aspect of the calcaneus tuberosity for adequate visualization of the Achilles tendon insertion. The deep incision is then carried in line with the skin incision directly onto the bone. No superficial skin flaps are made to protect the vascularity of the surgical wound. The distal insertion of the Achilles tendon at the inferior facet of the calcaneus is sharply peeled from the medial and lateral calcaneus tuberosity within the split tendon to fully expose the Haglund’s deformity. Care is taken during the medial dissection to prevent lacerating the flexor hallucis longus tendon. It is also important that during the subperiosteal dissection of the Achilles insertion not to completely detach the Achilles tendon. This can be done by leaving the very medial and lateral attachment of the tendon to the bone intact.
Once the Haglund deformity is fully exposed, a large rongeur is used to excise the entire retrocalcaneal bursa to visualize the superior most extent of the Haglund deformity (Fig. 3). the posterior subtalar joint. Exposure of the subtalar joint is critical to accurately mark the resection level of the Haglund’s deformity and to not violate the subtalar joint with the oscillating saw. Next, self-retaining retractors are placed on the medial and lateral aspect of the Haglund deformity to protect the Achilles tendon. An oscillating saw is then used to perform a calcaneal exostectomy (Fig. 4). Adequate resection of the Haglund lesion is confirmed on a lateral fluoroscopic image of the foot (Fig. 5). After removing the posterior tuberosity, the oscillating saw is placed at a 45-degree angle on either side of the resected area of the calcaneus to bevel any prominent edges of the bone. We also use a small rasp to ensure that the calcaneus has a smooth surface and so that there are no sharp edges that can bother patients. Once this is completed, the Achilles tendon is addressed.
Surgical Technique for Achilles Debridement and Repair
The Achilles tendon is then inspected to determine the extent of tendinopathy. The diseased tendon will seem like crab meat and will lack the longitudinal striations seen in the normal tendon. The diseased tendon may also have intrasubstance calcifications. Using a #10 blade, the deep degenerative Achilles tendon is carefully debrided on its flat surface to remove bone or thickened fibrous tissue (Fig. 6). Care must be taken not to transect the tendon during the debridement. If a substantial amount is tendon is debrided and there is insufficient tendon left for suture anchor repair, then consideration for a flexor hallucis longus should be made.
After the Achilles tendon is debrided, a 3.5 mm drill bit should be used to drill 4 holes for suture anchors placement. The 4 holes are placed 1 cm proximal to the inferior posterior calcaneus tuberosity and the holes are drilled in a square configuration to recreate the wide Achilles footprint. These 4 holes are then tapped using a 4.75-mm tap. After this, the 2 proximal 4.75-mm Speedbridge anchors (Arthrex, Naples, FL) are placed into the posterior calcaneus tuberosity (Fig. 7). After this, a suture needle is used to pass the single FiberTape (Arthrex) limb of the medial-proximal anchor through the medial half of the split Achilles tendon. The suture should be passed full-thickness through the Achilles tendon and slightly proximal to the anchor site to increase the tension of the Achilles tendon when it is repaired. This step is repeated for the lateral limb. Once both limbs are passed on either side of the Achilles tendon, 1 suture from each the proximal-medial and proximal-lateral limb are anchored together into the distal-medial anchor. This step is repeated for the distal-lateral anchor to create a double-row repair. To establish appropriate tendon tension, the foot should be plantarflexed. Next, the preloaded #2 FiberWire suture from the medial-distal anchor is then passed within the intrasubstance of the Achilles tendon from distal to proximal in a running manner to reapproximate the split Achilles tendon ends (Fig. 8).
The dermal layer is closed with deep 3-0 absorbable braided suture and the skin is closed with interrupted 3-0 nonabsorbable monofilament suture. Soft dressings and a well-padded short leg cast are placed with the foot in its resting plantarflexed position for 3 weeks.
The patient will be nonweight-bearing on the operative extremity for 3 weeks to allow for the incision to heal. After 3 weeks, the patient will then transition into a pneumatic walking boot and will be allowed partial weight-bearing with an assistive device. From 3 to 6 weeks, active plantarflexion is allowed, but passive dorsiflexion past neutral should be avoided. Full weight bearing on the operative extremity is initiated 6 weeks postoperatively. Physical therapy is initiated from 6 to 12 weeks, consisting of gentle concentric Achilles strengthening. Return to activities is usually at the 4-month mark.
The outcomes following Haglund excision utilizing the posterior midline approach have been shown to be favorable. McGarvey et al retrospectively reported on 21 patients (22 feet) who underwent Haglund’s excision and side-to-side insertional Achilles repair without suture anchors.14 At an average of 33 months follow-up, there was an 82% satisfaction rate and 91% return to work rate. Johnson et al17 studied 22 patients who underwent Haglund’s excision with Achilles repair utilizing 2 single-row bone anchors. At a mean follow-up of 34 months, the American Orthopaedic Foot and Ankle Society score (AOFAS) improved from 53 to 89, and pain scores improved from 7 to 33. In addition, 91% of the cohort was able to work full time and 77% of the cohort did not have pain with shoe wear. Nunley et al18 studied 27 patients (29 feet) that underwent Haglund excision and Achilles repair with the single-row bone anchor. They found at a follow-up of 4 years, the mean AOFAS score was 96. At 7-year follow-up, there was no strength deficit compared with the contralateral limb and patients reported a 96% success rate. Greenhagen et al19 studied 35 patients who underwent Haglund’s excision with suture bridge fixation of the Achilles tendon insertion. At a mean follow-up of 28.9 months, the mean AOFAS scores improved from 56.6 to 91.7 with a 97% success rate. Biomechanically, Beitzel et al15 performed a cadaveric study comparing single and double-row insertional Achilles tendon repairs and found that double-row repair had a higher peak load to failure. Cox and colleagues performed a randomized cadaveric biomechanical study comparing knotted versus knotless suture bridge repair for the Achilles tendon insertion. They found improved strength and improved lead to failure with knotted suture bridge repair.20 In regards to flexor hallucis longus transfer augmentation, Hunt et al21 performed a randomized control trial of 39 patients over the age of 50 with chronic insertional Achilles tendinopathy. One group of patients underwent Achilles debridement and direct repair whereas the experimental group underwent Achilles debridement with FHL augmentation. At 1-year follow-up, there was no difference in AOFAS or visual analog score despite improvement in ankle plantarflexion strength for the FHL augmentation group.
Complications after open Achilles insertional surgery are not insignificant.17–19,22,23 It is important to counsel patients that continued pain with shoe wear can occur in 23% of patients postoperatively.17 Wound dehiscence occurs in 6% to 12% of open insertional Achilles tendon surgery.17,22 Other complications include infection (6%),22 sural neuritis (0% to 4%),17,22 Achilles tendon rupture (3.8%),23 and deep venous thrombosis (3.1%).17
FUTURE OF THE TECHNIQUE
There is a paucity of literature on the benefits of biologic treatment for nonoperative management of insertional Achilles tendinopathy.24 Further research needs to be performed to understand the importance and clinical benefits of performing flexor hallucis longus tendon augmentation for severely degenerative Achilles tendons.
Pearls and Pitfalls
- The heel should be positioned distal to the edge of the bed to allow for adequate dorsiflexion during the procedure.
- An adequate longitudinal midline incision should be made to see the inferior most aspect of the Achilles tendon insertion.
- A full-thickness tissue flap should be made sharply with a knife to minimize superficial soft tissue stripping and devascularization.
- Adequate resection of the Haglund’s deformity should be made with an oscillating saw without violating the subtalar joint.
- After the Haglund’s deformity resection, the posterior calcaneus should be palpated for any sharp bony prominences.
- After bony anchor placement, the proximal anchor sutures should be passed slightly proximal through the split Achilles tendon and the foot should be plantarflexed to provide adequate tendon tension during the repair.
- If there is not adequate ankle dorsiflexion, then one should consider performing a gastrocnemius recession.
- The double-row repair allows for a more anatomic restoration of the Achilles tendon footprint.
1. Clain MR, Baxter DE. Achilles tendinitis. Foot Ankle. 1992;13:482–487.
2. Haglund P. Beitrag zur Klinik der Achillessehne [Clinic evaluation of the Achilles tendon]. Zeitschr Orthop Chir. 1928;49:49–58.
3. Knobloch K, Yoon U, Vogt PM. Acute and overuse injuries correlated to hours of training in master running athletes. Foot Ankle Int. 2008;29:671–676.
4. Ballal MS, Walker CR, Molloy AP. The anatomical footprint of the Achilles tendon: a cadaveric study. Bone Joint J. 2014;96-b:1344–1348.
5. Chen TM, Rozen WM, Pan WR, et al. The arterial anatomy of the Achilles tendon: anatomical study and clinical implications. Clin Anat. 2009;22:377–385.
6. Holmes GB, Lin J. Etiologic factors associated with symptomatic Achilles tendinopathy. Foot Ankle Int. 2006;27:952–959.
7. Clanton TWN Coughlin MSCA,RB. Athletic injuries to the soft tissues of the foot and ankle. Mann’s Surgery of the Foot and Ankle, 9th ed. Philadelphia, PA: Elsevier; 2014:1610–1617.
8. Verrall G, Schofield S, Brustad T. Chronic Achilles tendinopathy treated with eccentric stretching program. Foot Ankle Int. 2011;32:843–849.
9. Nicholson CW, Berlet GC, Lee TH. Prediction of the success of nonoperative treatment of insertional Achilles tendinosis based on MRI. Foot Ankle Int. 2007;28:472–477.
10. Keck SW, Kelly PJ. Bursitis of the posterior part of the heel: evaluation of surgical treatment of eighteen patients. J Bone Joint Surg Am. 1965;47:267–273.
11. Schepsis AA, Leach RE. Surgical management of Achilles tendinitis. Am J Sports Med. 1987;15:308–315.
12. Gould N. Approach to the posterior lower leg. Foot Ankle. 1984;4:221–224.
13. Leitze Z, Sella EJ, Aversa JM. Endoscopic decompression of the retrocalcaneal space. J Bone Joint Surg Am. 2003;85:1488–1496.
14. McGarvey WC, Palumbo RC, Baxter DE, et al. Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot Ankle Int. 2002;23:19–25.
15. Beitzel K, Mazzocca AD, Obopilwe E, et al. Biomechanical properties of double- and single-row suture anchor repair for surgical treatment of insertional Achilles tendinopathy. Am J Sports Med. 2013;41:1642–1648.
16. Paavola M, Kannus P, Paakkala T, et al. Long-term prognosis of patients with Achilles tendinopathy. An observational 8-year follow-up study. Am J Sports Med. 2000;28:634–642.
17. Johnson KW, Zalavras C, Thordarson DB. Surgical management of insertional calcific Achilles tendinosis with a central tendon splitting approach. Foot Ankle Int. 2006;27:245–250.
18. Nunley JA, Ruskin G, Horst F. Long-term clinical outcomes following the central incision technique for insertional Achilles tendinopathy. Foot Ankle Int. 2011;32:850–855.
19. Greenhagen RM, Shinabarger AB, Pearson KT, et al. Intermediate and long-term outcomes of the suture bridge technique for the management of insertional Achilles tendinopathy. Foot Ankle Spec. 2013;6:185–190.
20. Cox JT, Shorten PL, Gould GC, et al. Knotted versus knotless suture bridge repair of the Achilles tendon insertion: a biomechanical study. Am J Sports Med. 2014;42:2727–2733.
21. Hunt KJ, Cohen BE, Davis WH, et al. Surgical treatment of insertional Achilles tendinopathy with or without flexor hallucis longus tendon transfer: a prospective, randomized study. Foot Ankle Int. 2015;36:998–1005.
22. Wagner E, Gould JS, Kneidel M, et al. Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis. Foot Ankle Int. 2006;27:677–684.
23. Calder JD, Saxby TS. Surgical treatment of insertional Achilles tendinosis. Foot Ankle Int. 2003;24:119–121.
24. Indino C, D’Ambrosi R, Usuelli FG. Biologics in the treatment of Achilles tendon pathologies. Foot Ankle Clin. 2019;24:471–493.