Insertional Achilles tendinopathy (IAT) is a common but disabling pathology affecting both athletes and older subjects.

The aim of the present study was to provide a practical review of IA, addressing the following questions:

What are the etiologies and pathophysiology? Etiology is multifactorial, involving anatomic aspects and especially posterosuperior calcaneal prominence, biomechanical aspects such as short triceps surae, pes cavus or hindfoot varus, extrinsic aspects of footwear and overtraining, and metabolic aspects. Pathophysiology, depending on the individual case, implicates true insertional tendinopathy and posterior bone-tendon impingement to varying degrees, often with pre-Achilles bursitis; the distinction is crucial to decision-making. Impingement or enthesopathy lead to progressive disorganization of the collagen matrix, pathologic neovascularization and mucoid degeneration of the tendon, often with intratendon calcifications and inflammatory retrocalcaneal bursitis.

How to establish diagnosis? Diagnosis is primarily clinical, based on pain location, which is median in case of insertional tendinopathy and more lateral in case of posterior impingement with bursitis. Examination finds pain on palpation of the Achilles insertion, sometimes with local thickening, posterior tumefaction and painful restriction of ankle dorsiflexion. Tensing the tendon typically reproduces the pain. Functional tests may show restriction due to pain, without tendon tear. Weight-bearing X-ray, ultrasound and especially MRI analyze the respective roles of bone, tendon and bursa injury; weight-bearing CT can be contributive in some morphologically complex situations. Ultrasound reveals tendon thickening, hypoechogenic degenerative areas, hypervascularization on Doppler and associated bursitis. MRI shows lesion extension: intratendon degeneration, deep fiber involvement and retrocalcaneal inflammation.

What are the non-operative treatments? Initial treatment is conservative, based on adapting weight-bearing and footwear, with exercises adapted to the form of the insertion, extracorporeal shock waves and rehabilitation.

What are the surgical options and their expected results? In case of failure of well-conducted non-operative treatment, surgical strategy depends on lesion type, degree of posterior impingement, degree of tendon degeneration and degree of triceps surae stiffness. Expected results comprise pain relief, functional improvement on VISA-A score, and progressive return to activities, with timing depending on the technique and the initial level of activity.

How to choose the surgical treatment? Surgical options comprise bone decompression, debridement and tendon reinsertion, flexor hallucis longus transfer and gastrocnemius lengthening depending on lesion type on clinical examination and imaging.