Surgical Treatment of Insertional Achilles Tendinopathy: An Open Surgeon's Crisis of Faith

by Vince Vacketta, DPM

My Gospel: Open debridement of diseased tendon, resection of the osseous deformity, and reanchoring of the Achilles with tendon transfer when needed.

The heterodoxy

More developing literature refutes the significance of the Achilles tendon and instead treats insertional disease as little more than “bump pain”:

• Open vs. MIS repair: Minimally invasive tendon debridement and reinsertion achieves excellent outcomes comparable to open surgery, with less morbidity.

• Arthroscopic debridement + calcaneoplasty vs. percutaneous calcaneoplasty alone: Both techniques significantly improved outcomes with zero complications, while isolated calcaneoplasty actually produced lower postoperative pain.

• The Zadek osteotomy: Don't touch the tendon at all. MIS Zadek produced pain and functional outcomes comparable to open debridement/reattachment, but patients walked independently sooner and had fewer wound complications. 

Meanwhile, flexor hallucis longus tendons can finally breathe easy in this new world of insertional Achilles repair.

Losing my religion

Perhaps the key to treating insertional Achilles tendinopathy isn't removing the abnormal tendon, but changing the mechanical environment that made the tendon symptomatic in the first place.

The Zadek and percutaneous calcaneoplasty data make the strongest case: If we can achieve comparable outcomes without debriding or repairing the Achilles, how much of the tendon pathology actually needs to be treated at all?

The evidence is still retrospective, and the samples are relatively small, but it’s increasingly challenging to defend the assumption that abnormal tendon must come out for patients to get better.