Achilles tendon enthesopathy is pain at the insertion of the Achilles tendon at the posterosuperior aspect of the calcaneus. Diagnosis is clinical. Radiographs in the lateral view may show enthesophytes (osseous spurs). Treatment is with stretching, splinting, and heel lifts.
(See also Overview of Foot and Ankle Disorders.)
The cause of Achilles tendon enthesopathy is chronic traction of the Achilles tendon on the calcaneus. Contracted or shortened calf muscles (resulting from a sedentary lifestyle and obesity) and athletic overuse are factors. Enthesopathy may be caused by a spondyloarthropathy. Fluoroquinolone antibiotics increase the risk of Achilles tendinopathy or tendon rupture especially in people over age 60.
Pain at the posterior heel below the top of the shoe counter during ambulation is characteristic. Pain on palpation of the tendon at its insertion in a patient with these symptoms is diagnostic. Manual dorsiflexion of the ankle during palpation usually exacerbates the pain. Recurrent and especially multifocal enthesitis should prompt evaluation (history and examination) for a spondyloarthropathy.
Treatment of Achilles Tendon Enthesopathy
Stretching, splinting, and heel lifts
If present, treatment of spondyloarthropathy
Physical therapy is essential for home exercise programs aimed at calf muscle–stretching techniques, which should be done for about 10 minutes 2 to 3 times a day. The patient can exert pressure posteriorly to stretch the calf muscle while facing a wall at arms’ length, with knees extended and foot dorsiflexed by the patient's body weight (standing gastrocnemius stretch). To minimize stress to the Achilles tendon with weight bearing, the patient should move the foot and ankle actively through their range of motion for about 1 minute when rising after extended periods of rest. Night splints may also be prescribed to provide passive stretch during sleep and help prevent contractures.
Heel lifts should be used temporarily to decrease tendon stress during weight bearing and relieve pain. Even if the pain is only in one heel, heel lifts should be used bilaterally to prevent gait disturbance and possible secondary (compensatory) hip and or low back pain.
For patients with Achilles tendon enthesopathy related to an underlying spondyloarthropathy, treatment with a nonsteroidal anti-inflammatory drug (NSAID) or a biologic agent (eg, TNF inhibitor) may be beneficial.
For more recalcitrant forms of Achilles tendon enthesopathy, extracorporeal pulse activation therapy (EPAT), also known as extracorporeal shockwave therapy (ESWT), may be considered. In EPAT, low-frequency pulse waves are delivered locally using a handheld applicator. The pulsed pressure wave is a safe, noninvasive technique that is thought to stimulate metabolism and enhance blood circulation, which in turn may help regenerate damaged tissue and accelerate healing. Some data have shown improvement in symptoms and functional outcomes with EPAT (1); however, additional high-quality evidence is needed to determine duration and frequency of treatments (2).
Treatment references
1. Rompe JD, Furia J, Maffulli N: Eccentric loading compared with shock wave treatment for chronic insertional Achilles tendinopathy. A randomized, controlled trial. J Bone Joint Surg Am 90(1):52-61, 2008. doi:10.2106/JBJS.F.01494
2. Fan Y, Feng Z, Cao J, Fu W: Efficacy of extracorporeal shock wave therapy for Achilles tendinopathy: a meta-analysis. Orthop J Sports Med 8(2):2325967120903430, 2020. Published 2020 Feb 27. doi:10.1177/2325967120903430
