Nonoperative treatment of insertional Achilles tendinopathy: a systematic review

Abstract

Background Insertional Achilles tendinopathy is difficult to manage, and there is no definite consensus on which nonoperative treatment is superior over the others. We aim to provide a clear summary of the best available evidence for nonoperative treatment specific to insertional Achilles tendinopathy. Methods Literatures were searched in PubMed, Embase, and Web of Science databases from inception to October 2020. The results were evaluated independently by two reviewers and assessed against the inclusion/exclusion criteria. All included articles were assessed for methodological quality, and study characteristics were extracted. Results Twenty-three studies (containing 35 groups) were eligible for the final review. The treatments included eccentric training, extracorporeal shockwave therapy (ESWT), injections, and combined treatment. Visual analog scale (VAS), Victorian Institute of Sport Assessment-Achilles questionnaire, AOFAS, satisfaction rate, and other scales were used to assess the clinical outcome. Conclusion Current evidence for nonoperative treatment specific for insertional Achilles tendinopathy favors ESWT or the combined treatment of ESWT plus eccentric exercises.

Extracorporeal Shockwave Therapy for Mid-portion and Insertional Achilles Tendinopathy: A Systematic Review of Randomized Controlled Trials

“…Our results for ins-AT are not supported by two recently published systematic reviews [ 52 , 53 ] which indicate that adding ESWT to an eccentric loading program increases outcomes for ins-AT. As these two reviews included primary studies with predominantly lower evidence levels such as retrospective and prospective cohort studies, case series, case control studies and pilot studies, this may have contributed to different outcomes compared to our review.…”

“…Mid-AT appears to involve isolated tendon pathology, in contrast to ins-AT [ 13 , 67 ]. It is possible that ESWT is less effective in treating certain non-tendinous tissues, as ins-AT may be accompanied by metabolic diseases [ 52 ], and often includes pathology in adjacent bursae and bone tissue, making the source of pain difficult to diagnose [ 13 , 68 , 69 ]. In particular, intratendinous bone formation in ins-AT is considered difficult to treat [ 68 ].…”

Management of Insertional Achilles Tendinopathy

“…For IAT, studies demonstrate a wide range of effectiveness, from 28 to 83%. 7,8 On average, about 45.6% of patients endorsed an excellent or good outcome in a recent meta-analysis. 8 ESWT is a modality in which pressure waves outside the body are delivered to damaged tissue to reduce pain and promote healing.…”

“…7,8 On average, about 45.6% of patients endorsed an excellent or good outcome in a recent meta-analysis. 8 ESWT is a modality in which pressure waves outside the body are delivered to damaged tissue to reduce pain and promote healing. ESWT was directly compared with eccentric strengthening for IAT by Rompe et al 7 in a level 1 study and found to be more effective at improving pain (64% versus 28%).…”

“…Overall, failure of nonsurgical management remains high. 8 Risk factors for failure of nonsurgical treatment include a high visual analog scale score, limited ankle range of motion, previous corticosteroid injection, and the presence of an Achilles tendon enthesophyte. 13 Despite this, it is generally agreed among treating sur-geons that patients with IAT should undergo at least 3 to 6 months of nonsurgical treatment before surgical management is chosen.…”