Initial conservative management should consist of nonsteroidal anti-inflammatory drugs, ice, rest, or activity modification. In combination with shoe gear modification, patients may benefit from an orthosis to help control hyperpronation, which often is a contributing factor. In patients with insertional Achilles tendinopathy, shoes that do not cause frictional pain are helpful in reducing symptoms. Physical therapy is beneficial, especially when strengthening, stretching, proprioception, and anti-inflammatory modalities are used in combination. Heel lifts are helpful in reducing the load on the Achilles during daily activity. Patients who do not respond well to these options or are noncomplaint may benefit from immobilization in either a boot or a cast for a short period of time.
Injecting corticosteroids into the tendon is controversial because of the risk of rupture, especially without immobilization. Some studies suggest injecting platelet-rich plasma or sclerosing agents to help reduce pain and improve function, but supporting data are insufficient to support this therapy.
Surgery for patients with insertional tendinopathy requires removal of the prominent bone, or the Hagland deformity, and debridement of the Achilles tendon. Often, this surgery involves removing a large part of the Achilles insertion in order to access the bony deformity or calcific tendinosis. The Achilles tendon then needs to be reattached.
When the insertion site is not the source of pain, tendon debridement can reduce symptoms. Other options include tendon transfers or augmentation, specifically with the flexor digitorum longus. Percutaneous options (Tenex and Topaz procedures) break up scar tissue and stimulate vasculature in order to reduce symptoms. Large studies have not been performed, however, to validate these treatment modalities.