Insertional Calcific Tendinopathy of the Achilles Tendon and Dysmetabolic Diseases: An Epidemiological Survey

Hyperuricemia May Increase Risk of Achilles Tendon Rupture: A Case Control Study

It has been demonstrated in a number of studies that high levels of uric acid can cause crystal deposition in the tendons of the lower extremities, which in turn can impair the Achilles tendon. This study aimed to interpret whether hyperuricemia is relevant with Achilles tendon rupture. Patients diagnosed with Achilles tendon rupture at the same institution between 2013 and 2022 were included in the case group. Healthy subjects who had physical examinations during the same period were included in the control group. Propensity score matching was used to match in a 1:1 ratio. Demographic and clinical characteristics of patients in both groups were compared. Five hundred and fourteen patients were included in the study (ATR=257; Control group=257). The proportion of individuals with hyperuricemia varied significantly between the two groups (Achilles tendon rupture group=43.6%; control group=27.6%; p<0.001). The Achilles tendon rupture and hyperuricemia were linked by conditional logistic regression (p<0.001; OR=2.036; 95CI%=1.400-2.961). Compared with healthy subjects, patients with hyperuricemia have a higher risk of Achilles tendon rupture. Further studies are required to verify the effects of hyperuricemia and monosodium urate crystals on Achilles tendon structure.

Haglund resection versus Haglund non-resection for calcific insertional Achilles tendinopathy with Haglund deformity: A retrospective study

BACKGROUND

Calcific insertional Achilles tendinopathy(CIAT) with Haglund deformity is a type of recalcitrant tendinopathy. The necessity of concomitant removal of Haglund deformity during CIAT treatment is controversial. The present study aimed to evaluate the functional outcomes between Haglund resection and Haglund non-resection in the treatment of CIAT with Haglund deformity.

METHODS

A retrospective study included 29 patients who were underwent Achilles tendon debridement, bursal excision, and subsequent tendon reattachment.for CIAT with Haglund deformity. All patients were divided into 2 groups according to Haglund resection (resection group, n = 16) and Haglund non-resection (non-resection group, n = 13) using the parallel line method on lateral calcaneal X ray after surgery. Patients were evaluated in terms of the American Orthopedic Foot and Ankle Society (AOFAS), Visual Analog Scale (VAS) and Victorian Institute of Sports Assessment-Achilles (VISA-A) scores and the mean time of activities of daily living (ADL). Anatomy changes included the Fowler-Philip angle, calcaneal pitch angle and Achilles tendon force arm were measured with radiography preoperatively and postoperatively.

RESULTS

Both groups exhibited a significant increase in AOFAS, VAS and VISA-A scores after surgery. There were no significant differences between the resection group and the non-resection group for the AOFAS (92.38 ± 5.7 vs. 93.15 ± 12.17; P = 0.82), VAS (0.5 ± 0.52 vs. 0.61 ± 0.87; P = 0.66) and VISA-A questionnaire (82.56 ± 13.46 vs. 74.92 ± 16.4; P = 0.18) at the latest follow-up. The mean time of ADL in the non-resection group was significantly faster compared to that of the resection group (8.15 ± 2.51 weeks vs. 11.31 ± 4.06 weeks, P = 0.02). The Fowler-Philip angle of the resection group decreased from 55.55° ± 12.34° preoperatively to 44.52° ± 10.24° at the latest follow-up (P = 0.001). The Fowler-Philip angle of the non-resection group decreased from 54.38° ± 8.41° preoperatively to 46.52° ± 8.02° at the latest follow-up (P = 0.016). The calcaneal pitch angle of the resection group increased from 22.76° ± 5.37° preoperatively to 25.98° ± 6. 4° at the latest follow-up (P = 0.018). The Achilles tendon force arm of the resection group decreased from 178.50 mm ± 5.37 mm preoperatively to 173.90 mm ± 8.07 mm at the latest follow-up (P = 0.018).

CONCLUSION

Resection or non-resection of the posterosuperior calcaneal tuberosity for CIAT with Haglund deformity would both provide satisfactory functional outcomes. Haglund non-resection may expedite patients' return to their daily activities, suggesting a Haglund deformity resection may be unnecessary in the surgical treatment for CIAT with Haglund deformity.

Association of calcific rotator cuff tendinopathy with nephrolithiasis and/or cholelithiasis: A case-control study

This study aimed to examine the association between calcific rotator cuff tendinopathy (RCT) and nephrolithiasis and/or cholelithiasis. A case-control study was conducted on patients diagnosed with RCT between June 2016 and June 2022. RCT was confirmed by ultrasound, and patients were divided into 2 groups: calcific RCT (case) and non-calcific RCT (control). Data were collected retrospectively from electronic medical records and completed by phone calls, looking for a history of nephrolithiasis and/or cholelithiasis; based on clinical features or incidental findings on abdominal and pelvic imaging. A total of 210 patients with RCT were included. Among the 95 cases of calcific RCT, 43 had a history of lithiasis (45.3%) against 23 (20%) from the non-calcific RCT group (P < .001); 21 patients suffered from nephrolithiasis (22.1%) and 26 had cholelithiasis (27.4%) versus 10 (8.7%) (P = .006) and 16 (13.9%) (P = .015) in the non-calcific RCT group, respectively. Logistic regression showed that the independent predictors of calcific RCT included a history of nephrolithiasis (OR, 4.38; 95% CI: 1.61-11.92, P = .004) and a history of cholelithiasis (OR, 3.83; 95% CI: 1.64-8.94, P = .002). In patients with calcific RCT, the occurrence of lithiasis was significantly associated in the bivariate analysis with higher age, body mass index, fasting blood sugar, and HbA1c (all with P < .05), but only with the presence of another site of calcific tendinopathy than the shoulder (OR, 3.11; 95% CI: 1.12-8.65, P = .03) in the multivariate analysis. Nephrolithiasis and/or cholelithiasis are associated with calcific RCT, and their presence predicts calcific RCT at least 3 times. Further research is required to determine the common risk factors and preventive measures against lithogenesis in patients with calcific RCT, nephrolithiasis, and cholelithiasis.

Pathological calcification in canine tendon-derived cells is modulated by extracellular ATP

Tendon calcification is a commonly associated with degenerative tendinopathy of the Achilles tendons in dogs. It is characterised by the formation of calcific deposits and is refractory to treatment, often re-forming after surgical removal. Little is known about its pathogenesis and therefore the aims of this study were to develop an in vitro model of canine tendon calcification and use this model to investigate mechanisms driving calcification. Cells from the canine Achilles tendon were cultured with different calcifying media to establish which conditions were best able to induce specific, cell-mediated calcification. Once optimum calcification conditions had been established, the effect of ATP treatment on calcification was assessed. Results revealed that 2 mM di-sodium phosphate combined with 2 mM calcium chloride provided the optimum calcifying conditions, increasing calcium deposition and expression of osteogenic-related genes similar to those observed in tendon calcification in vivo. ATP treatment inhibited calcification in a dose-dependent manner, reducing calcium deposition and increasing cell viability, while osteogenic-related genes were no longer upregulated. In conclusion, the in vitro model of canine tendon calcification developed in this study provides the ability to study mechanisms driving tendon calcification, demonstrating that ATP plays a role in modulating tendon calcification that should be explored further in future studies.

Imaging of calcific tendinopathy: natural history, migration patterns, pitfalls, and management: a review

Calcific tendinopathy is characterized by the deposition of calcium hydroxyapatite crystals in various tendons of the body. Terms like calcium tendinitis, tendinosis, and tendinopathy are used interchangeably. Calcific tendinopathy is a common and well-documented ailment in the literature. Although common, the natural history, aetiology, and progression of calcific tendinitis are poorly understood. The treatment options include conservative and interventional measures. However, these measures cannot be applied as a blanket and are often tailored depending on the stage/phase of the disease. Out of the recognized stages of the disease, the resorptive stage causes the utmost symptoms when the calcium is rather soft and unstable. During this stage, the calcium may migrate beyond expected resorption and get deposited in the adjacent tissues contiguous with the calcium focus. The common destinations include bursal migration, intraosseous migration, muscular migration, and other less common migration sites. Such atypical presentations can lead to dilemmas in the diagnosis, prolongation of the diagnostic pathway, unwarranted apprehension, and treatment delay. Radiologists' role in this situation is to correctly recognize the imaging findings of atypical presentations of calcific tendinopathy and prevent unnecessary diagnostic and interventional studies. In this review article, we describe the pathogenic pathway and natural history of calcific tendinopathy from a radiologist's perspective and discuss different migratory patterns of calcium in calcific tendinopathy not only around the shoulder but also in other areas of the body on different imaging modalities. We also show a few examples of mimics and pitfalls on imaging. Finally, we discuss the appropriate management option of this condition.

Recurrence rates for surgically treated insertional Achilles tendinopathy

INTRODUCTION

Insertional Achilles tendinopathy (IAT) is a challenge for every orthopedic surgeon. Although surgical intervention is difficult to avoid after frustrating conservative therapy, little is known about recurrence of this disorder. Therefore the aim of the study was to assess the recurrence rate after primary IAT surgery.

MATERIALS AND METHODS

The authors previous published cohort on primary IAT surgery was reanalyzed. Patients with a follow-up Foot and Function Index (FFI) at one year and final follow-up were included. IAT recurrence was defined as a FFI worsening between one year and final follow-up of > 6.5 points. General demographics, surgical details, complications, and the patient reported outcome (PROM) were assessed.

RESULTS

Out of 58 included patients (51 ± 14 years), 8 patients (14%) suffered IAT recurrence after an average of 50 ± 25 months. None of the assessed factors was predictive for an IAT recurrence.

CONCLUSION

IAT recurrence after primary surgery occurs in up to 14% of patients.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Immediate and Short-Term Effects of In-Shoe Heel-Lift Orthoses on Clinical and Biomechanical Outcomes in Patients With Insertional Achilles Tendinopathy

Background

Physical therapists frequently employ heel lifts as an intervention to reduce Achilles tendon pain and restore function.

Purpose

To determine the short-term effect of heel lifts on clinical and gait outcomes in participants with insertional Achilles tendinopathy (IAT).

Study Design

Case series; Level of evidence, 4.

Methods

Participants with IAT underwent eligibility screening and completed assessments at baseline and 2 weeks later. Primary outcomes included symptom severity (Victoria Institute of Sports Assessment-Achilles [VISA-A]), gait analysis with the 10-m walk-test at 2 speeds (normal and fast), and pain during walking. Pain and gait analysis were assessed under 3 conditions: before fitting 20-mm heel lifts, immediately after heel-lift fitting, and after 2 weeks of wearing heel lifts. Ultrasound images and measurements at the Achilles insertion were obtained from prone and standing positions (with and without heel lifts). Spatiotemporal gait parameters and tibial tilt angles were evaluated at normal speed using inertia measurement units during the 3 study conditions. Differences between the conditions were analyzed using paired t test or analysis of variance.

Results

Overall, 20 participants (12 female, 13 with bilateral IAT; mean age, 51 ± 9.3 years; mean body mass index 31.6 ± 6.8 kg/m2) completed all assessments. Symptom severity (VISA-A) of the more symptomatic side significantly improved at 2 weeks (60 ± 20.6) compared with baseline (52.2 ± 20.4; P < .01). Pain during gait (Numeric Pain Rating Scale) was significantly reduced immediately after heel-lift fitting (0.7 ± 2.0) when compared with baseline (2.2 ± 2.7, P = .043). Spatiotemporal gait parameters and tibial tilt angle before and after using heel lifts at normal walking speed were not significantly different; however, gait speed, stride length, and tibial tilt angle on both sides increased significantly immediately after using heel lifts and were maintained after 2 weeks of wear.

Conclusion

Using heel lifts not only improved symptom severity after 2 weeks but also immediately reduced pain during gait and had a positive impact on gait pattern and speed.

Different clinical presentations of Achilles tendinopathy: a cross-sectional study

Achilles tendinopathy (AT) is a common debilitating tendon disorder in the lower extremity. Clinical presentation of AT might differ from place to place, depending on different variables including cultural factors. This study was conducted to determine the clinical picture of AT in a group of clients referring to an outpatient orthopedics clinic in Shiraz, southern Iran. In this cross-sectional study, a convenient sample of 61 (46 female and 15 male) patients attending to a referral outpatient clinic affiliated to Shiraz University of Medical Sciences with a definite diagnosis of AT was studied. Patients with partial- or full-thickness tear of Achilles tendon, history of radicular pain or lower extremity injury, previous history of surgery on their lower extremity, and pregnant women were excluded from the study. We used Maffulli et al. (Foot Ankle Surg 26:240-9, 2020) criteria for the diagnosis of AT in our patients. The patients had a mean age of 47.7 (SD 11.1) years and mean BMI of 28.7 (4.2) kg/m2. There was no significant correlation between the age and body mass index of the participants (Pearson's r = -0.028, p = 0.832). The prevalence of insertional AT among 58 patients with only one site affected, was 84% (95% CI 72-92%), significantly (p < 0.001) higher than that of midportional AT (16%). Women were more frequently affected than men (p < 0.001). The clinical presentation of AT in southern Iran is somewhat different from those reported in other parts of the world. Further studies on larger groups of patients should be done to determine the causes of the observed differences.

Two-Year Clinical and Radiologic Outcomes Following Surgical Treatment of Insertional Achilles Tendinopathy Using a Central Tendon-Splitting Approach

BACKGROUND

If conservative treatment of insertional Achilles tendinopathy (IAT) fails, surgery is often considered. Various surgical approaches have been used including the central Achilles tendon splitting approach. This study aimed to report the 2-year clinical and radiologic outcomes after surgical treatment of IAT with a central tendon-splitting approach.

METHODS

Seventy-five cases of IAT treated surgically via the open central tendon-splitting approach were analyzed. Clinical outcomes included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, visual analog scale (VAS), 36-Item Short Form Health Survey (SF-36) physical (PCS) and mental (MCS) component summary scores, all measured at baseline and 6 and 24 months postoperatively. Radiologic parameters measured included the Fowler-Philip angle (FPA) and parallel pitch lines (PPL).

RESULTS

Three patients had clinically significant wound issues but healed completely by 3 weeks. Mean AOFAS score improved from 45.63 preoperatively to 94.71 at 24 months. Mean VAS score improved from 6.73 preoperatively to 0.55, mean SF-36 PCS from 35.98 to 48.74, and mean SF-36 MCS from 53.04 to 55.43 at 24 months. Satisfaction at 2 years was 94.3%. Mean FPA decreased from 62.0 degrees preoperatively to 34.0 degrees postoperatively. PPL was positive in 82.7% (62 of 75) of cases preoperatively, decreasing to 1.3% (1 of 75) postoperatively. Increasing age and higher preoperative VAS and SF-36 MCS scores were significantly associated with improvements in postoperative AOFAS, SF-36 PCS, and MCS scores.

CONCLUSION

Surgical treatment of IAT via the central tendon-splitting approach achieved substantial improvements in all patient-reported outcome measures measured. These excellent clinical outcomes continued to show improvement 2 years postoperatively.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Scavenging of reactive oxygen species can adjust the differentiation of tendon stem cells and progenitor cells and prevent ectopic calcification in tendinopathy

Tendinopathy is a common disorder that leads to pain and impaired quality of life. Recent studies revealed that osteogenic differentiation of tendon stem/progenitor cells (TSPCs) played an important role in the pathogenesis of tendon calcification and tendinopathy. In this study, we found that the growth hormone-releasing hormone agonist (GA) can prevent matrix degradation and osteogenic differentiation in TSPCs. As oxidative stress is a key factor in the osteogenic differentiation of TSPCs, we used bovine serum albumin/heparin nanoparticles (BHNPs), which have biocompatibility and drug loading capacity, to scavenge reactive oxygen species (ROS) and achieve sustained release of GA at the site of inflammation. The newly developed BHNPs@GA had a synergetic effect on reducing ROS production in TSPCs. In addition, BHNPs@GA effectively inhibited tendon calcification and promoted collagen formation in a rat model of tendinopathy. Focusing on the ROS underlying the differentiation and dedifferentiation of TSPCs, this work demonstrated that sustained release of GA targeting ROS and ectopic ossification is a practical therapeutic strategy for treating tendinopathy. STATEMENT OF SIGNIFICANCE: Osteogenic differentiation of tendon stem/progenitor cells (TSPCs) plays an important role in the pathogenesis of ectopic calcification in tendinopathy. In this study, we found that growth hormone-releasing hormone agonist (GA) can reduce reactive oxygen species (ROS) production and adjust TSPCs differentiation. Bovine serum albumin/heparin nanoparticles (BHNPs) were developed to encapsulate GA and achieve sustained release of GA at the site of inflammation. The developed compound, BHNPs@GA, with a synergistic effect of inhibiting ROS and thus, can effectively adjust TSPCs differentiation, inhibit tendon calcification, and promote collagen formation in tendinopathy. This study highlighted the role of ROS underlying the differentiation and dedifferentiation of TSPCs in tendinopathy, and findings may help to identify new therapeutic targets and develop novel strategy for treating tendinopathy.

Achilles Tendon Rupture and Dysmetabolic Diseases: A Multicentric, Epidemiologic Study

Introduction: Achilles tendon ruptures are common. Metabolic disorders, such as diabetes mellitus, hypercholesterolemia, thyroid disorders, and obesity, impair tendons health, leading to Achilles tendinopathy and likely predisposing patients to Achilles tendon ruptures. Materials and methods: Patients who visited the Orthopedic Outpatient Clinics and the Accident and Emergency Departments of five different hospitals in Italy were recruited. Through telephone interviews, we administered a questionnaire to all the patients who had undergone surgical ATR repair, evaluating their past medical history, sport- and work-related activities, drug use, and post-operative rehabilitation outcomes. Results: “Return to work activities/sport” was negatively predicted by the presence of a metabolic disorder (β = −0.451; OR = 0.637) and ‘open’ surgery technique (β = −0.389; OR = 0.678). “Medical complications” were significantly predicted by metabolic disorders (β = 0.600 (0.198); OR = 1.822) and was negatively related to ‘mini-invasive’ surgery (i.e., not ‘open’ nor ‘percutaneous’) (β = −0.621; OR = 0.537). “Immediate weightbearing” and “immediate walking without assistance” were negatively predicted by ‘open’ technique (β = −0.691; OR = 0.501 and β = −0.359 (0.174; OR = 0.698)). Conclusions: Metabolic conditions can strongly affect post-operative outcomes following surgical repair of acute Achilles tendon tears.

Management of Insertional Achilles Tendinopathy

Insertional Achilles tendinopathy is a common condition that can lead to chronic, debilitating heel pain in athletes and nonathletes alike. Conservative treatment options include activity and shoe wear modification, physical therapy, injections, and extracorporeal shock wave therapy. When nonsurgical treatment fails, surgical treatment is recommended. Although there are options aimed at preserving the tendon and débriding the retrocalcaneal bursa and excess bone formation, others are aimed at detaching the Achilles tendon to perform a thorough débridement and subsequent reattachment. Additional or alternate procedures may include a calcaneal closing wedge osteotomy, gastrocnemius lengthening, and flexor hallucis longus tendon transfer. Recent advances in suture anchor techniques further add to the complexity of available options. This review discusses the relevant anatomy, biomechanics, and pathophysiology as well as the recent available evidence for nonsurgical and surgical management of this condition to guide surgeons in selecting the most appropriate treatment for their patients.

The Cincinnati incision is safe and effective for revision surgery for insertional tendinopathy of the Achilles tendon

The present study reports the outcomes of revision surgery using a Cincinnati incision with tendon debridement and calcaneoplasty for insertional Achilles tendinopathy (IAT) in a cohort of patients at 24-month follow-up. Patients undergoing revision surgery following failed previous surgery for IAT were prospectively recruited. Patients were assessed pre-operatively and at 3, 6,12 and 24 months. The Victorian Institute of Sport Assessment Scale for Achilles Tendinopathy (VISA-A), the EQ5D questionnaire and the visual analogue scale (VAS) were used for evaluation. Data from 33 patients with a mean age of 43.9 years old are reported. 27% (9 of 33 patients) were female. The left side was involved in 58% (19/33) of patients. No clinically relevant complications were reported in any of the patients. Most of subscales of EQ5D improved at last follow-up: Usual Activities (P = 0.01), Mobility (P = 0.03), Pain/Discomfort (P = 0.001), Thermometer (P = 0.04). No statistically significant change for the subscales Self-Care (P = 0.08) and Anxiety-Depression (P = 0.1) was evidenced. The VISA-A score improved significantly at last follow-up (P < 0.0001), as did the VAS score (P < 0.0001). These results indicated that a Cincinnati incision followed by tendon debridement and calcaneoplasty for revision surgery for IAT is feasible and reliable, achieving clinically relevant improvement in the VISA-A, EQ5D and VAS at 24 months follow-up.

Dyslipidemia Is Associated With Increased Risk of Achilles Tendon Disorders in Underweight Individuals to a Greater Extent Than Obese Individuals: A Nationwide, Population-Based, Longitudinal Cohort Study

Background:

The association between dyslipidemia and Achilles tendinopathy (AT) or Achilles tendon rupture (ATR) remains controversial, although some studies have examined this topic.

Purpose:

To evaluate the correlation of dyslipidemia and the risk of AT or ATR, and its association with body mass index (BMI), by assessing data from a nationwide population-based cohort.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We used the National Health Insurance database, which includes the entire population of the Republic of Korea, to evaluate participants in the National Health Screening Program between January 2009 and December 2010. Participants diagnosed with AT or ATR before December 31, 2017, were selected. The variables assessed were age, sex, frequency of high-intensity exercise per week, BMI, waist circumference, systolic blood pressure, and levels of low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and fasting blood glucose. Multivariate Cox proportional hazards regression was used for data analysis.

Results:

A total of 16,830,532 participants were included. Of these, 125,814 and 31,424 participants developed AT and ATR, respectively. A higher level of LDL-C was associated with an increased risk of AT (adjusted hazard ratio [HR], 1.16) and ATR (adjusted HR, 1.18). A slightly increased risk of AT was observed in participants with higher TG levels (adjusted HR, 1.03), whereas higher HDL-C level was associated with a slight risk reduction for AT (adjusted HR, 0.95). However, no significant association was observed between higher TG or HDL-C levels and ATR. In the underweight group (BMI <18.5 kg/m²), a higher LDL-C level was associated with an increased risk of AT and ATR by 37% and 116%, respectively, compared with lower LDL-C. Higher LDL-C level was associated with an increased risk of AT and ATR by 10% and 16%, respectively, in the obese group (BMI ≥25 kg/m²).

Conclusion:

Dyslipidemia was related to the development of AT and ATR. The association of higher LDL-C levels with AT and ATR risk was more pronounced in underweight than in overweight and obese individuals.

Small interfering RNAs in tendon homeostasis

BACKGROUND

Tenogenesis and tendon homeostasis are guided by genes encoding for the structural molecules of tendon fibres. Small interfering RNAs (siRNAs), acting on gene regulation, can therefore participate in the process of tendon healing.

SOURCES OF DATA

A systematic search of different databases to October 2020 identified 17 suitable studies.

AREAS OF AGREEMENT

SiRNAs can be useful to study reparative processes of tendons and identify possible therapeutic targets in tendon healing.

AREAS OF CONTROVERSY

Many genes and growth factors involved in the processes of tendinopathy and tendon healing can be regulated by siRNAs. It is however unclear which gene silencing determines the expected effect.

GROWING POINTS

Gene dysregulation of growth factors and tendon structural proteins can be influenced by siRNA.

AREAS TIMELY FOR DEVELOPING RESEARCH

It is not clear whether there is a direct action of the siRNAs that can be used to facilitate the repair processes of tendons.

Nonoperative treatment of insertional Achilles tendinopathy: a systematic review

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.