Prediction of the Success of Nonoperative Treatment of Insertional Achilles Tendinosis Based on MRI

Background: Insertional Achilles tendinosis is a common clinical diagnosis for posterior heel pain. Nonoperative treatments often are unsuccessful. The purpose of this paper was to review a series of patients with insertional tendinopathy to determine whether MRI stratification could predictably identify patients in whom nonoperative treatment would fail. Methods: Review of records identified 157 patients (176 tendons) who were treated for insertional posterior heel pain. All patients who required surgery had MRI and their tendinosis was classified based on tendon size and degree of involvement (type I, II, or III). Patients who required surgery had standard two-incision decompression and debridement. Results: Of the 157 patients (176 tendons) with insertional heel pain, 83 (53%) responded to nonoperative treatment (96 tendons). Most of these patients who had MRI evaluation had type I involvement. The remaining 74 patients (47%) required operative intervention after an average of 12 months of conservative treatment (80 tendons). Most of these tendons were types II and III. Overall, two of the 16 type I tendons (12.5%) required surgery, 59 of the 65 type II tendons (90.8%) needed surgery, and 19 (70.4%) of the 27 type III tendons required surgery. Conclusions: Patients with tenderness of the Achilles tendon insertion without obvious signs of inflammation who demonstrate confluent areas of intrasubstance signal changes on MRI (types II and III) are not likely to respond to nonoperative treatment. Early identification of these patients and operative intervention may lead to earlier return to function.