JFAS 30(5): 457-459, 1991

Calcified Tendo Achillis Insertion: A New Surgical Approach

The authors present a new surgical approach to the medical condition that is known as
enthesiopathy of the tendo Achillis. The cases presented demonstrate a surgical technique
that addresses the calcified Achilles tendon at its insertion, without weakening the
insertion fibers. This technique allows bone-to-bone healing instead of tenodesis and
significantly reduces the likelihood of a ruptured tendo Achillis.

Lawrence Marczak, DPM, FACFS1,2

Steven Gelsomino, DPM, FACFS1
Debra Lusk, DPM3

Retrocalcaneal exostosis due to abnormal ossification or spurring at the site of insertion

of the tendo Achillis, as well as calcification within the tendon itself, may be found in
conjunction with several other medical problems, which is beyond the scope of this
article. This deformity has been given names by various authors including Achilles
tendonitis, tendo Achillis bursitis, and enthesiopathy (1, 2). Medical literature describes
various surgical techniques for treatment of the posterior calcaneal deformity. However,
many of the authors describe an approach that requires partial calcanectomy that may not
respect the integrity of the tendo Achillis insertion, or strictly avoids tampering with the
insertion, leaving the direct cause of the problem alone. The authors have experienced
these problems and propose an alternative approach, utilizing a calcaneal osteotomy with
no or minimal bone resection.

Anatomy

Mercado (3) states that calcification at the attachment of the tendo Achillis is not
an unusual finding and may be seen in a lateral radiograph of the foot. He also submits
that the calcification is primarily situated on the lateral segment of the posterior surface
of the calcaneus but may extend across the entire insertion. Fiamengo et al. (4) note the
presence of a step in the middle of the posterior surface, which corresponds to the level of
the insertion.
When reviewing the anatomy of the tendo Achillis, Malay and Duggar (5) note
the absence of tendon sheath and that the tendon's pull on the inferior half of the posterior
surface of the calcaneus is reflected by the trabecular pattern of the bone.

Treatment

The patients presented in this paper were treated first by conservative means in an
effort to relieve the symptoms. After x-ray exposure (Fig. 1), special fitting shoes with
heel lifts, and oral nonsteroidal anti-inflammatory medications provided only temporary
relief of their symptoms. Therefore, since conservative methods of alleviating discomfort
were exhausted, and being convinced that no other underlying medical pathology was
presented, the authors opted for surgical intervention.
The operative technique requires meticulous skin incision and deep tissue
handling to avoid permanent injury to overlying vessels and nerves, as well as avoidance
of adhesions and scar tissue. The authors recommend approximately a 4.0-cm. linear
incision, commencing posterior to the lateral malleolus, parallel, and slightly anterior to
the Achilles tendon over the lateral aspect to the level of the inferior insertion of the
Achilles tendon. The incision is deepened to periosteum of the posterior lateral calcaneus.
The periosteum is incised and reflected, exposing the insertion of tendo Achillis. The
surgeon may now opt to remodel any co-existing deformity present, such as an osseous
prominence (Fig. 2A) with a crescentic blade on a power saw. A through-and-through
osteotomy is made encompassing the portion of the calcaneus containing the insertion of
the tendo Achillis from lateral to medial (Figs. 2A and B). The anterior portion of the
osteotomy site is further deepened and widened along the superior aspect (Fig. 2B). The
detached bone and tendon fragments are reapproximated in an anterior and slight plantar
rotation. This maneuver brings the calcified insertion flush with the posterior surface of
the calcaneus. The authors recommend utilizing intra-operative x-rays to confirm proper
placement is achieved.

____________________________________________________________
From the Department of Podiatric Surgery, Thorek Hospital,
Chicago, Illinois.
0449/2544/9 1/3005-0457$03.00/0
Copyright ©1991 by The American College of Foot Surgeons

457

Also, due to the deepening of the osteotomy, the newly attached bone fragment is
superiorly advanced to compensate for shortening of the tendon caused by the plantar
rotation (Fig. 2C). The newly formed inferior gap is packed with bone chips from the
second bone cut. The osteotomy now is fixated with an appropriate sized cancellous
screw (Fig. 3).

Figure 1. Preoperative lateral radiographic view. Arrow demonstrates

enthesiopathy.

Figure 2. A. Initial crescentic osteotomy. Note calcification is the darkened

section within the tendon. B. The second osteotomy is superior and anterior to the initial
cut. Note wedge of bone removed is shown by arrow. C. Fragment rotated clockwise
(dotted arrow) and superiorly positioned. Note the wedge of bone repositioned inferiorly.
D. Cancellous bone screw fixation.
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Finally, proper deep and superficial wound closure is performed with application of a
below-the-knee cast with the foot in equinus. A postoperative steroid injection is not
recommended due to its possible weakening effect upon the tendon.
After 6 weeks of nonweightbearing cast immobilization, the patients begin a
physical therapy program to regain muscle strength and joint range of motion. Limited
ambulation may begin with a removable weightbearing splint device for an additional 4
weeks. At this point of recovery, a good compression stocking, i.e., Jobst ready fit
(Vairox®)4 stocking, will help control the anticipated edema.

Discussion

The authors recommend conservative care in the initial treatment of symptomatic

calcification of the tendo Achillis insertion. Oral anti-inflammatory medications,
elimination of abnormal external pressure such as ill fitted shoe gear, steroid injections,
or immobilization of the leg in a short leg walking cast for a limited period of time may
reduce the acute symptoms. If the patient's pain persists after a concerted effort, surgical
intervention may become necessary. Surgical techniques that involve reflection and
repair of all or part of the tendo Achillis entail a certain risk of complications, such as
iatrogenic triceps equinus and potential weakening of the tendons.
The proposed osteotomy ensures that the prominent portion of bone is adequately
repositioned, thereby alleviating the patient's symptoms, without disturbing the integrity
of the tendon. The patient should be prepared for potential postoperative swelling,
particularly upon cast removal, so that rehabilitation and physical therapy become an
integral part of the treatment plan. Painful cicatrix and neuropathy due to sural nerve
entrapment are the other possible complications that should be considered.
Fortunately, the authors were able to maintain longterm follow-up of their
patients. The cases discussed are two 74-year-old females and a 32-year-old man.
Following physical therapy, all were wearing regular shoes comfortably and their gait
was normal. At 6 months postoperative, slight to no edema without complaint of pain was
noted after excessive amount of walking. After 2 years, these patients have not reported
any recurrence of their original conditions.

Summary

The authors have presented an alternative surgical approach to a challenging

problem. The major advantages to this procedure include maintaining the tendo Achillis
insertion intact, and reducing inflammation and pull of the triceps surae. This technique is
effective
and produces good results.

Figure 3. Postoperative lateral radiography demonstrating screw insertion.

References

1. Jones, D. C., James, S. L. Partial calcaneal ostectomy for retrocalcaneal

bursitis. Sports Med. 12:72-73, 1984.
2. Smith, T. F. Resection of common pedal prominences: navicular, calcaneus,
metatarsocuneiform. J. A. P. A. 73:95-97, 1983.
3. Mercado, O. A. An Atlas of Foot Surgery, vol. 2, pp. 71-72, Carolando Press,
Inc., Oak Park, Illinois, 1987.
4. Fiamengo, S. A., Warren, R. F., Marshall, J. L., Vigorita, V. T., Hersh, A.
Posterior heel pain associated with a calcaneal step and Achilles tendon calcification.
Clin. Orthop. 167:203-205, 1982.
5. Malay, D. S., Duggar, G. E. Heel Surgery. In Comprehensive Textbook of Foot
Surgery, vol. 1, edited by E. Dalton McGlamry, p. 279, Williams & Wilkins, Baltimore,
1987.

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