The Achilles tendon insertion has three distinct structural zones: the tendon proper, a fibrocartilage transition zone (enthesis), and the calcaneal bone. Insertional tendinopathy affects the deep fibres at the bone-tendon junction, producing the characteristic calcification within the tendon at the insertion. Haglund's deformity (posterosuperior calcaneal prominence) adds a compressive impingement component.
The insertional zone transmits all plantarflexion forces to the calcaneus — the bone-tendon junction undergoes the highest compressive and tensile loads
Insertional Achilles tendinopathy is managed differently from mid-portion tendinopathy — the decline squat that loads the mid-portion is contraindicated (the decline increases insertional compression). Flat-surface eccentric loading or isometric holds are preferred. Surgical detachment of the Achilles tendon (Zadek calcaneal osteotomy) combined with tendon debridement and reattachment with anchors is the definitive procedure for refractory insertional disease.
Calcaneal enthesis degeneration producing posterior heel pain at the insertion managed with flat-surface eccentric loading and Zadek osteotomy for refractory cases.
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