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Haglunds deformity correction; Arthrex Speedbridge technique

    Overview

    Learn the Haglunds deformity correction; Arthrex Speedbridge technique surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Haglunds deformity correction; Arthrex Speedbridge technique surgical procedure.
    There are three main varities of pathology effecting the area of the achilles tendon insertion and to which the description of a Haglunds’ deformity is commonly(and loosely) applied.
    Most often the pathology is one of degenerative change at achilles the insertion associated intra-tendinous calcification. There may or may not be an element of anatomical prominence of the postero-lateral calcaneus associated. This tends to produce a fairly broad based swelling across the back of the heel. Usually the painful area is located laterally but it can on occasion be postero-medial.
    Less commonly the achilles tendon is normal and the issue is an anatomical prominence of the postero-lateral corner of the calcaneus, causing pressure when in shoe-wear.
    The third variation is a calcaneus that is anatomically prominent posteriorly, laterally and also superiorly. This can cause direct impingement upon the deep(anterior) aspect of the Achilles in the retro-calcaneal area.
    These cases should be imaged using cross sectional imaging to determine the location of both bony deformity and tendinopathy. This will assist in deciding upon the surgical approach to be taken. This will also on occasion show evidence of associated retro-calcaneal bursitis which should be intercurrently treated.
    These variations in pathology can be treated using the same surgical principles and with successful outcome expected in the majority of patients. The key is to identify the exact location and nature of the pathology causing symptoms. Non-operative treatment is somewhat less successful when adopted here than for problems with the main body of the achilles tendon.
    In my practice I use the Speedbridge for cases of insertional achilles tendinosis where there is significant intra-tendinous calcification that will require extensive detachment of the tendon for adequate access. The Speedbridge provides a far more robust level of fixation for the achilles than any alternatives. One can be as extensive as required therefore with the level of dissection. The technique is though without doubt more involved than simply using a postero-lateral or postero-medial approach and fixing the tendon back with a Bio-corkscrew anchor, which covered on OrthOracle at Haglunds deformity: Arthrex Bio-corkscrew fixation and a postero-lateral approach.Generally the surgery is easier performed with the patient prone but as this technique demonstrates it cab be done with the patient well supported in a lateral position.
    The Arthrex SpeedBridge implant itself is very much a really useful part of the surgical armamentarium available to treat Haglunds cases. It should be remembered however that of greater importance is identifying the various potential sources of symptoms and treating them all. Also whatever the operative technique used careful skin handling throughout is required as well as in the post-operative period. The soft tissue cover here is thin and prone to delayed healing.

    Indications

    INDICATIONS
    In my practice I use the Speedbridge for cases of insertional achilles tendinosis where there is significant intra-tendinous calcification that will require extensive detachment of the tendon for adequate access. The Speedbridge provides a far more robust level of fixation for the achilles than any alternatives. One can be as extensive as required therefore with the level of dissection. The technique is though without doubt more involved than simply using a postero-lateral or postero-medial approach and fixing the tendon back with a Bio-corkscrew anchor, which is covered on OrthOracle at Haglunds deformity: Arthrex Bio-corkscrew fixation and a postero-lateral approach
    Generally the surgery is easier performed with the patient prone but as this technique demonstrates it can be done with the patient well supported in a lateral position.
    The Arthrex SpeedBridge implant itself is very much a really useful part of the surgical armamentarium available to treat Haglunds cases. It should be remembered however that of greater importance is identifying the various potential sources of symptoms and treating them all. Also whatever the operative technique used careful skin handling throughout is required as well as in the post-operative period. The soft tissue cover here is thin and prone to delayed healing.
    SYMPTOMS & ASSESSMENT
    The “true” Haglunds deformity is a variant of the normal postero-lateral calcaneal anatomy with a prominent edge to the calcaneus that is at risk of rubbing on the heel counter of a shoe. Once this rubbing starts, and some superficial soft tissue thickening develops, the area self-evidently becomes more prominent and further rubbing is more likely. This type of presentation is classically in the younger patient and without any associated change to the structure of the tendon. The inserting tendon is normal. Swelling is limited to the postero-lateral aspect of the calcaneus and it would be unusual to have more generalised posterior calcaneal tenderness or tenderness of the distal Achilles tendon before it attaches. Symptoms are exclusively when pressure is directly on the heel (such as in shoes or occasionally in bed).
    More common is insertional tendinosis of the Achilles. There may (or may not) be a variation in the shape of the postero-lateral calcaneus and the prominence here is often much more diffuse and greater. Here pain is not infrequently also when out of shoes and activity related. On examination the swelling and tenderness is much often more diffuse and may include the distal, non-insertional Achilles tendon.
    The exact areas of tenderness should be noted as the distal tendon, prior to insertion, may require a degree of debridement. It is also worth examining the retro-calcaneal area, sitting immediately anterior to the distal tendon and inferiorly bordered by the most superior and distal part of the calcaneus. This can be another source of alternate (or not infrequently associated) pain due to the presence of intercurrent bursitis.
    INVESTIGATION
    Imaging is required prior to operative intervention. This is to identify the extent and location of pathological changes within the achilles and also the bony pathology. It should be appreciated in imaging the bone that though both a superior calcaneal prominence and intra-tendinous calcification can both be easily seen a pure postero-lateral “pump-bump” may be better visually appreciated than imaged.
    Plain X-Ray: A lateral X-Ray may show larger areas of intra-tendinous calcification. It may also have a role in identifying some bony Haglunds deformities where the issue is one of a posterior and superior prominence of the calcaneus. If however the deformity is a purely lateral ridge it will not be detected by plain X-Ray.
    MRI: A better investigation is an MRI which will assess the 3D nature of the calcaneus as well as the state of the achilles tendon. In particular it is of use in determining how much achilles( especially how far medially ) will likely need to be elevated off the bone to clear and debride intra-tendinous calcification. Inflammation in the retro-calcaneal area can also be diagnosed.
    Ultrasound :(plus or minus injection therapies) have little role in this area unless there is a well defined and inflammed retro-calcaneal bursa
    CONSERVATIVE MANAGEMENT
    Avoidance of aggravating shoe-wear.
    In very flat feet a small medial arch orthotic may make the postero-lateral heel less prominent in shoes.
    For insertional tendinosis a short course of physiotherapy to the tendon itself may possibly help (but is not likely to be as definitive as it would be with problems of the tendon body). This may include shock-wave therapy (see results section).
    SURGICAL ALTERNATIVES.
    A postero-lateral approach: The Achilles insertion can be accessed through a postero-lateral approach and the same objectives achieved, depending upon the location of the pathological process.
    Realigning Calcaneal osteotomy: With a Haglunds deformity that has a posterior and superior bony prominence the postero-lateral calcaneus can be angled away from impinging on the Achilles by a closing wedge osteotomy through the superior & posterior aspect of the Calcaneus (Zadiks operation).
    Minimally invasive technique: With a Haglunds deformity that has a posterior and superior bony prominence the postero-lateral calcaneus can be treated by a minimally invasive burr technique.
    Medial approach: On occasion a medial approach to the deformity, skirting the anterior border of the Achilles medially, is more appropriate. This is determined by the location of symptoms (which can be predominantly medial) if this is where the main intra-tendinous pathology lies.
    CONTRAINDICATIONS
    No specific ones. Poor compliance , poor vascularity and conditions or medications that compromise wound healing are relative ones that will require optimisation.

    Setup

    Operation – 1

    A typical appearance of a large (right sided) area of insertional achilles tendonosis. The full width of the heel is effected.

    A plain X-ray is a useful investigation where a large area of intra-tendinous calcification is expected.

    An MRI gives much more useful detail in these cases, though will not show as dramatic an appearance in terms of the calcification.
    It is however much more helpful in gaining an understanding of where medio-laterally the intra-tendinous bone sits as well as how much is present.
    This will help inform the choice of surgical approach used.
    An axial T1 view (not shown) is also useful in conjunction.




    The T2 weighted image should be inspected for the presence of retrocalcaneal bursitis (1), the extent of degenerate change in the tendon proximal to its insertion (2) and bone oedema in the postero-superior calcaneus. These may all require intercurrent surgical treatment if present.
    The extent of intra-tendinous calcification and its location can also be identified as well as the extent of insertional degenerative change.
    The most useful MRI sequences to study in determining the extent of the task are the T2 sagittals and T1 axials.

    The patient is generally positioned prone though in this case the patient has been placed supine with a lot of external rotation as well as a large sterile bolster behind the calf.
    Adequate exposure to the full width of the calcaneous as well as the full width of the achilles tendon is required.

    A midline longitudinal skin incision is made which extends from the junction of the plantar and dorsal skin inferiorly up to the distal 5cms of the achilles insertion.Full thickness skin flaps should be raised and one should avoid undermining the skin edges as far as possible.

    The distal incision extends down to the junction of the plantar and dorsal skin. One should palpate the plantar surface of the calcaneus and does not need to go quite as far inferior.

    Blunt scissors dissection is used to elevate the skin and fat (preserved as a single layer) off the underlying thickened and degenerate achilles tendon.What is evident here with the fat removed from the underlying tendon is that the paratenon is very thickened and the normal fibrillar appearance of the achilles tendon has been lost due to severe tendinosis.

    One or two Wests retractors will be needed throughout and these need to be placed well beneath the skin and fat.
    These should be recurrently loosened off to avoid as far as possible iatrogenic damage to the skin.
    It is important that the full width of the achilles tendon is exposed both medially and laterally. There is no natural soft tissue plane between the achilles tendon and the underlying deep fascia.
    The debridement of the tendon itself (which is separate from the Haglunds procedure itself) is an important part of the procedure which should be carried out to whatever degree is required.

    The achilles tendon is split longitudinally in its midline. Distally it will be possible to palpate with the tip of the blade the underlying area of intratendinous calcification.As shown by the pre-operative plane x-rays and also MRI imaging there is a significant degree of intratendinous calcification in this case.

    The appearance of the tendon insertion is significantly bulkier than normal and this image shows well the demarcation between the normal fibrillar appearance of the tendon (also shown were the tendon has been split) compared to the overlying thickened tendonotic tissue.

    In addition to sharp dissecting off the thickened paratenon areas of tendonosis are dealt with by placing longitudinal incisions into the body of the tendon and through its full thickness. These should be judiciously placed and not too many used. In a case such as this where there is significant soft tissue thickening there should be no hesitation in a meaningful debridement of the tendonotic tendon tissue.
    This slide demonstrates the amount that may need to be excised from the superficial aspect of the tendon to reveal its underlying healthy fibrillar pattern.
    These small incisions throughout the tendon in the line of the fibres are way of stimulating “healing” of the tendonotic areas.

    The underlying more normal looking tendon tissue is now exposed having removed the significantly thickened paratenon.

    This shows the tendon insertion after both removal of the overlying thickened paratenon but also after the tendon has started to be elevated from its underlying bony insertion (as shown by the inferior portion of the tendon).

    The achilles tendon is carefully sub-periosteally dissected off the underlying intra-tendinous calcification within it’s insertion.The extent of the location of this dissection will be informed by the pre-operative x-ray and MRI scan.
    This approach and technique is used for in my practice for the more severely degenerate tendons with large areas of intratendinous calcification and a radical removal of the achilles tendon from the calcaneous is often required. This is why I used the speedbridge and using it, a more extensive elevation of the tendon off the bone can be undertaken.

    This image reveals underlying thickening of the paratenon prior to the more radical tendon debridement.

    Point A is the point of achilles insertion to the calcaneus were the tendon has been debrided off the posterior aspect of the calcaneus.
    This aspect of the calcaneus should be entirely smooth and the bony prominence is easily identified. This should also be referenced to the more superior portion of the calcaneus (for example were the McDonalds retractor is located) which will help differentiate normal bone from abnormal bone

    Both sides of the split achilles are subperiosteally dissected off the calcaneus, leaving native tendon attachment intact that doesn’t compromise the bony debridement.The Wests retractor has been placed deep within the tendon tissue to assist this process.
    The McDonalds retractor (A) is being used to lever the achilles off the most superior aspect of the calcaneus, an area where, if there is retro-calcaneal bursitis, it will be sitting. This may well have been identified pre-operatively with the MRI imaging but should be looked for in every case with this approach

    A medium sized double action bone nibbler is being used to remove the retro-calcaneal bursitis. Care should be taken here not to wander too far medially in particular as the posteromedial vascular structures sit close to this point.

    The larger area of intra-tendinous calcification/ossification is located posterolaterally and has been identified here with the assistance of sharp dissection and the McDonalds.
    Not all of the intra-tendinous prominence will necessarily be bone and one should throughout the elevation of the tendon off the bone be palpating the elevated tendinous tissue for anything which is not soft tissue. Areas of cartilage like tissue can also occur here.
    If the deep aspect of the achilles tendon, once elevated from the calcaneus, appears very amorphous and without normal fibrillar pattern, this can be debrided. This will also assist in debulking the tendon insertion. It is not possible to be didactic about how much tissue should be resected and a judgement needs always to be made about leaving appropriate amounts of tendon to reattach into the calcaneus. Err on the side of caution at this point.

    As much of the bony calcaneus that needs to be exposed is exposed here. To the right of the picture is the intratendinous calcification and to the left of the image, towards the apex of the tendon incision is the prominent postero-superior lip of the calcaneus.
    One should be mindful throughout the dissection about how much of the native insertion is being left but the objective is the removal of an appropriate amount of bone and also debridement of an appropriate amount of tendon.

    The Wests retractor can simply be placed more superiorly and deeply here to further improve the exposure prior to excision of the bone.
    The yellow fat seen to the left of the exposure sits in the retro calcaneal area.

    The lambotts osteotome is being used here to feel along the superior aspect of the calcaneus to better get an idea of where its “normal” level is, prior to resection of the highest and most posterior aspect of the bone.
    It is by no means invariable that this superior lip of bone needs to be removed and in fact in most cases with Haglunds deformity this is not the case.

    A broad lambotts or Hibs osteotome is used to remove any prominent postero-superior bone from the calcaneus.

    Any postero-superior calcaneal prominance is removed with bone nibblers after resection with a Lambotts osteotome.

    Operation – 2

    The lambotts osteotome is next used to remove the intra-tendinous calcification which has been defined by the elevation of the achilles tendon.

    A generous resection of bone is on occasion, such as here, required.

    Double action bone nibblers are used to smooth down any jagged edges left after the use of the osteotomes.
    It is evident that there is still good attachment of the achilles laterally as been shown by the tension which is possible to place on the tendon using the Langenbecks retractor.

    The appearance of the posterior aspect of the calcaneus after bony resection.

    The components of the Arthrex SpeedBridge kit.
    A: The bio-composite swivel-lock anchor with fibre tape. Note that the fibre tape is wound around the centrally placed paddle and on the end of this is a single needle.
    Note also that a centrally placed within the mechanism is a retention suture which is wound around the base of the handle.
    B: The bio-composite swivel-lock anchor, with central retention suture (but no fibre tape) and distally placed wire loop which assists in delivery of the suture ends).
    C: Tap.
    D: Drill guide.
    E: 3.5mm drill (note the thicker proximal portion of the drill which acts as a stop on the drill guide to allow a pre-determined depth to be drilled).

    The components to the bio-swivel lock are:
    A distal “plug” through which the fibre tape is woven and which remains in the tunnel anchoring the fibre tape.
    The marked shank of the introducer which indicates by the green mark the depth which is drilled.
    The bio-composite swivel-lock anchor.

    This is the bio-composite swivel lock anchor without the fibre tape or sutures, of which there are 2 in each set.
    This swivel lock has attached to it a wire loop (1) which is used to pull the loose (non-attached end) of the fibre tape through the anchoring bio swivel-lock anchor.
    The plastic orange tab (2) is used to pull the wire loop through the very tip of the implant, thus delivering the fibre tapes to the tip of the implant.

    The bio-composite swivel lock anchor has a paddle (1) which is held firmly between thumb and forefinger whilst the implant is driven home by rotating the handle (2) and the bio swivel lock anchor is advanced into the tunnel that has been drilled for it.

    The 3.5mm drill is mounted on a quick release chuck and guided into position on the posterior calcaneus with the green handled drill guide. The thicker end of the drill is stopped from entering the drill guide by it’s diameter and in this way a known depth of hole is recurrently drilled.
    The depth of the hole drilled is the precise depth of the bio swivel-lock anchor and the grey cap that sits at it’s tip.

    The first bone tunnel should be drilled approximately 1cm inferior to the most superior attachment point of the achilles tendon and positioned so that it will leave the swivel lock anchor approximately centrally placed within the half of the tendon which it is being used to reattachIn all, four tunnels are drilled into the prepared surface of the calcaneus.
    Two are first of all drilled superiorly and once the swivel locks have been implanted here a further two are drilled distally.
    It is also important when drilling the first hole to ensure that there will be appropriate space to drill the parallel hole at the same level.
    The angle that the drill should make is approximately 90⁰ to the longitudinal access of the calcaneous.

    The second proximal drill hole is placed again with the same constraints and ensuring that it remains well contained within the calcaneus and approximately parallel to the first drill hole.Note at this point the drill has just contacted the cortical bone and drilling has not started. The amount of the drill which will be delivered into the bone is 1cm and this is marked by the figure 1 on this image.

    Here the drill has been drilled fully home to a 1cm depth, the correct depth to accept the implant.

    The proximal 2 holes are drilled ready to accept the bio composite swivel lock anchors.
    It is worth noting here how relatively bulky the distal end of the achilles tendon remains. This may require some debulking depending on how it sits when rest back on the calcaneus.

    Each of the tunnels is tapped with the tap supplied which must be fully inserted into the bone.
    If when the bio composite anchor is inserted into the hole and screwed in, insertion is difficult then the anchor should be backed out and the tap reused. It is possible to fracture the implant in dense bone and this should of course be avoided.

    The first bio swivel lock anchor is ready for insertion into it’s tunnel.
    The tip of the implant will be inserted into the tunnel and the metallic shank will be inserted up until the green line is level with the surface of the bone tunnel.
    At this stage the anchor is not screwed into the bone, to interference fit the fibre tape.

    The green tip of the bio swivel lock is introduced using manual pressure into its tunnel. It is introduced until the threads of the anchor have just met the cortical bone (as shown in the next slide).

    The handle is gently tapped with a small mallet until the initial few threads engage within the bone tunnel.

    The Bio-composite swivel-lock paddle is held firmly and the anchor is introduced by rotating in a clockwise direction the spherical handle.Note that the fibre tape remains under tension and its distal portion is wound securely around the paddle (which is how the implant and introducer come ready assembled).

    Once the implant is fully inserted and it’s threads are within cortical bone the tip retention suture is unwound from the circular handle entirely.
    Once this is done the introducer and handle can be disengaged from the implant by gentle reverse traction on the introducer.

    The Bio-composite swivel lock introducer and handle is now disengaged from the implant, after the tip retention suture is unwound from the circular handle.

    The anchor is showing well inserted into the bone.
    The tip retention suture (1) can simply be left insitu at this stage and a mayo needle attached to it subsequently to assist with anchoring down the tendon. Alternatively, it can be cut flush to the implant and discarded

    A second fibre tape on Bio-composite SwiveLock anchor is then inserted with the same technique proximally.
    Both implants are tested for pull-out strength by putting a direct traction upon them.

    The two fibre tapes attached to each implant (1) run confluently onto a fibre wire suture (2) which further away from the implant becomes a single fibre wire suture (3) to which the needle is attached.
    This is sewn into a central portion of one side of the reflected tendo achilles.

    The tendon is re-approximated to the calcaneus by sewing the fibretape through the detached tendon.Adjustments are made to the point of entry of the fibre tape into the tendon if an appropriate position is not achieved or if the fibre tape cuts through the tendon tissue.

    Operation – 3

    The same process is repeated with the second anchor and the other split portion of the achilles insertion.
    Note that there are two fibre tapes associated with each implant and one tape from each implant is subsequently inserted distally into a common hole, thus producing a crossed pattern across the achilles insertion and thus direct pressure upon the surface of the tendon, assisting in it’s apposition to bone

    The distal end of the tendon should be re-inspected at this stage and an assessment made of whether it appears prominent when re-applied to the bone. If this is the case a small amount of judicious debulking of the deep surface of the tendon can on occasion be worthwhile undertaking.

    The needle has here been cut from the suture. This is done on both sides.

    Two distal holes are drilled and placed immediately inferior to the superior holes and with a gap of approximately a cm or so.They should be approximately parallel to the line of the superior holes. Again, the same technique is used with the drill and the drill guide, ensuring the appropriate depth of hole is produced.

    The bio swivel lock anchor with the suture introducing wire is taken. This also has a central tip retention suture that allows control of the end of the implant and is again secured around the proximal handle(not shown).

    One fibre tape with it’s attached fibre wire is taken from each implant.

    The fibre wire is fed through the introducing wire loop as shown.

    Once one fibre wire from each of the proximal implants is sat well within the wire loop the orange tag is detached from the tip of the implant by pulling it. This leads to the fibre wire sutures being fed through the tip of the distal implant.

    The fibre wire ends have been fed through the tip of the implant and these need then to be captured and pulled further.

    One fibre tape from each proximal implant (1, 2) is now negotiated onto the tip of the distal swivel lock anchor by simply pulling the fibre wire and fibre tape suture.

    The separate tip of the lower bio-composite implant is “snugged” down onto the fibre tape at a guessed optimal distance (1). The tension is controlled partly by maintaining tension on the free end of the fibre tape (3) as well as downward pressure exerted from the handle of the introducer.This is an important step in terms of applying appropriate tension to the fibre tape sutures and ensuring they provide an appropriate surface pressure on the achilles.
    It is important that the ankle is placed in the neutral during this particular step.
    The tip of the implant (1) is placed up to the mouth of the bone tunnel but not into it. The tension within the fibre tapes (2) is assessed at this point to see if it is appropriately tensioned.

    Whilst maintaining the tip of the introducer on the outer margin of the cortical bone of the lower bone tunnel the fibre tape is kept under appropriate tension and marked with a pen adjacent to the tip of the bio-composite swiveLock anchor

    Whilst maintaining the tip of the introducer on the outer margin of the cortical bone of the bone tunnel the fibre tape is kept under appropriate tension and marked with a pen adjacent to the tip of the bio corkscrew anchor

    The fibre tape is loosened off on the paddle of the handle to allow the tip of the bio composite implant to move along the fibre tape from it’s old position (1) to its new position as marked with the pen in the previous step (2).Once the tip of the implant is sitting on it’s new position, the fibre tape is anchored back onto the paddle section of the introducer handle under tension (this is shown in the next step).

    The green tip of the bio composite implant is now aligned at it’s new position on the fibre tape (1) and the fibre tape is now placed under appropriate tension and wrapped securely around the paddle handle (2).

    The first few threads of the distal bio-composite anchor are engaged by gently tapping on the handle.

    Tension is maintained on the fibre tape and the distal swiveLock implant is screwed home by holding the paddle and rotating the handle.

    Once the distal swiveLock implant is fully threaded home the fibre tape is released from the paddle, the retention suture is loosened from the handle and the introducer is then disengaged from the implant by gentle traction.A second distal anchor is then placed.

    The remaining fibre tape which is surplus to requirement (1) can now be cut from the implanted bio anchor.

    The same process is repeated for the second anchor.
    The distal (green) tip of the implant is used to tension and guide the fibre tape to the cortical surface of the remaining bone tunnel (1). Once seated in this position and under appropriate tension the length of fibre tape between the green most distal tip and the tip of the main implant (2) is marked on the fibre tape as before.

    The green tip of the implant has been moved to point 2 so that it is in contact with the fibre tape which was in the deepest part of the tunnel.
    The implant is screwed into place with the same technique as before.

    A typical appearance after implantation of the speedbridge.
    At the point marked 1 there is a potential dead space given the removal of a significant amount of bone and also some debridement of some tendon. This should be closed over with the deeper tissue and absorbable sutures as a routine part of the closure.

    The achilles is closed with a heavy gauge Vicryl suture either interrupted or as a continuous closure.

    Skin is closed with an interrupted 3.0 Vicryl suture.

    The lateral X-ray showing significant intra-tendinous calcification (1).

    Operation – 4

    The post-operative image, showing good clearance of the bony component of the pathology.
    Careful inspection also shows evidence of one of the bone tunnels where a SwiveLock implants sits(1).

    Post Operative

    The first two weeks are spent in a lightweight cast, touch weight bearing only.
    After two weeks compliant patients may be transferred into a long post-operative boot and commence progressive weight bearing slowly & carefully using crutches. How quickly weight-bearing progresses (and in fact I sometimes delay it till 4 weeks post-op) depends upon how much of the tendon has been detached from its insertion and the quality of the bone and implant fit.
    Usually by the end of 4 weeks post op it is comfortable to weight-bear just in the boot without the need for crutches.
    From 5 weeks commence weight-bearing physiotherapy rehab (strength & balance) and non-weight bear strengthening and range of motion excercises.
    Static bike may be possible from 5 weeks
    Cross-training may be possible 7 weeks
    Light Full weight bearing jog on treadmill may be possible from 10 weeks
    (sooner on Alter-G treadmill or in pool)
    A return to full and unrestricted sporting activity is very patient dependent but unlikely sooner than 4 months post-operatively( see published results)
    Of upmost importance through-out the post-operative period is that the wound is looked after. Wound infection and small areas of breakdown occur easily in a freshly healed wound that is allowed to rub on socks/shoewear.
    Any exudate from the wound which is allowed prolonged contact with the wound will further excacerbate any skin breakdown. Dressing changes may therefore need to be frequent if such a complication ensues.
    Once out of cast I advise another month of daytime dressings when in shoes and also nocturnal dressings whilst any of the wound remains unhealed
    Showering & bathing is from when out of cast.

    Recommended Reading

    Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy.
    J Bone Joint Surg. 2008.90-A.52-61.
    J.D.Rompe, J.Furia, N Maffuli.
    50 patients treated with either Shock wave or eccentric loading program.
    1/3 had success with the loading program versus 2/3 with the shock wave treatment.
    Haglund’s Syndrome: Disappointing results following surgery-A clinical and radiographic analysis .
    Schneider W, Neihus W, Knhar K.
    Foot & Ankle International January 2000 vol. 21 no. 1 26-30
    49 cases who underwent a resection of the postero-superior portion of the calcaneus with a mean follow-up of 4 years. The clinical results were complete relief in only 34 procedures. This equates to 70% of the cohort which I think is quite impressive given the “bluntness” of the operation in targeting specific symptoms. 7 patients were worse. Rehabilitation took an average of 6 months .
    Calcific insertional achilles tendinopathy :Reattachment with bone anchors.
    Am J sports Med.2004 .32(1):174-82
    Maffuli N,Tesata V, Capasso G,Sullo A.
    21 patients treated operatively as per the technique described in the Atlas. Outcome was graded excellent or good in 2/3 of cases. 5 patients unable to return to previous level of sport .
    Treatment of insertional achilles pathology with dorsal wedge calcaneal osteotomy in athletes
    Foot & Ankle Int 2016. Dec.
    Georgiannos D, Lampridis V, Vasiliadis A, Bisbinas I.
    52 patients who had failed conservative management were followed up for a minimum of 3 years following a dorsal closing wedge calcaneal osteotomy performed through the superior aspect of the Calcaneus. No direct surgery to the Achilles itself. The results were rated as excellent in 73%. The time on average required to return to sport is noted as 21 weeks.
    Operative treatment of insertional achilles tendinopathy through a transtendinous approach
    Foot & Ankle International March 2016 vol. 37 no. 3 288-293
    Ettinger S et al
    Forty patients (failed conservative treatment) operated upon using a trans-tendinous approach, debridement of pathological tissues and reattachment of Achilles with suture anchors. Over 80% had either good or excellent results.

    Reference

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