After other treatments have failed, patients with insertional Achilles tendinopathy (IAT) may need surgery. The traditional open Achilles debridement requires an incision of up to six centimeters on the back of the heel and nine months to a year of recovery. In recent years, minimally invasive techniques have been developed to shorten recovery without sacrificing outcomes.

Recent longitudinal analysis confirms that the minimally invasive Zadek osteotomy (ZO) is equally effective as traditional open surgery. “In our two-year post-surgery data, we found that 96% of patients would opt for the procedure again,” says Jonathan Robert Manning Kaplan, MD, foot and ankle orthopaedic surgeon with Duke Health. “These patients are seeing decreased pain, and they’re able to return to daily activities and remain active.”

IAT, involving inflammation and microtears of the Achilles tendon, typically presents with post-heel pain during normal activity. Nonsurgical options are the first line of treatment, including physical therapy, orthotics such as heel lifts, and NSAIDs. Approximately 70% of patients with IAT improve with nonsurgical treatment.

For the 30% of patients with continued pain after nonoperative care, surgery is usually the next step. “When I meet with patients at this stage,” says Kaplan, “I explain their options thoroughly, including the ZO. Often with the minimally invasive choice, patients are more amenable to surgery.”

Unlike traditional open surgery, the ZO involves small, three- to four-millimeter incisions in the side of the heel. The surgeon rotates the calcaneus bone, attached to the Achilles tendon, to relieve tension on the tendon. After surgery, patients are typically nonweightbearing in a boot for two weeks before they’re able to walk again and begin returning to activities.

“Almost all patients with IAT or Haglund’s syndrome who have failed nonoperative treatments are candidates for the Zadek,” says Kaplan. “Only factors which would limit healing or being unable to sustain any period of nonweightbearing preclude the ZO.”

Kaplan encourages early referral for patients with IAT. “Referring early allows us to establish timelines with patients so they understand they have options,” he says. “Conversely, if you’ve tried nonsurgical treatments and your patient still has pain, it’s reasonable to refer then as well.”

“Duke Health has a high level of patient care throughout our facilities, including our teams in foot and ankle, both clinics, and surgery,” says Kaplan. “Advancing procedures and patient outcomes is a key part of our mission at Duke, especially through minimally invasive procedures to help patients get back to activities faster.”