Partial insertional Achilles tear--how does this heal?

I have a similar running background & training volume as you and had an Achilles tear a few years ago due to a freak accident not running related. I am not a medical expert so listen to the doctors but I will provide my input based on my experience. I could walk completely pain free even on the day of the tear but couldn’t take a single step running without intense pain, very infuriating.

The biggest thing that the doctors taught me is that the Achilles stretches a little bit while walking and a lot while running and jumping. The doctors put me in a boot because those tiny tugs on the fibers while walking slows down the recovery process because you’re stretching the torn fibers. The boot mitigates most of the Achilles stretch while walking. Before putting on the boot the Achilles would be trying to repair itself while I was making microscopic tears by walking which was inhibiting my ability to recover. I had to suck it up and spend 2 months in the boot. This was the key to my recovery but your situation may be different as no 2 injuries are exactly alike.

Cross train in as Achilles-friendly of a manner as you can to maintain fitness. I biked with the boot on which is probably not recommended. Ask a PT for recommendations.

Thank you very much for your response. I am just like you in terms of being able to walk completely fine throughout this whole injury.

I have not given a super serious long-term time in the boot much of a chance. I suppose I'm most scared of sitting around doing nothing for 2 months, then taking the boot off and seeing no improvement. It would feel like a wasted 2 months, and given how little of an effect resting has seemed to have so far, it seems like a decent possibility.

That being said, how did you feel when you got out of the boot? No pain and you just had to ease back in to loading and running? Or was the issue still there to some extent and you had to work through it? What was that process like? Cheers.

Sounds like you are on the right track with progressively loading the tendon. I can't post links but I'd recommend searching Jill Cook & Ebonie Rio separately on Youtube and watching those lectures.

I've been dealing with an insertional injury for roughly 2 years now but it may be a bit different to you (not sudden onset etc) since I do have a minor case of haglunds deformity also which I think causes irritation in that area. Originally I had the issue in both heels also but my right heel is the only one I'm struggling with still. For me personally doing isometrics and increasing load on the tendon is the only thing that has really helped (and perhaps increasing the drop in my shoes to 8mm), but longer periods of rest doesn't seem to address the issue at all. Also did a ton of eccentric heel drops which didn't have any noticeable impact.

Achilles help wrote:

.... I suppose I'm most scared of sitting around doing nothing for 2 months, then taking the boot off and seeing no improvement. It would feel like a wasted 2 months. ......

Food for thought: if you take the boot off after 2 months and it still hurts, then you know it definitely wasn't going to stop hurting without the boot. So you wouldn't have wasted the two months because of the boot, it would have been wasted either way. If the boot doesn't work, it means surgery or giving up running forever are your only two realistic options, unless you believe prayer is a realistic option...

Tendons show healing for up to 2 years! The bulk of the healing takes a full 6 months, with the rest of the healing being mostly reorganization of the fibers and maturation of fiber types. This is not a short term injury. Remove all expectations of a quick fix from your mind. You need to think long term. If this goes poorly, you'll be having pain with walking for the rest of your life, running won't be your motivation to feel better at that point.

Btw, there is essentially no research to support eswt for insertional Achilles tears. Same with PRP. Those both have very limited evidence to suggest they help anywhere, but essentially none for this injury. That being said, it likely didn't hurt you at all.

Earlier you wrote "it isn't clear what surgery could do." They'd have two possible courses of action: 1) anchor the torn fibers to the rc, likely after shaving away some bone, so they're able to heal at the correct attachment point 2) trim away the torn fibers with no attempt at reattached.

1 would be if enough of the Achilles is torn that they are concerned it could rupture without that section healing. Also, it requires the tear to be "clean" enough to reattach. In a full rupture, this is almost never the case, it almost always requires a portion of the Achilles to be flipped down to replace the torn fibers.

2 would be if only a small section was damaged, so you will have enough integrity without it. This will remove the source of inflammation, which not only remove the pain over the course of weeks, but also prevents you from entering a cycle of chronic inflammation, which results in degradation of the tendon over time

Speak with your surgeon about options. He or she should be able to look at the ultra sound and have some idea of the extent of the damage. See if the boot is an option. The 2 months in the boot won't be the end of that process, though, you're really looking at a 6 month protocol. Boot with lifts, boot with no lifts, then shoes with lifts, then shoes with no lifts, with PT starting partway through that. Running shouldn't resume until maybe the 4 month mark.

Thank you holterskolter2 for this excellent reply. It is supremely helpful. I will say a few things:

1. I'm not sure it's necessarily true that if the boot and rest doesn't work, then no boot was certain not to work either. There are many injuries that take work and PT to get better, but don't respond well to rest. That being said, I'm not discounting your point. I think it does provide a strong data point that can inform future treatment.

2. Appreciate the sobering point about the length of recovery. I probably will need to adjust my expectations.

3. In terms of ESWT, I had it done before when I had this same injury (partial tear at the insertion my sophomore year) and it worked like a charm. After 8 weeks of PT I was back training and competed at NCAAs that fall. However I've read papers saying it's only marginally more effective than the Alfredson protocol. In terms of PRP, I know, I'm not convinced by the science much either. But a family friend offered to do it on the cheap, and given the anecdotal successes I'd read, it seemed worth a shot.

4. I am most thankful for your insights about the surgical options available. This is exactly what I was looking for, and both procedures make sense. I'll talk with my doctor about the potential for surgical success.

5. I bought a lift today for my boot. Hope it helps.

Thanks so much again. Cheers