Zadek Osteotomy for Insertional Achilles Tendonitis: Benefits, Recovery, and Who May Be a Candidate
What Is a Zadek Osteotomy?
Persistent pain at the back of the heel can make walking, exercising, and even wearing certain shoes uncomfortable. When this pain is caused by insertional Achilles tendonitis, traditional treatments may not always provide lasting relief.
For patients who continue to experience symptoms despite appropriate nonsurgical treatment, a Zadek osteotomy may be an effective surgical option.
A Zadek osteotomy, also called a dorsal closing wedge calcaneal osteotomy or Keck and Kelly osteotomy, is a procedure that changes the shape and position of part of the heel bone (calcaneus). Unlike traditional surgery that may require extensive detachment and reattachment of the Achilles tendon, the Zadek procedure can address the mechanical forces contributing to insertional Achilles tendon pain while potentially preserving the Achilles tendon attachment.
Research has found significant improvements in pain and functional scores following Zadek osteotomy in patients with insertional Achilles tendinopathy.
Understanding Insertional Achilles Tendonitis
The Achilles tendon connects the calf muscles to the heel bone. Insertional Achilles tendinopathy occurs where the Achilles tendon attaches to the back of the heel.
It is different from mid-portion Achilles tendinopathy, which affects the tendon farther above the heel.
Insertional Achilles tendonitis may be associated with:
Chronic pain at the back of the heel
Pain when walking or running
Tenderness where the Achilles tendon meets the heel bone
Stiffness, particularly after periods of rest
Swelling or thickening around the Achilles tendon
Pain when wearing shoes that press against the back of the heel
A bony prominence known as a Haglund's deformity
Retrocalcaneal bursitis
Insertional Achilles tendinopathy is often a degenerative condition rather than simply inflammation. Because of this, treatment may require more than simply reducing activity or taking anti-inflammatory medication.
How Does a Zadek Osteotomy Work?
The goal of a Zadek osteotomy is to change the geometry of the calcaneus and reduce mechanical stress and impingement around the Achilles tendon insertion.
During the procedure, the surgeon creates a controlled dorsal closing wedge osteotomy in the heel bone. Removing and closing this wedge changes the shape of the calcaneus and can shorten and reposition the posterior portion of the heel.
This may reduce the mechanical conflict between the Achilles tendon and the back of the heel and decrease tension on the diseased portion of the tendon.
One important potential advantage is that the procedure can be performed without routinely requiring complete detachment of the Achilles tendon from the heel bone.
What Are the Benefits of a Zadek Osteotomy?
1. It Can Reduce Chronic Heel Pain
One of the primary goals of surgery for insertional Achilles tendinopathy is to relieve persistent pain.
A 2023 systematic review and meta-analysis involving 10 studies and 232 patients found that pain levels significantly improved following Zadek osteotomy.
For patients who have dealt with chronic posterior heel pain despite conservative treatment, this can be a significant potential benefit.
2. It May Improve Achilles Tendon Function
Pain isn't the only issue associated with insertional Achilles tendinopathy. Patients may also experience reduced strength, difficulty exercising, and limitations in everyday activities.
Studies evaluating Zadek osteotomy have demonstrated improvements in functional measures, including the VISA-A (Victorian Institute of Sport Assessment–Achilles) and AOFAS scores.
In one systematic review, the weighted mean VISA-A score improved from 52.7 before surgery to 87.8 after surgery, while the weighted mean AOFAS score improved from 56.3 to 92.9.
3. It May Address the Mechanical Cause of Symptoms
Insertional Achilles problems can be influenced by the shape of the heel bone and the way the Achilles tendon interacts with it.
A Zadek osteotomy changes the orientation of the calcaneus and Achilles tendon mechanics. This can help decrease impingement and stress at the tendon insertion rather than simply treating the symptoms of the condition.
This is one reason the procedure can be particularly interesting for patients with insertional Achilles tendinopathy associated with a Haglund's deformity.
4. The Achilles Tendon May Not Need to Be Fully Detached
Traditional surgery for severe insertional Achilles tendinopathy can involve removing damaged tendon tissue, removing a portion of the heel bone, and partially or completely detaching and then reattaching the Achilles tendon.
Depending on the patient's anatomy and the surgical technique being used, a Zadek osteotomy may allow treatment of the underlying mechanical problem without extensive Achilles tendon detachment.
Preserving the tendon attachment may be beneficial because it can potentially simplify the surgical reconstruction and rehabilitation process.
However, the best procedure depends on the severity of the tendon damage, the patient's anatomy, the presence of a Haglund's deformity, and other individual factors.
5. It May Offer an Alternative to Traditional Achilles Tendon Reconstruction
Not every patient with insertional Achilles tendinopathy needs extensive tendon debridement and reconstruction.
For appropriately selected patients, a Zadek osteotomy can provide another surgical option.
A 2024 systematic review comparing open and percutaneous Zadek osteotomy found improvements in pain and functional outcome measures with both approaches. The authors noted that percutaneous Zadek osteotomy is an emerging technique, but that more research is needed because substantially fewer patients have been studied with the minimally invasive approach.
Who May Be a Candidate for a Zadek Osteotomy?
A Zadek osteotomy is generally considered for patients with persistent insertional Achilles tendinopathy who have not improved with appropriate nonsurgical treatment.
Depending on the individual patient, conservative treatment may include:
Activity modification
Physical therapy
Calf and Achilles stretching and strengthening
Appropriate footwear
Heel lifts or orthotics when indicated
Other physician-directed treatments
Surgery is generally considered only after an appropriate course of nonsurgical treatment has failed.
The decision to perform a Zadek osteotomy requires a thorough examination and appropriate imaging. Your foot and ankle specialist will evaluate the condition of your Achilles tendon, the shape of your heel bone, and whether a Haglund's deformity or other structural problem is contributing to your symptoms.
Zadek Osteotomy vs. Traditional Achilles Surgery
There is no single surgical procedure that is right for every patient with insertional Achilles tendinopathy.
Traditional surgery may involve removal of diseased Achilles tendon tissue, removal of a Haglund's prominence, and Achilles tendon reattachment. This can be appropriate when there is significant tendon degeneration or other structural pathology.
A Zadek osteotomy takes a different approach by modifying the calcaneus to change the mechanics around the Achilles insertion.
The potential advantages of a Zadek osteotomy include:
Addressing the mechanical source of irritation
Potentially preserving the Achilles tendon attachment
Avoiding extensive tendon detachment in appropriately selected patients
Improving pain and function
Providing an alternative to more extensive Achilles tendon reconstruction
Your surgeon can determine which approach is most appropriate based on your symptoms, imaging, tendon quality, and activity goals.
What Does Recovery From a Zadek Osteotomy Look Like?
Recovery varies from patient to patient and depends on the surgical technique, bone healing, tendon condition, and individual health factors.
Because a Zadek osteotomy involves cutting and repositioning the heel bone, patients need to allow adequate time for the osteotomy to heal.
Your postoperative plan may include:
Protection of the surgical site with a splint or boot.
Restricted weight-bearing during the initial healing period, depending on your surgeon's protocol.
Gradual progression of weight-bearing as the bone heals.
Physical therapy to restore ankle mobility, calf strength, balance, and function.
Gradual return to exercise and sports once adequate healing and strength have been achieved.
It is important to understand that even when a minimally invasive approach is used, a Zadek osteotomy is still a bone-healing procedure. Recovery should therefore be individualized rather than based on an aggressive return-to-activity timeline.
Are There Risks With Zadek Osteotomy?
As with any surgery, a Zadek osteotomy carries potential risks.
Published studies have reported complications including wound problems, temporary or persistent sensory changes involving the sural nerve, symptomatic hardware, nonunion, deep vein thrombosis, and other complications.
A systematic review and meta-analysis of 232 patients reported 22 complications, which the authors characterized as minor, with superficial wound infection and sural nerve paresthesia among the most commonly reported.
It's also important to recognize the limitations of the current evidence. Much of the published research consists of retrospective or prospective observational studies, and there are not yet well-designed randomized controlled trials directly comparing Zadek osteotomy with other surgical treatments for insertional Achilles tendinopathy.
Your foot and ankle surgeon can discuss the potential benefits and risks based on your individual condition.
When Should You See a Foot and Ankle Specialist?
If pain at the back of your heel has persisted despite rest, activity modification, physical therapy, and other conservative treatments, it may be time for a more detailed evaluation.
An accurate diagnosis is important because posterior heel pain can have several causes. Imaging and a physical examination can help determine whether your symptoms are related to insertional Achilles tendinopathy, a Haglund's deformity, bursitis, a partial Achilles tear, or another condition.
If surgery becomes necessary, there are several possible approaches. A Zadek osteotomy may be an excellent option for appropriately selected patients, particularly when the mechanics of the heel are contributing to chronic insertional Achilles pain.
Find Out If a Zadek Osteotomy Is Right for You
Chronic insertional Achilles tendonitis can interfere with everything from walking and working to running and participating in the activities you enjoy.
Fortunately, advances in foot and ankle surgery have expanded the treatment options available to patients who do not respond to conservative care. The Zadek osteotomy offers a unique approach to treating insertional Achilles tendinopathy by changing the mechanics of the heel while potentially preserving the Achilles tendon attachment.
If you have ongoing Achilles pain or a painful bump at the back of your heel, a comprehensive evaluation can help determine the cause of your symptoms and identify the most appropriate treatment options.
Schedule an evaluation with Greenville's foot and ankle specialists to learn whether a Zadek osteotomy or another treatment approach may be appropriate for your Achilles tendon condition.
Frequently Asked Questions About Zadek Osteotomy
Is a Zadek osteotomy the same as Achilles tendon surgery?
A Zadek osteotomy is a type of foot and ankle surgery used to treat insertional Achilles tendinopathy. Unlike some traditional procedures, it focuses on changing the mechanics and shape of the calcaneus rather than routinely requiring extensive detachment and reconstruction of the Achilles tendon.
Does a Zadek osteotomy treat Haglund's deformity?
A Zadek osteotomy can be used in patients with insertional Achilles tendinopathy and an associated Haglund's deformity. Whether it is the best treatment depends on the individual's anatomy and the extent of tendon and bone involvement.
How successful is a Zadek osteotomy?
Published studies have generally reported significant improvements in pain and function after the procedure. However, much of the available evidence comes from observational studies, so individual outcomes can vary and more high-quality comparative research is needed.
Can a Zadek osteotomy be performed minimally invasively?
Yes. Percutaneous and minimally invasive Zadek osteotomy techniques have been described. Current research is encouraging, but the minimally invasive literature is smaller than the body of research on open procedures.
Is a Zadek osteotomy right for everyone with Achilles tendonitis?
No. Treatment should be individualized. Many patients with Achilles tendinopathy improve with nonsurgical treatment, while others may require a different surgical procedure depending on the amount of tendon degeneration, heel anatomy, and other factors.
