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. 2025 Jul 24;12(3):e70374.
doi: 10.1002/jeo2.70374. eCollection 2025 Jul.

Endoscopic versus open surgery for insertional achilles tendinopathy: A systematic review and meta-analysis of comparative outcomes

Po-Yuan Chen  1 , I-Shiang Tzeng  2 , Kai-Chiang Yang  1   3 , Chen-Chie Wang  1   4
Affiliations

Endoscopic versus open surgery for insertional achilles tendinopathy: A systematic review and meta-analysis of comparative outcomes

Po-Yuan Chen et al. J Exp Orthop. .

Abstract

Purpose: Insertional Achilles tendinopathy (IAT) causes chronic hindfoot pain and functional impairment. Although conservative treatment remains the first-line management approach, surgery is often necessary when nonoperative measures fail. Both open and endoscopic techniques are commonly used, but their comparative efficacy remains debated. Accordingly, this meta-analysis compared surgical outcomes, complications and recovery between open and endoscopic techniques; it also conducted a subgroup analysis to assess return to sports in highly active individuals.

Methods: A systematic literature search was conducted in PubMed, the Cochrane Library, Scopus, ScienceDirect, Web of Science and Embase (2003-2024). Studies were included if they reported outcomes for open or endoscopic IAT surgery with ≥20 patients and ≥6 months of follow-up. Outcomes included the American Orthopaedic Foot and Ankle Society (AOFAS) scores, time to return to sports, complication rates and additional functional outcome measures.

Results: Thirty-nine studies (1559 patients, 1625 procedures) were included. Mean AOFAS scores improved from 56.07 to 89.17 (p < 0.001), with no significant difference between surgical techniques (p = 0.18). However, endoscopic surgery was associated with a lower complication rate and faster recovery, enabling earlier return to daily activities (6.75 ± 2.25 vs. 22.45 ± 4.74 weeks, p < 0.001) and sports (12.63 ± 2.2 vs. 22.13 ± 7.42 weeks, p < 0.001). Among highly active individuals, endoscopic surgery facilitated return to sports within 12-18 months, whereas open surgery required 20-30 months.

Conclusions: Endoscopic surgery demonstrates a low complication rate and expedited recovery, making it a preferable option for patients requiring an early return to activity. More high-quality studies, such as randomized controlled trials and standardized protocols, are needed to improve surgical decisions and treatment strategies for IAT.

Level of evidence: Level IV.

Keywords: Haglund's deformity; Haglund's syndrome; endoscopic; insertional Achilles tendinopathy; retrocalcaneal bursitis.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Prisma flow diagram for study selection.
Figure 2
Figure 2
Forest plot of change between pre‐OP and post‐OP in open and endoscopic surgical intervention. CI, confidence interval; IV, intravenous; post‐OP, post‐operative; pre‐OP, preoperative; SD, standard deviation.
Figure 3
Figure 3
One‐study‐removed sensitivity analysis for functional improvement in the endoscopic surgery group. CI, confidence interval.
Figure 4
Figure 4
One‐study removed the sensitivity analysis for functional improvement in the open surgery group. CI, confidence interval.
Figure 5
Figure 5
Mean time (weeks) return to daily life post‐operatively after open and endoscopic surgery.
Figure 6
Figure 6
Mean time (weeks) return to sport post‐operatively after open and endoscopic surgery.
See this image and copyright information in PMC

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