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.