Disorders of the posterior heel may present at any age. The multitude of posterior heel problems include retrocalcaneal and pretendinous bursitis, Achilles tendonitis, retrocalcaneal exostosis and Haglund’s deformity. It is essential to consider each of these disorders as a separate entity and, although they often occur in combination, each entity requires a separate course of therapy.
When it comes to disorders of the Achilles tendon (see “A Review Of Anatomical Insights” below), the greatest number of papers are associated with noninsertional tendonitis. There is minimal independent literature dealing with insertional tendonitis. In general, conservative and surgical treatment of insertional Achilles tendonitis did not fare as well as treatment for noninsertional tendonitis.
It is possible to have mild insertional tenderness of the Achilles tendon. However, when it comes to true Achilles tendonitis associated with degeneration of the tendon, one will not see this without an associated calcaneal deformity such as Haglund’s deformity or retrocalcaneal exostosis.3 The histologic changes associated with insertional Achilles pain are similar to those in the noninsertional cases. However, there is often associated ossification of the tendon and degenerative cystic changes of the tendon in the region of ossification.3
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Common presenting factors for posterior heel pain are related to shoe gear changes and difficulty with finding properly fitting shoes. In cases of Haglund’s deformity, the pain may be instigated by shoe gear changes associated with the start of a professional career. The change to hard posterior heel counters leads to inflammation of the tendon and bursal projections against the enlarged posterior heel tubercle leading to pain.
In the case of retrocalcaneal exostosis, the pain is associated with chronic strenuous activity. This tends to result in progressive degeneration of the Achilles insertion, bony prominence and replacement of the posterior insertion site of the Achilles tendon with a bony prominence. Chao studied this prominence and found it to be larger in size than what was shown on radiographs as it extended from the medial to lateral posterior border of the insertion site.1 Whereas the typical Haglund’s deformity patient is young and active, the retrocalcaneal exostosis patient is often middle-aged and inactive. He or she will usually have a sedentary job and lifestyle as well.
In both cases of posterior calcaneal deformity, you will note pain with direct pressure on the posterior calcaneus from shoe gear. Often, the patient will say the pain is worse with prolonged ambulation, walking or running on hills and hard surfaces. The pain is localized to the insertion site of the tendon. In cases of Haglund’s deformity, you will note edema and pain in the posterior lateral region of the heel with or without associated bursal inflammation. The bursal inflammation is secondary to pinching between the Achilles and prominent heel region.
In retrocalcaneal exostosis cases, there may be no pain associated with the enlarged heel region yet the patient may often note increased pain with increased mileage and uphill ambulation. Often, you will find the pain is palpable with medial and lateral pinching of the distal tendon insertion or direct pressure of the retrocalcaneal spur region. The pain dramatically increases if a portion of the retrocalcaneal spur detaches within the tendon substance. If this occurs, there is tenderness associated with the loose body rubbing against the posterior heel region, resulting in inflammation.
You will note an underlying equinus in many cases and with forced dorsiflexion of the tendon, there is tenderness and pain in inflamed cases of insertional tendonitis with or without retrocalcaneal exostosis. With dorsiflexion of the ankle, the bursal sack is forced between the Achilles tendon and posterior heel, resulting in increased pain. Although it is difficult to identify the bursal inflammation in association with retrocalcaneal pain, direct lateral and medial pressure along the edges of the posterior Achilles just proximal to its insertion site will place pressure on the bursal projection, resulting in pain and a sense of fullness within the bursa.