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 What You Can Learn From The Exam 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. How And When You Should Use Diagnostic Studies Quite often, there is minimal need for excessive diagnostic studies. The most common study performed is a lateral radiograph. A weightbearing lateral radiograph shows a prominent posterior superior tubercle. Although various methods of evaluation for Haglund’s deformity are possible, the most common and most easily reproduced method is the parallel pitch line technique.4-7 You would perform this technique by drawing a line of the plantar aspect of the calcaneus and a second line from the posterior talar articulation parallel to the plantar calcaneal line. Any protrusion above this upper line is considered a prominent posterior calcaneal tubercle. In the case of retrocalcaneal exostosis, you should use a lateral radiograph to diagnose the size and extent of the exostosis. If you can’t easily identify the width of the exostosis with your examination, you may obtain a modified calcaneal axial image with the patient standing on the involved foot in maximal dorsiflexion. While the foot is maximally dorsiflexed at the ankle by anterior shift of the leg over the foot, position the X-ray tube posterior to the foot at 90 degrees and obtain a direct dorsal to plantar projection. One can use this to get a better view of the fragmentation and size of the exostosis. One may perform further evaluation via magnetic resonance imaging (MRI) or diagnostic ultrasound. I only use these studies in cases of associated tendon or bursal irritation. MRI is generally the most utilized technique and a good radiologist with foot and ankle experience can easily identify bursal and tendinous irritation. Ultrasound is my preferred imaging technique as it is a cheap in-office procedure. With a sound knowledge of ultrasound techniques, you can rapidly visualize bursal inflammation and tendon disorders. It has been my experience that ultrasound imaging of the retrocalcaneal exostosis allows for proper diagnosis of the exostosis size and width, and the quality of surrounding tendon and bursal involvement prior to surgical intervention. Furthermore, you may perform a dynamic study with motion of the foot during the study. Doing so allows you to see the exostosis against the tendon and any other irritation factors on the tendon. What You Should Know About Conservative Therapy Nonoperative care of both retrocalcaneal exostosis and Haglund’s deformity rely heavily on antiinflammatory measures. These include physical therapy, antiinflammatory medication and, in persistent cases, casting possibly with a one-time, phosphate-based cortisone injection into the retrocalcaneal bursal region during the casting period. In the case of Haglund’s deformity, employing shoe modifications and using a lubricating agent, such as petroleum jelly, on the inflamed region is very helpful. It may also be helpful to emphasize an orthotic device that adjusts the position of the calcaneal exostosis and decreases the pull of the Achilles tendon on the rear projection. Retrocalcaneal exostosis therapy is far more difficult with conservative measures. I have found that a stable orthotic, which decreases excess rearfoot motion and is well posted, decreases the pain associated with the pull of the Achilles tendon. However, this is only successful in 60 percent of cases at best. Conservative care with heel lifts and physical therapy is very short term and often the patient will become frustrated, requesting a second opinion. Pertinent Surgical Pearls For Haglund’s Deformity The surgical therapy for Haglund’s deformity is straightforward with only two simple cautions. One must be sure not to end the exostectomy prior to reaching the medial aspect of the calcaneus. By leaving behind the medial portion of the calcaneus, one runs the risk of added irritation and pain. A second important point is to remove enough bone and round off the remaining calcaneus in order to have a soft curvature without any associated rough regions that could irritate the bursa or tendon. When performing a Haglund’s deformity exostectomy, one would begin with a 3 to 4 cm lateral incision that is just lateral to the Achilles tendon and positioned over the posterior calcaneal projection. Deepen the incision while protecting the lateral sural nerve. In certain cases, you may find an inflammed pretendon bursa, which you should remove. Proceed to perform minimal medial reflection of the Achilles tendon in order to visualize the projection. You may use a sagittal saw or osteotome to remove the involved projection of bone. Use a reciprocating rasp or hand rasp to remove any remaining rough regions and round off the posterior calcaneal tubercle. If there is an associated enlarged or irritated retrocalcaneal bursa, you can easily see and remove it at this point. Reapproximate the tendon with an absorbable suture and close the skin with your choice of technique and suture. Apply a cast and emphasize no weightbearing for two weeks. Afterward, the patient may proceed with guarded weightbearing and physical therapy for the next three weeks. Let your patients know that a return to full activity oftentimes requires three months of recovery with associated swelling of the region for up to six months. How To Treat Younger Athletes With Retrocalcaneal Exostosis The surgical treatment of retrocalcaneal exostosis is very age-dependent. In the young, athletic patient, the amount of spur formation is often minimal. However, there are three involved symptomatic issues that require treatment. These include a small retrocalcaneal exostosis, a Haglund’s deformity and an inflamed retrocalcaneal bursa. The treatment does not require extensive detachment of the Achilles tendon and incision placement is critical. I prefer to make a “J” incision along the medial aspect of the Achilles tendon, curving it laterally at the level of the retrocalcaneal exostosis. Place the transverse portion of the incision in a skin line and it virtually disappears with proper wound closure. Proceed to detach the Achilles tendon minimally at its medial border and remove the Haglund’s deformity and retrocalcaneal bursa. Under fluoroscopic guidance, you should see the distal exostosis. Make a small transverse incision directly over the exostosis, allowing for complete resection of the region. It is rarely necessary, but you may use a bone anchor to reattach the tendon. Perform closure with absorbable suture for tendon repair and close skin as desired. One should emphasize cast protection and nonweightbearing for two weeks followed by guarded ambulation in a removable boot and physical therapy. A return to full activity often requires three months of recovery with associated swelling of the region for up to six months. Key Pearls For Treating Older, Minimally Active Patients With Retrocalcaneal Exostosis The most difficult patient to treat and the patient with the most complicated surgical treatment is a patient who is typically minimally active and over the age of 50. This patient has years of accumulated retrocalcaneal exostosis that may extend into the tendon, resulting in very poor Achilles tendon quality. When treating these patients, I utilize an “S” incision with a medial proximal extension and a lateral distal extension. I make the transverse portion of the incision at the region of greatest exostosis near the distal Achilles insertion site. An alternate incision is a straight central incision. Full thickness flaps are raised and, in the case of the “S” incision, I prefer to fold and tack the skin down so there is minimal strain to the skin during the remaining procedure. One would make a central incision full thickness into the Achilles tendon. Raise medial and lateral tendon flaps to the medial and lateral calcaneal borders. Take care not to fully detach the tendon. Perform complete resection of the Haglund’s deformity, retrocalcaneal bursa and retrocalcaneal exostosis. Use fluoroscopy to check the full removal of all exostoses as it is easy to miss the distal region of prominence, which would result in continued pain and a failed surgery. Debride the Achilles tendon of any degenerative regions and any intratendinous bone. If you find the tendon to be of poor quality, I highly suggest performing a flexor hallucis tendon (FHL) transfer to the posterior calcaneus. This allows for less strain and better function of the Achilles tendon during push-off. One may harvest the flexor tendon through the posterior incision via deep dissection of the posterior quadrant and distal dissection of the FHL tendon as far distally along the medial calcaneus as possible. Pass the harvested tendon through the calcaneus and either tie it onto itself or place it into the calcaneus and hold it in place with a tendon transfer system of your choice. Reapproximate the Achilles tendon with two bone anchors stacked on the posterior calcaneus. Utilize the proximal anchor to pull the tendon distally and hold the majority of the tendon in position. Use the distal anchor to reattach the distal tendon to the calcaneus. Close the superficial tendon with an absorbable suture and close the skin flaps with your choice of suture and technique. In cases of severe gastrocnemius equinus, I will sometimes lengthen the gastrocnemius tendon at the same time as the retrocalcaneal surgery. Be careful to make sure the equinus is not secondary to a forefoot equinus and is a true rearfoot issue. Also take care to avoid an early return to weightbearing. I will keep the patient nonweightbearing for six weeks and not bring the foot to full dorsiflexion for four of those weeks. At four weeks, the patient may begin physical therapy followed by guarded weightbearing for an additional four to six weeks. Strengthening of the Achilles and transferred tendon require two to three months of physical therapy for best results. Caution patients that a return to unrestricted activity often takes six months and there is mild pain and swelling for six months to one year. Final Notes Although there is not much literature on the surgical treatment of insertional Achilles tendon deformities, the results are often excellent. In most cases, several underlying factors contribute to pain, thus requiring a thorough workup. In cases of prolonged retrocalcaneal exostosis and an older patient, results vary widely and often extensive tendon degeneration leads to these poor results. It has been my experience that performing an FHL tendon transfer substantially improves the results in these difficult cases and patient satisfaction is much better. When one emphasizes an adequate examination and proper use of diagnostic studies, proper surgical planning and implementation, and post-op physical therapy, results are often good to excellent with relief of pain and a return of the patient to full and unrestricted activity. Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine and is the Co-Director of the Foot and Ankle Institute of Santa Monica. He is a Fellow of the American College of Foot and Ankle Surgeons.
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