How To Master Posterior Heel Disorders

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A Review Of Anatomical Insights

The Achilles tendon, posterior calcaneus, retrocalcaneal bursa and pre-Achilles tendon bursa are the anatomic structures representing the posterior heel. The Achilles tendon is composed of the medial and lateral heads of the gastrocnemius muscles in combination with the soleus muscle. These muscles combine distally to form the Achilles tendon. The Achillies tendon crosses three joints: the knee, the ankle and the subtalar joint.

Therefore, it is essential to consider Achillies tendon equinus with both the straight leg and bent leg examinations. If the tendon is tight during the straight leg and bent leg examinations, the patient has an ankle equinus. On the other hand, if there is adequate motion of the ankle joint with the knee bent, the Achillies tendon is not the tight structure and the gastrocnemius muscle is the site and cause of the equinus deformity.

Chao studied the insertion of the Achilles tendon extensively.1 He found in his study of 17 specimens that the tendon insertion was in the middle third of the posterior calcaneal tuberosity. He also noted that the tendon did not have significant medial or lateral extension. The average distance from the dorsal tuberosity was 9.97 mm with a 19.83 mm length of insertion. Chao also found that the greater extension of insertion was on the medial aspect of the joint.

The calcaneal bursa is horseshoe-shaped and is 4 mm deep, 22 mm long and 8 mm wide at its central region.2 It is meant to be a protective and soft surface on the anterior surface of the Achilles tendon. There is a second bursa posterior to the Achilles in the pre-tendon region. This pretendinous bursa is also meant to be a lubricating structure.

In certain cases, the posterior dorsal aspect of the calcaneus may be enlarged, resulting in a prominent bony region which is often on the lateral aspect of the posterior calcaneus. This is referred to as a Haglund’s deformity.

Here one can see Achilles tendonitis/tendinosis without calcaneal involvement.
Here is a typical presentation of retrocalcaneal exostosis with an enlarged posterior tubercle and thickened insertion of the Achilles tendon insertion site.
Here is a view of intratendinous calcifications of the Achilles tendon secondary to chronic microtears.
Here one can see exposure of the posterior deep quadrant and the flexor hallucis longus tendon.
One can see the transfer of the tendon into the posterior calcaneus. A tendon transfer plug is currently the preferred tendon transfer technique.
One can perform a gastrocnemius tendon lengthening in combination with retrocalcaneal exostectomy in order to decrease posterior pull of the Achilles on the heel region.
By Babak Baravarian, DPM

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.

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