Current Concepts In Retrocalcaneal Heel Spur Surgery
Retrocalcaneal heel pain, also known as insertional Achilles tendinopathy, can occur in both sedentary and athletic populations. Accordingly, this author offers a primer on posterior heel anatomy and insights on conservative and surgical management in these patient populations.
Achilles tendon disorders are a common complaint of patients presenting to the foot and ankle specialist’s office. While plantar heel pain tends to garner greater attention due to its prevalence, posterior heel pain is often more debilitating for the patient and challenging for the treating physician.
Retrocalcaneal heel pain or insertional Achilles tendinopathy may occur as a single entity but more frequently occurs with other posterior heel disorders such as retrocalcaneal bursitis, Haglund’s deformity and subcutaneous (pretendinous) tendo-Achilles bursitis. DeOrio and Easley feel the term “tendinopathy” should be applied to the clinical diagnosis and one should only utilize the terms “tendonitis” and “tendinosis” when making a histologic confirmation of specific tendon pathology.1
Traditionally, physicians thought Achilles tendinopathy occurred with overuse, causing microtrauma at a degree and frequency at which the tendon can no longer heal and leading to mechanical breakdown of the tendon.2 Researchers and clinicians have studied various factors that may influence the development of tendinopathy such as training mileage, rest periods between runs, anatomic alignments of the lower limb and biomechanical factors. Researchers have also looked at footwear to determine its role in the development of the condition. Further confusion as to the etiology arises because tendinopathy commonly occurs in individuals who are relatively inactive.3
What To Look For In The Clinical Presentation
In clinical practice, there are two distinct groups of patients that present with posterior heel pain. The first group is the older, sedentary and often obese patients with women more commonly affected than men. They will report pain and stiffness that is worse after a period of rest. Initially this pain will resolve after a short period of walking. This problem is likely an acute process in the beginning and patients often report that they initiated stretching exercises or ice therapy. Other patients ignore the problem, assuming it will resolve on its own.
As the problem evolves, the pain may lessen in its intensity when the patient walks but will usually not resolve. Patients will often cite the disability associated with this pain as a cause of weight gain as they are unable to exercise. Their inactivity would suggest that the problem is due to degenerative changes within the tendon along with irritation over the osseous protuberance. (See “A Guide To Posterior Heel Anatomy” on page 44.)
Over time, the clinical picture often changes and the patient experiences pain on a much more frequent basis. This is likely reflective of chronic changes within the tendon osseous interface. The patient will pinpoint the area of pain as being directly over the insertion of the Achilles tendon on the posterior aspect of the heel. When localized edema develops, shoe wear will then become an irritant. A stiff heel counter that exerts direct pressure to the posterior heel will also cause discomfort.
The second group of patients is the athletic population that presents with a clinical picture of an overuse syndrome. In a review of runners presenting with an injury, Clain and Baxter reported that the most common form of tendonitis was Achilles tendonitis with an incidence of 6.5 to 18 percent.12 Athletes will typically describe pain and stiffness in the posterior heel when they first rise and begin to ambulate. As motion increases, the pain will generally diminish in its intensity or resolve altogether.