Current Concepts In Retrocalcaneal Heel Spur Surgery
Keys To Conservative Management In Sedentary Patients And Athletes
In the sedentary group, non-operative management consists of rest, ice and physiotherapy. As far as footwear goes, management includes heel lifts; heel cups; and a change in footwear to a soft heel counter, open heeled shoes or sandals. Other treatments include topical anti-inflammatory medication, laser therapy and night splints. Extracorporeal shockwave therapy has demonstrated promising results in the management of insertional Achilles tendinopathy.19,20
In this sedentary group, weight loss plays an important role in the management of the condition and consultations with a personal trainer and dietician can be very helpful. Many patients with this condition cite the inability to walk along with their weight gain, not knowing there are many other exercise options available that will help them reach their goal.
The non-operative management in the athletic group consists of rest, ice, cross-friction massage, the Graston technique, rehabilitation exercises and addressing the biomechanical factors that have contributed to the condition. Altered knee kinematics and reduced muscle activity have been associated with Achilles tendinopathy in runners. Rehabilitation exercises and the appropriate use of orthotics to control the abnormal biomechanical influences that affect kinematics and muscle activity would be beneficial in the treatment of runners with Achilles tendinopathy.21
Modification of footwear or appropriate footwear selection is extremely important and one can do this in consultation with a local running shoe store with experienced staff. Changes in training routine may be necessary as well and patients can achieve this by working with a running coach and physiotherapist.
For other sports, alterations to hockey skates, figure skates and ski boots will often eliminate the pain, which is due to external pressure.
Assessing The Benefits Of Different Surgical Approaches
If non-operative management has failed to relieve the pain and allow the patient to resume normal activities, then consider surgery. Researchers have described a number of surgical approaches for this procedure. They include a medial incision, a medial-J incision, a combined medial and lateral incision, a step down incision and a posterior midline incision.1,17,22-25
Consider a medial incision if it is necessary to harvest an adjacent tendon for augmentation. However, with the advent of regenerative tissue matrix products, one can often avoid this. The medial-J incision will provide exposure to the Achilles tendon, the retrocalcaneal bursa, the posterior calcaneus and adjacent tendons if augmentation is required.
The lateral incision is an option when the main area of concern is the posterior superior calcaneal protuberance and/or retrocalcaneal bursa with no intratendinous spurring or calcification present. Take care to identify and protect the sural nerve during this approach.
A Closer Look At The Author’s Surgical Technique
The following is a guide to the author’s surgical technique. After anesthetizing the patient, apply a thigh tourniquet and ensure the patient is in the prone position on the operating table. Exsanguinate the leg to ensure good visualization. The surgeon would utilize either a step down incision or a posterior midline incision depending on the width of the posterior calcaneal involvement. One can modify the step down incision to provide greater exposure to the posterior calcaneus, allowing for full resection of the osseous protuberance and remodeling of the medial and lateral edges.
Once one has reflected the overlying soft tissue off the Achilles tendon, employ a central tendon splitting approach. The extent of the tendon detached depends on the size of the osseous structure one is removing. After reflecting the overlying soft tissue, excise any intratendinous calcification and degenerative tendinosis from the healthy tendon. Then carefully excise the retrocalcaneal bursa from the surrounding structures. Using a saw, rongeur and rasp, one would remove the posterior spur and posterior superior osseous prominence. Remodel the calcaneus and remove any sharp or rough edges. Lavage the area to remove all loose resected bone.