Essential Insights On Treating Retrocalcaneal Exostosis

Michael S. Downey, DPM, FACFAS­­

   The management of posterior heel pain can be a perplexing diagnostic and therapeutic problem. The differential diagnosis is extensive and even the skilled clinician can experience difficulty establishing an accurate diagnosis. Of the challenging conditions affecting the back of the heel, the retrocalcaneal exostosis may be the most onerous to treat.

   Unlike Haglund’s deformity, which is generally a posterior-superior or posterior-superior-lateral prominence, the “true” retrocalcaneal exostosis involves an intratendinous component. This is often considered a distal insertional Achilles enthesiopathy. To remove the exostosis or “spur,” the surgical approach must include incision through at least a portion of the tendinous substance of the Achilles tendon.

   Accordingly, let us take a closer look at a technically simplified, reproducible method for treating this most arduous condition.

   The clinical presentation of the patient with a retrocalcaneal exostosis or insertional spurring within the Achilles tendon is very similar to that of the patient suffering from a Haglund’s deformity.

Keys To Recognizing And Differentiating The Clinical Presentation

   The patient will typically complain of a prominence of the posterior heel associated with pain, tenderness, erythema and edema that may increase with activity or certain types of shoes. Typically, the patient experiences a dull, aching pain with localized tenderness near the insertion of the Achilles tendon. Occasionally, one may note a palpable “hardness” or “thickening” in the Achilles tendon just proximal to its insertion into the calcaneus. This might represent concomitant calcification of the tendon itself or, more likely, degenerative changes associated with partial tendon rupture. The patient often complains of what Cicchinelli described as a “bulky posterior heel.”1

   Patient ages range from the early 20s to the 80s. However, the presentation is more common in middle-aged or older patients, and is more common in obese or poorly conditioned patients. Younger patients who present with the condition are usually involved in athletics or are obese. The condition is more common in women and is most likely secondary to the shoe styles they tend to wear.2-4

   The retrocalcaneal exostosis or spurring within the insertion of the Achilles tendon can occur concomitantly with a Haglund’s deformity, retrocalcaneal bursitis, Achilles tendinitis, ankle equinus or plantar heel spur syndrome. One should take care to distinguish among these conditions.

   Podiatrists can best accomplish this differentiation by assiduous clinical palpation and radiographic evaluation. Identify the painful retrocalcaneal exostosis with direct palpation of the insertional area of the tendo-Achilles. Generally, this will be the point of maximum tenderness although the patient may have pain that extends around this area. The pain may be aggravated by passive and active ankle joint range of motion, especially dorsiflexion.

   The role of ankle equinus in this condition is difficult to state with certainty but it is often associated with this condition. The general lack of flexibility of the insertional area of the tendon may simply be present throughout the entire tendon structure. Radiographically, a standard lateral view will demonstrate the retrocalcaneal exostosis, posterior calcaneal step or intratendinous spur. Magnetic resonance imaging (MRI) studies may also be helpful if thickening of the Achilles tendon is present or if one suspects chronic bursitis, tendinitis or the partial tendon rupture to be involved.

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