Keys To Diagnosing And Treating Achilles Insertional Pain And Retrocalcaneal Exostosis Pain

Bob Baravarian, DPM

Posterior insertional Achilles pain and retrocalcaneal exostosis pain are commonly grouped together as one common problem referred to as posterior insertional Achilles pain. However, these are two different problems with common approaches to treatment. Accordingly, let us take a closer look at retrocalcaneal pain and Achilles insertional pain, explain the different issues with each and their proper treatment options.    When a patient presents with posterior heel pain, the most common diagnosis is retrocalcaneal exostosis. If a radiograph reveals a bone spur, the physician commonly tells the patient that the bone spur is the source of the pain. Twenty to 30 years ago, physicians tended to blame plantar fasciitis pain on a noted heel spur. Similarly, posterior heel pain is also blamed on the spur.    In plantar fasciitis cases, we have come to realize that the spur is not the source of the pain and that the pain is due to a soft tissue inflammatory problem and scar tissue/fibrosis of the plantar fascia. This is also mostly true for retrocalcaneal issues. Commonly, the source of pain is inflammation of the Achilles at the insertion site and bursal inflammation at the calcaneal insertion site. However, as the spur enlarges, it may be a source of irritation with shoes and if the spur breaks loose from the posterior calcaneus, it can also be painful and irritating.

What You Should Know About Pinpointing The Source Of Pain

So how should one go about finding out the true source of a patient’s pain?    The first key is to take a good history. Most cases of Achilles problems are associated with overtraining or increased activity resulting in overstrain of the tendon. Bursal inflammation is common with a sudden onset of pain, which improves with rest. Calcaneal exostosis/loose body pain is associated with shoewear and commonly grows worse over an extended period of time from months to many years.    It is also exceptionally important to perform a physical exam. Pressure on the Achilles attachment will result in pain with any of the three aforementioned problems, namely Achilles problems, bursal inflammation and calcaneal exostosis. It is important to consider and test each problem separately in order to perform a complete exam.    Bursal pain occurs at the most proximal heel projection and becomes worse with medial and lateral compression of the proximal heel without pressure on the Achilles. Achilles pain occurs along any part of the insertion but in tendinosis cases, there is usually scar formation and thickening of the tendon at the insertion site and more commonly just proximal to the insertion site.    Exostosis pain may not be present if shoes are not pressing on the spur. An enlarged spur is not commonly painful unless the superficial tendon and soft tissue are being squeezed between the spur and the shoe. In cases of a loose spur, the pain mainly occurs at the distal Achilles insertion site on the posterior heel and direct posterior heel pressure results in pain.    The best diagnostic tool is magnetic resonance imaging (MRI) of the ankle and posterior heel. Although ultrasound is also a great source of information, the amount of information one attains from MRI is significant and simple to unravel. The main point of ordering MRI is to see the quality of the tendon and surrounding soft tissue. One can also check for loose bodies within the attachment of the Achilles and bursal inflammation.    It is important to remember that the combination of all three problems — those being Achilles tendonitis/tendinosis, calcaneal bursitis and calcaneal exostosis/loose body — may be contributing to the pain. Unless I can easily identify the problem, I will often get a MRI prior to starting treatment as treatment options vary according to my findings.

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