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

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Bob Baravarian, DPM

Pertinent Pointers On Conservative Treatments

In cases of bursal irritation, I have found excellent outcomes with non-steroidal, anti-inflammatory injections and rest. I will often use a combination of Traumeel (Heel, Inc.) and Arnica injected under ultrasound guidance in and around the bursal region. In very rare cases and if I am casting a patient, I may use a very short-acting steroid injection, placing this under ultrasound guidance into the bursa. In most cases, I will use a controlled ankle motion (CAM) walker boot and place a heel lift of ½ inch in the boot to take the strain off the Achilles and decrease the squeeze of the posterior bursa.

   Achilles insertional tendinosis has been the most difficult problem to treat. I have tried multiple treatment options including physical therapy, rest and surgery prior to coming up with what works for me. Physical therapy and rest are my first treatment options. Patients are allowed to swim or ride a stationary bike. During bike riding, the patient wears a boot to protect the tendon. Walking for short periods is allowed but not for exercise. The patient also wears an orthotic with a heel lift. If the problem continues, I may try an injection. In tendonitis cases that are associated with inflammation, I will often use an anti-inflammatory injection such as Arnica and Traumeel.

   Most cases of posterior Achilles insertional pain are associated with tendinosis and long periods of standing. In such cases, there is minimal inflammation and extensive scar tissue. For these patients, I will often turn to inflammatory treatments such as shockwave therapy, platelet rich plasma (PRP) injection, the Topaz procedure (Arthrocare Sports Medicine) or deep cross-fiber massage with dry needling.

   All of these treatments seem to work depending on the level of fibrosis and amount of inflammation. I have found multiple low intensity shockwave treatments very helpful in more minor cases and PRP injection to be helpful in moderate cases. In my experience, Topaz treatment is helpful in cases that may require surgical debridement but the patient would like to try one more conservative measure. Depending on the size of the spur, I will suggest surgical versus non-surgical treatment of the tendinosis issues.

Emerging Insights On Surgical Options

The spur formation on the posterior heel is often necessary to remove as it grows larger and also may break loose. No form of conservative treatment except for shoe modification seems to help in such cases. If there is extensive Achilles damage, one removes the damaged tendon and, in most cases, removes the posterior bursa. It is very important to remember what is causing the offensive pull on the posterior calcaneus. In many cases, it may be associated with an equinus deformity and this will require treatment at the time of surgery.

   My surgical options for posterior heel pain have dramatically improved in the past few years with the addition of stronger and better fixation techniques. Of greatest interest to me is the use of the Achilles SutureBridge™ (Arthrex) technique. While this technique was initially developed for rotator cuff repairs, it allows a knotless distal attachment of the Achilles and a very strong proximal anchoring of the Achilles after posterior calcaneal spur removal.

   To perform this technique, one would make a central posterior incision and split the tendon centrally, leaving the medial and lateral attachments. Remove all spurring, bursal projections and tendon damage.

   If extensive Achilles damage is present and additional strength on the posterior insertion is necessary, perform a flexor hallucis longus (FHL) tendon transfer from the same posterior approach with biotenodesis of the FHL to the posterior calcaneal insertion. This allows a decreased pull on the Achilles and the FHL transfer will take some of the stress from the Achilles.

   Reattach the Achilles by placing anatomic tension on the tendon at the attachment site. Finally, one should deal with any form of equinus, commonly through a gastrocnemius recession if necessary.

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