Patients commonly complain about pain in the region of their Achilles tendon. Through a careful examination and patient history, one may diagnose more than one condition that can be inter-related. Rather than simply diagnosing the problem as an “Achilles tendinitis” or a “heel spur,” practitioners can provide a more accurate diagnosis and ultimately an appropriate treatment protocol through a more straightforward examination.
The common diagnoses that affect the Achilles tendon include bone conditions such as a Haglund’s deformity (figure 1) and posterior heel spurs, with or without intratendinous calcifications (figure 2). Soft tissue disorders include tendinitis, tendinosis and retrocalcaneal bursitis. Even though the treatment may be similar for these conditions, we can see some notable exceptions.
It is important to ask pertinent questions regarding the patient’s symptoms. First, one should determine whether there is an element of post-static dyskinesia, pain after rest and improvement (loosening) as the patient ambulates. If so, it is likely that there is at least a condition of tendinitis. Secondly, it important to assess whether the source of pain is from pressure to the back of the heel within a closed-in shoe. This would be consistent with a posterior heel spur, Haglund’s deformity and/or distal Achilles tendinosis.
Practitioners should examine the Achilles complex by first visualizing both extremities. One should look for areas of asymmetry such as swelling of the body of the tendon (figure 3) or a notable lump on the back of the heel (figure 4). These areas are likely pathologic and practitioners can further investigate the region with palpation and range of motion testing. Palpation of the Achilles complex typically occurs in three zones. Zone one is the mid-body of the Achilles tendon (the watershed region). Zone two is in the retrocalcaneal bursa and zone three is at the posterior heel at the attachment site of the Achilles tendon (figure 5).
When there is pain on palpation of the Achilles tendon in zone one without any appreciable thickening, hardening or swelling of the tendon, this is a tendinitis. This is typically an acute overuse injury. However, if there is palpable swelling and hardness of the tendon in this region, then the condition is tendinosis, which is a chronic degenerative disease state of the tendon. The treatment for these two conditions is very different.
Pain in zone two is consistent with a retrocalcaneal bursitis. Patients with a cavus foot type or a Haglund's deformity may be predisposed to bursitis.
Pain in zone three is consistent with an insertional Achilles tendinitis and if there is an appreciable lump, then it is more likely an insertional Achilles tendinosis. In any of these conditions, there may be an associated posterior heel spur.
So what does that mean? In the condition of plantar fasciitis, we tell our patients all day long that the spur does not cause the pain and that it is a soft tissue problem. Is that the case with posterior heel pain? It is my opinion that the spur does not cause the pain (figures 6 and 7). However, when I do surgery for insertional Achilles tendinitis/tendinosis, I do remove the heel spur.
The reason is twofold. First, it is important to provide a raw cancellous bone interface with the tendon for tenodesis. The second reason is that the bleeding of the bone provides a good healing environment and vascularization for the diseased state of the distal Achilles tendon. It is no different when performing a Kidner procedure. It is preferable not only to remove the accessory bone but also to remove overhanging navicular. This is so the overhanging navicular can be flush with the medial cuneiform and there is good raw bone to provide vascularity to the posterior tendon. This is an analogous condition to the insertional Achilles tendinosis.
Once the appropriate diagnosis occurs, treatment can begin. Although some of the surgical interventions are similar, there are notable exceptions.
For tendinitis, we are dealing with an acute inflammatory condition, which we can treat with any modality that will reduce inflammation. Typically, tendinitis patients initially receive rest, icing and a heel lift for a three- to four-week period. One can refer the patient to physical therapy at this time as well. Typically, that is my second line of treatment but it is also appropriate for initial treatment.
If these treatments fail, then I initiate an immobilization period by using a fracture boot. If there are no contraindications, I will use a tapered dose of prednisone consisting of 60/40/20/10/5 mg for three days each. After a month of immobilization, if there is still pain, one can consider intermediate alternatives to surgery, which would include injections of PRPs or extracorporeal shock wave therapy. These may be somewhat experimental but they certainly have a role in the treatment protocol. Only time will tell if these intermediary treatments will become a standard of care in the treatment of tendon disorders.
Finally, one can perform surgery if all else has failed. Generally, I will do a gastrocnemius recession if there is a significant equinus deformity and radiofrequency Coblation of the Achilles tendon in the area of pain.
For insertional Achilles tendinosis, anti-inflammatory medications do not typically fare well. I will generally start with physical therapy. There are two proven techniques to conservatively treat tendinosis. These include ASTYM (a manual tendon scraping technique using a plastic or metal spoon-like apparatus) and eccentrically loading exercises. If these conservative therapies fail, I will try immobilization in a fracture boot with a tapered dose of prednisone as noted above.
From a surgical standpoint, if there is a Haglund’s deformity and/or a posterior heel spur, one should remove both (figure 8). Radiofrequency Coblation along with debulking of the distal Achilles tendon should also occur (figure 9). Fixation of the tendon to the heel bone can occur per surgeon preference. In cases in which there is no abnormality of the posterior heel (i.e. no heel spur or Haglund’s deformity), radiofrequency Coblation alone has been quite effective (figure 10).
For mid-body Achilles tendinosis, I perform a similar protocol for insertional tendinosis. If conservative treatment fails, then surgery will include a gastrocnemius recession to address any equinus (if present), debulking/tubularization of the tendon and radiofrequency Coblation (figure 11). If there is a severe diseased state of the tendon and/or an element of Achilles weakness, then a flexor hallucis longus transfer is necessary. This will provide vascularity from the muscle belly of the flexor hallucis longus tendon to the Achilles tendon and provide more power to the Achilles tendon.
What about cortisone injections? I do not recommend injecting cortisone into a tendon due to potential rupture. The only area that is safe for a cortisone injection is in the retrocalcaneal bursa. It has been my experience that bursitis alone is the least common condition that I encounter in the realm of Achilles-associated pain. If indeed the only condition is bursitis, then I will consider either oral anti-inflammatory medication or an injection of 2 mg of decadron into the bursa. I typically integrate fracture boot immobilization after a cortisone injection into the bursa to minimize stress around the tendon during this period. In cases in which there is bursitis in addition to insertional Achilles tendinitis, I typically remove the bursa when resecting the Haglund’s deformity and/or posterior spur.
Careful examination of the Achilles tendon and associated structures will uncover each of the elements of tendinitis, tendinosis and bursitis. Although the treatments for these conditions are similar, remember that tendinosis is a chronic, degenerative state of tendon. Typically, anti-inflammatory treatments are ineffective. It has been my experience that radiofrequency Coblation works well to resolve pain associated with tendinitis and tendinosis. Finally, although this may seem counterintuitive, more often than not, the posterior bump on the heel is not bone but rather thickened tendon (tendinosis).