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Conquering Posterior Heel Pain In Athletes

    Americans of all ages are participating in athletic activities, including football, at a higher level than ever before. Unfortunately, this also leads to an increased incidence of injury. Heel pain is a common complaint among athletes. It can be particularly disabling and result in a loss of playing time.

    Heel pain comes in many forms: plantar fasciitis, Baxter’s neuritis, tarsal tunnel syndrome, calcaneal apophysitis, Achilles tendonitis, bursitis, calcaneal stress fractures and contusions. Typically, it is a combination of these that causes pain and discomfort.

    With the return of high school athletes to two-a-day practices in the fall season, many experience some form of heel pain. One must consider multiple factors when treating athletes. Clinicians should determine if the athlete is currently “in season” or is in the “off-season.” Taking a considerable amount of time off during the season is simply not an option for many athletes. Professional athletes are paid to play and perform while college and high school athletes may have scholarship considerations. Not to be overshadowed are the millions of recreational athletes who are training for events that are just as important to them as the professional games. Athletes in the off-season may have more time to rest and rehab the injury.

    Podiatrists should also consider the competitive level of the athlete. High school, college and professional athletes may have better access to athletic trainers, physical therapy and rehabilitation services than the layperson. Ultrasound, electrical stimulation, iontophoresis and deep tissue massage are powerful healing tools, but not every athlete has access to these on a daily basis. Therefore, recreational or weekend athletes may have to do more of their rehab on their own at home. Regardless of the season or level of involvement, modification of activity is the key component to treatment.

    There are many other factors to consider when treating the athlete. Does the athletic schedule permit time to cross-train or attain relative rest? Exercise bikes, elliptical trainers and pool running may help to maintain cardiovascular fitness while reducing stress on the injured area. What is the athlete able to do off the field? Can he or she be immobilized in a CAM walker or surgical shoe for the 22 hours a day that he or she is not playing? Can the athlete tolerate a night splint to help with stretching? Is he or she able to warm down properly and use ice after activity? Can the athlete tolerate antiinflammatory medications, steroidal or nonsteroidal?

Why Shoe Gear Plays A Critical Role

    Shoe gear also plays an important role in the athlete with heel pain, particularly with football players. Shoes should match the conditions and the playing surface. For example, at every game, the athlete should have three pairs of shoes: molded cleats, turf shoes and flats/sneakers.

    Synthetic turf fields are becoming more common at high schools and colleges across the country. The new synthetic turf fields are no longer the thin carpet on a slab of concrete from years ago. Many have enhanced cushion and synthetic blades that match the length and feel of natural grass. However, all of the synthetic fields are not equal. Some fields with higher synthetic grass blades may have too much grip with turf shoes. This does not allow the shoe to release during cutting maneuvers, thereby causing increased transverse plane torque on the ankle and knee. Unfortunately, this all too often results in serious injury. Other fields may be too slippery for typical molded cleats while others require sneakers or “flats.”

    Wearing improper shoes on natural grass fields can also cause problems. Often, problems can arise from practicing on hard, dried-out fields with large studded cleats. Turf shoes or sneakers are usually more appropriate for these conditions. Turf shoes often have wider heel contact and increased stability, which reduce the risk of injury. Not only do large studs or screw-ins cause increased local plantar pressures but they are also often placed close together, which may allow increased inversion and eversion of the hindfoot. This may make the athlete more susceptible to inversion ankle injury, peroneal tendonitis or tibialis posterior tendonitis.

    Adolescent athletes may be heavy and strong enough to drive the large heel spikes into the ground but not the large forefoot studs that remain on top of the ground. This forces a relative dorsiflexion of the foot and may increase strain on the plantar fascia and Achilles tendon.1 One often sees this among 9- to 12-year-old athletes who present with signs and symptoms of calcaneal apophysitis. Turf shoes and sneakers with a slightly elevated heel help reduce some of this strain. Small 1/8- to 3/8-inch neoprene heel lifts can also help alleviate some of the stress in flat shoes and cleats. Athletes should use a quality running shoe for all fitness training.

    One should evaluate shoe gear for wear patterns and breakdown. Last season’s cleats may be too old to continue providing support for this season. Certain cleats may aggravate Achilles tendinopathy. Some athletic shoes have an anteriorly sloped heel counter that may cause irritation of the Achilles. Others have a relatively vertical heel counter that may reduce some of the pressure. Also evaluate the top of the heel counter. A notched heel may help alleviate some of the direct pressure on the Achilles tendon. Shoes with a very stiff plantar plate and limited forefoot flex also can cause overuse injuries with the Achilles tendon.

    If the athlete wears orthotics, one should evaluate these in the cleat as well. The orthotic should fit the shoe properly for length, width and heel height. Pay special attention to the medial aspect of the arch. Some cleats have a narrow midfoot area that will not allow the orthotic to sit down into the shoe. This causes a varus positioning of the orthotic and may lead to ankle sprains or tarsal tunnel syndrome. Undercutting the medial arch of the orthotic will often alleviate this problem without compromising the integrity or function of the device.

Pertinent Pearls On Diagnosing Posterior Heel Pain

    There are many potential etiologies for posterior heel pain. These include biomechanical, systemic, traumatic, neurologic, infectious, neoplastic and autoimmune etiologies. Mechanically induced and traumatic posterior heel pain are most common in the athlete. Examples may include Achilles tenosynovitis/tendinosis, retrocalcaneal bursitis, Haglund’s deformity, calcaneal apophysitis, Achilles enthesopathy, calcaneal stress fracture, bone contusions and fracture of the posterior talar process.

    Neurologic conditions contributing to posterior heel pain include S-1 radiculopathy and Baxter’s neuritis. While it is less common to see systemic conditions contribute to posterior heel pain among athletes, these conditions may include rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome, gout, Behçet’s syndrome, systemic lupus erythematosus, gonorrhea and tuberculosis.
Diagnosis begins with a thorough history and physical exam. The patient’s age, specific sport, training habits, field conditions, shoe gear, preexisting injury and past medical history, as well as a thorough description of any traumatic event, are extremely important in establishing a specific diagnosis. The physical exam should include the specific location of the pain as well as evaluation for edema, erythema, increased temperature and ecchymosis. One should also thoroughly evaluate muscle strength as well as subtalar and ankle joint ROM. Limitation of ankle joint dorsiflexion with gastrocnemius and/or gastrocnemius-soleus equinus deformities is an extremely common factor in nontraumatic posterior heel pain.

    The initial examination often includes radiographs. One should evaluate these for the presence of a posterior superior calcaneal process (Haglund’s deformity), Achilles intratendinous calcification (posterior calcaneal spur), fracture of the posterior talus and/or posterior talar tubercle, and open growth plates as is the case with calcaneal apophysitis.

    Bone scans may prove to be useful when it comes to detecting subtle stress fractures. Bone scans can also aid in the diagnosis of various seronegative arthropathies. Magnetic resonance imaging is most useful in diagnosing Achilles tenosynovitis, tendinosis and intrasubstance tearing as well as retrocalcaneal bursitis, Achilles enthesopathy and stress fracture. Nerve conduction velocities and electromyography may prove useful if one suspects radiculopathy. When it comes to athletic patients with heel pain, bloodwork may be necessary if one suspects seronegative arthropathies or other systemic causes of the pain.

Essential Tips On Conservative Treatment

    Treatment of posterior heel pain in the athlete is designed to get the patient back to the sport in the quickest and safest way possible. One would naturally tailor the treatment toward a specific diagnosis. In general, however, ice, NSAIDs and oral steroids can help reduce the inflammatory process of the injury or condition.
Keep in mind, however, that corticosteroid injections are often contraindicated in the presence of the posterior heel pain, specifically in the area of the Achilles tendon.

    Injectable corticosteroids near the Achilles tendon can weaken collagen cross-links and result in rupture of the Achilles tendon, especially in the presence of tendinosis and/or an equinus condition. Low volume peritendinous injections under fluoroscopy may be a safe option for the properly selected patient.2

    Incorporating heel lifts or custom orthoses and posterior heel pillows into sneakers and cleats can be quite beneficial in treating heel pain related to apophysitis, tenosynovitis, tendinosis, retrocalcaneal bursitis and Achilles enthesopathy. Physical therapy modalities, including electrical stimulation and ultrasound as well as active and passive stretching exercises, are integral to the treatment regimen.

    One may also employ night splints. On occasion, relative rest using a CAM Walker boot between workouts is necessary for resistant cases. Athletes may continue to compete but the area is protected for the other 22 hours a day when they are not playing. Clinicians often reserve complete immobilization for those chronic injuries resulting in tendon rupture and/or fracture. Extracorporeal shockwave therapy can be helpful in the presence of Achilles insertional tendinosis.

When Conservative Therapy Fails

    Surgical management of a specific condition is reserved only for those who fail to respond to conservative measures. When treating athletes, make efforts to get them through their current season. If surgery is indicated, one may perform the procedure immediately after the season ends.

    There are a number of different surgical procedures used to treat resistant posterior heel pain caused by retrocalcaneal bursitis, Achilles tenocalcinosis, posterior calcaneal spur, tenosynovitis and tendinosis of the Achilles tendons. The surgeon may recommend removal of the retrocalcaneal bursa and/or intratendinous calcification, and posterior spur through an open procedure. Depending on the amount of Achilles tendon that is detached, this approach can frequently lead to a long postoperative healing course and a posterior heel scar that is aggravated by shoe gear.

    We have found the presence of an equinus deformity in the majority of athletes with chronic and resistant posterior heel pain. More specifically, it is most often a gastrocnemius equinus deformity. We have found that simply lengthening the gastrocnemius tendon will frequently yield the desired result of pain cessation with a shorter postoperative course. A number of procedures are available for lengthening the tendon and surgeons can perform some of these procedures through a percutaneous rather than open approach.

    We prefer performing a proximal gastrocnemius recession 1 to 2 cm distal to the musculotendinous junction. Strayer advocated this technique almost 60 years ago.3

    One would make a midline, posterior incision 1 to 2 cm distal to the gastrocnemius musculotendinous junction. Then divide the superficial fascia and paratenon, carefully avoiding the sural nerve, to reveal the gastrocnemius tendon. Then section the tendon transversely. Dorsiflexion of the foot elongates the tendon. One may then suture the proximal aspect of the tendon into the underlying soleus to hold its position. Close the incision in layers and protect the patient postoperatively in a splint. This procedure has the advantage of not affecting the soleus muscle so the entire gastrocnemius-soleus complex is not weakened, a common problem with the Achilles tendon lengthening.4 The patient then progresses back to full function with a course of physical therapy.

    The Baumann procedure is another option to lengthen the gastrocnemius.5 It involves performing an anterior aponeurosis lengthening of the gastrocnemius from a more proximal incision. Section the aponeurosis transversely and have the patient dorsiflex the foot. If one achieves insufficient lengthening, perform a second transverse cut 1 cm distal to the first. This procedure does not require suturing the aponeurosis in the new lengthened position. As with the Strayer type procedure, this does not affect the soleus muscle so the entire gastrocnemius-soleus complex is not altered. This allows for a faster return to activity.

In Conclusion

    Posterior heel pain in the athlete can be a debilitating injury that results in significant pain, a decrease in functional level and a potential loss of playing time. The treatment of posterior heel pain should focus on reducing pain and discomfort, and facilitating a timely and safe return to activity. Conservative treatments are the first line of therapy and include relative rest, modification of activity, inflammation reduction, physical therapy and appropriate shoegear. One may treat recalcitrant cases surgically and in a manner that does not weaken the entire Achilles tendon. Overall, one should tailor the selection of treatments to the sport-specific goals of the individual athlete.

    Dr. Corwin is a Fellow of the American College of Foot and Ankle Surgeons. He is in private practice in Media and Phoenixville, Pa.

    Dr. Erfle is board certified in foot and ankle surgery. He is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Erfle is in private practice in Media and Phoenixville, Pa.

    The authors would like to thank Bill Battey Sporting Goods in Media, Pa., for their assistance with the athletic shoes.

    For related articles, see “Inside Insights For Tackling Football Injuries” in the December 2005 issue of Podiatry Today or “Mastering Plantar Heel Pain In Athletes” in the November 2004 issue.

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1. Walter J, et al. The evaluation of cleated shoes in the adolescent athlete in soccer. The Foot 12(9): 158-165, 2002. 2. Gill S, et al. Fluoroscopically guided low-volume peritendinous corticosteroid injection for Achilles tendinopathy. JBJS 86-A(4): 802-806, 2004. 3. Strayer L. Recession of the gastrocnemius: an operation to relieve spastic contracture of the calf muscles. JBJS 32-A(3): 671-676, 1950. 4. Lamm B et al. Gastrocnemius soleus recession: a simpler, more limited approach. JAPMA 95(1): 18-25, 2005. 5. Baumann J et al. Lengthening of the anterior aponeurosis of the gastrocnemius muscle (in German). Operat Orthop Traumatol 1: 254, 1989.

By Christopher R. Corwin, DPM, MS, and David C. Erfle, DPM
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