Calcific Achilles tendonitis, retroachilles bursitis, Haglund’s deformity and insertional tendinosis are very common amongst the athletic and military communities in my experience. Over 30 years of practice, it amazes me how young patients have these conditions. Interestingly, an article on the American Medical Society for Sports Medicine website states that “calcific Achilles tendonitis is common amongst women from 30-50 years of age.”1 My experience at Ft. Leonard Wood and within the Army suggest this is far from true. We see these conditions clinically and radiographically on a daily basis, from basic trainees (aged 17 to 30) and seasoned military servicepeople (aged 35 to 50) to obese women in their fifties. But to label calcific Achilles tendonitis solely as a female condition is so far from reality. The article further added that many theories exist as to why these conditions develop.1 The simplest theory is one of genetics, degenerative and progressive as outlined in an article from Shakked and Raikin in 2017.2
The focus for this particular column is purely radiological. Back in 2010, Brent Haverstock, DPM, FACFAS did an excellent job reviewing resection techniques in Podiatry Today for Achilles insertional calcific tendinosis.3 A plethora of articles address the surgical exposure, debridement and repair that I have no interest in rehashing. Similarly, it seems a multitude of conferences and online videos highlight variations on the technique.
There are many published radiological surveys and retrospective reviews. In 2012, Kang and colleagues looked at surgical results.4 One study published by Johansson and team in 2014 actually reviewed 1661 operations for chronic Achilles tendinopathy over 40 years.5 Unlike my observations, their focus was purely on intraoperative pathology, and histologically-oriented, not radiographically.
From an athletic standpoint, Amol Saxena published two papers; one with Steven Cheung, DPM, in 2003 reviewing surgical results for 91 cases of chronic Achilles tendinopathy and one specifically looking at track athletes, also in 2003, which reviewed nine years of such surgeries.6,7 The data showed significant promise with a high return rate back to sports. Our institution sees similar results amongst our active duty servicepeople whether they required surgery or not. Saxena made no mention of gastroc lengthening amongst his athletes.
One Podiatric Team’s Observations On Calcific Achilles Tendonitis
Over the past five years, I have identified over 1000 cases of calcific Achilles tendonitis within our X-ray database. My clinical review focused more on tracking symptoms rather than demographics. Very few cases actually presented with chronic posterior heel pain, and many soldiers had no idea they had retrocalcaneal spurs. Instead, the presenting concerns were plantar fasciitis, bunions or ankle issues. More often the calcification was simply an X-ray finding with very little clinical significance (see first photo above).
When patients did complain of posterior heel pain, what amazed me was the lack of correlation between the size of calcification and their symptoms. More often these consults were for trainees having boot irritation (see second photo set above). During that span of time over the past six years, my colleagues and I only operated on 76 cases, which is rather low. It is not because we are overly conservative, instead, we did not base the need for surgery and the degree of symptoms on an X-ray.
I think too many surgeons, myself included, see the development of the insertional pathology and simply want to shave it off. When you deal with professional athletes (soldiers who are poorly paid) as we do, surgery is often not indicated. It is amazing how some ibuprofen, ice and maybe even a different pair of boots can reduce pain. We always focus on educating patients that the disease process is progressive and the spurs will and do get larger. I am simply amazed when we see that 55-year-old with a significant deformity who has had no previous complaints of pain, or the 70-year-old with a huge posterior heel mass kept in check by wearing sandals for the past 15 years (see third photo set above).
Within our database, the demographics are widely split amongst men and women and do not show a trend favoring females for this pathology. Patient ages ranged from 18 to 70 years. Half were active duty military and the other half were retirees or dependents. Despite the literature, we only treated a handful of females with diabetes and morbid obesity. Our demographics lean heavily towards the 35 to 50-year-old male soldiers. While at Ft. Bragg, we jokingly called this the “Sergeant Major Disease.” You pretty much could guarantee they had calcific Achilles tendonitis. (see fourth photo above). One tell-tale sign that we often see in symptomatic cases is an osteolytic change in the upper one-third of the posterior calcaneus. We find this is associated with significant inflammation (see fifth photo above).
A Closer Look At The Impact Of Equinus
Another trend we note that departs from the literature is the role of equinus in calcific Achilles pathology.1,3,8 In my observation, some sources feel equinus is the key precipitator of calcific Achilles tendinosis; but in my 30 years of evaluating thousands of patients with Achilles issues, the number of those cases with equinus was miniscule. I see the logic, but I see no proof in my practice. To make matters worse, I have observed surgeons during meetings and condemning the entire notion of calcific Achilles debridement and resection and instead advocating for gastroc recession.
After three decades of practice, despite hearing multiple conference lecturers state the contrary, I don’t recall ever seeing a patient with tendinosis or calcific Achilles tendonitis with equinus. Not once did I consider an Achilles or gastroc lengthening on athlete or soldier. In fact, I am down right impressed at how so many of the patients I evaluate with calcific Achilles tendonitis or tendinosis had better than 10 degrees of dorsiflexion. It completely debunks the whole theory of traction spurs. Some of the largest degrees of calcification and tendinosis I see have excessive ankle dorsiflexion. I’ve seen colleagues order ski-jump lateral X-rays just to show equinus, convinced that everyone has to have equinus.
Does The Morphology Of The Calcaneus Play A Role In Calcific Achilles Pathology?
Another aspect that may or may not play a role is the shape of the calcaneus, specifically the Philip-Fowler angle. Two studies looked at the shape of the posterior calcaneus and tried to correlate whether how squared off the posterior heel was played any role in the symptoms.9,10 One 1982 paper concluded that shape was not a factor, just a morphological characteristic.9 The other paper out of China in 2007 went a step further and performed charger views on patients in addition to Phillip-Fowler and parallel pitch line measurements.10 They concluded there was no statistical significance of these measurements between patient with symptomatic Haglund syndrome and those with no posterior heel pain.10 So, shape probably has no role, it only guides what and how much to resect.
Regardless of etiology, age, activity level or weight, I find the degree of calcification does not correlate to pain. It amazes me that we see radiographic changes as early as 18 to 20 years old. Whether we diagnose chronic posterior heel pain as Haglund’s deformity, retroachilles bursitis or eventually insertional tendinosis, the condition is surely progressive.
Why can we not then explain why one patient hurts and another doesn’t? That is a mystery. All I can do is look at the X-rays, and if the patient has pain, we treat. If all conservative therapy fails, we resect. Just as so many surgeons see, the more degenerated the insertional tendinosis becomes, the more work required. We see this also in some cases that have both insertional and non-insertional calcification (see sixth photo above).
We must remind our patients that we will see re-calcification postoperatively. Patients who had surgery elsewhere and re-develop pain years later, or simply have another foot issue, are amazed when they see the amount of re-calcification (see seventh photo above). I find it is inevitable, especially with insertional tendinosis. The good news is that very few of my patients over the years required revision surgery. Those who needed revision usually had very conservative resections leaving an area of prominence. Ultimately, I recommend we spend more time treating symptoms than looking at X-ray findings.
Dr. Spitalny is a staff podiatrist at General Leonard Wood Army Community Hospital and Adjunct Faculty of the SSM Depaul Podiatry Residency Program in St. Louis, Mo.
1. Oliveira L, Hilgers M. Calcific tendonitis. Sports Med Today. Available at: https://www.sportsmedtoday.com/calcific-tendonitis-va-146.htm . Accessed January 6, 2020.
2. Shakked RJ, Raikin SM. Insertional tendinopathy of the Achilles: debridement, primary repair, and when to augment. Foot Ankle Clin. 2017;22(4):761-780.
3. Haverstock B. How to conquer Achilles insertional calcific tendinosis. Podiatry Today. 2010;23(12):54-60.
4. Kang S, Thordarson DB, Charlton TP. Insertional Achilles tendinitis and Haglund's deformity. Foot Ankle Int. 2012;33(6):487-491.
5. Johansson K, Lempainen L, Sarimo J, Laitala-Leinonen T, Orava S. Macroscopic anomalies and pathological findings in and around the Achilles tendon: observations from 1661 operations during a 40-year period. Orthop J Sports Med. 2014;2(12). doi: 10.1177/2325967114562371 . Published December 19, 2014. Accessed January 6, 2021.
6. Saxena A, Cheung S. Surgery for chronic Achilles tendinopathy. Review of 91 procedures over 10 years. J Am Podiatr Med Assoc. 2003;93(4):283-291.
7. Saxena A. Results of chronic Achilles tendinopathy surgery on elite and nonelite track athletes. Foot Ankle Int. 2003;24(9):712-720.
8. Howell MA, McConn TP, Saltrick KR, Catanzariti AR. Calcific insertional Achilles tendinopathy-achilles repair with flexor hallucis longus tendon transfer: case series and surgical technique. J Foot Ankle Surg. 2019;58(2):236-242.
9. Fiamengo SA, Warren RF, Marshall JL, Vigorita VT, Hersh A. Posterior heel pain associated with a calcaneal step and Achilles tendon calcification. Clin Orthop Relat Res. 1982;167:203-211.
10. Lu CC, Cheng YM, Fu YC, Tien YC, Chen SK, Huang PJ. Angle analysis of Haglund syndrome and its relationship with osseous variations and Achilles tendon calcification. Foot Ankle Int. 2007;28(2):181-185.