Retrocalcaneal heel pain, also known as insertional Achilles tendinopathy, can occur in both sedentary and athletic populations. Accordingly, this author offers a primer on posterior heel anatomy and insights on conservative and surgical management in these patient populations.
Achilles tendon disorders are a common complaint of patients presenting to the foot and ankle specialist’s office. While plantar heel pain tends to garner greater attention due to its prevalence, posterior heel pain is often more debilitating for the patient and challenging for the treating physician.
Retrocalcaneal heel pain or insertional Achilles tendinopathy may occur as a single entity but more frequently occurs with other posterior heel disorders such as retrocalcaneal bursitis, Haglund’s deformity and subcutaneous (pretendinous) tendo-Achilles bursitis. DeOrio and Easley feel the term “tendinopathy” should be applied to the clinical diagnosis and one should only utilize the terms “tendonitis” and “tendinosis” when making a histologic confirmation of specific tendon pathology.1
Traditionally, physicians thought Achilles tendinopathy occurred with overuse, causing microtrauma at a degree and frequency at which the tendon can no longer heal and leading to mechanical breakdown of the tendon.2 Researchers and clinicians have studied various factors that may influence the development of tendinopathy such as training mileage, rest periods between runs, anatomic alignments of the lower limb and biomechanical factors. Researchers have also looked at footwear to determine its role in the development of the condition. Further confusion as to the etiology arises because tendinopathy commonly occurs in individuals who are relatively inactive.3
What To Look For In The Clinical Presentation
In clinical practice, there are two distinct groups of patients that present with posterior heel pain. The first group is the older, sedentary and often obese patients with women more commonly affected than men. They will report pain and stiffness that is worse after a period of rest. Initially this pain will resolve after a short period of walking. This problem is likely an acute process in the beginning and patients often report that they initiated stretching exercises or ice therapy. Other patients ignore the problem, assuming it will resolve on its own.
As the problem evolves, the pain may lessen in its intensity when the patient walks but will usually not resolve. Patients will often cite the disability associated with this pain as a cause of weight gain as they are unable to exercise. Their inactivity would suggest that the problem is due to degenerative changes within the tendon along with irritation over the osseous protuberance. (See “A Guide To Posterior Heel Anatomy” on page 44.)
Over time, the clinical picture often changes and the patient experiences pain on a much more frequent basis. This is likely reflective of chronic changes within the tendon osseous interface. The patient will pinpoint the area of pain as being directly over the insertion of the Achilles tendon on the posterior aspect of the heel. When localized edema develops, shoe wear will then become an irritant. A stiff heel counter that exerts direct pressure to the posterior heel will also cause discomfort.
The second group of patients is the athletic population that presents with a clinical picture of an overuse syndrome. In a review of runners presenting with an injury, Clain and Baxter reported that the most common form of tendonitis was Achilles tendonitis with an incidence of 6.5 to 18 percent.12 Athletes will typically describe pain and stiffness in the posterior heel when they first rise and begin to ambulate. As motion increases, the pain will generally diminish in its intensity or resolve altogether.
A common picture is an athlete who will ignore a minor Achilles strain and continue the running regimen. Baxter reported that 54 percent of runners will continue their activity despite the pain while only 16 percent will abandon the activity altogether.13 Recently, Zafar and colleagues reported a 52 percent lifetime risk of developing Achilles tendinopathy in former elite male distance runners.14 They suggested that up to 29 percent of Achilles tendinopathy patients may require surgery. This often results in chronic pain and discomfort along with failure to regain full function.
Training errors are frequently responsible for the onset of Achilles tendinopathy. These include excessive running mileage and training intensity, hill running, running on hard or uneven surfaces, ineffective pre- and post-running stretching and wearing poorly designed or worn out running shoes.15,16 Biomechanical factors such as tight hamstrings, a tight gastroc-soleus complex, limb length discrepancy and overpronation of the feet can cause Achilles tendinopathy.
Researchers carried out a biomechanical comparison of runners free from injury and runners with Achilles tendinopathy. Knee range of motion (heel strike to midstance) was significantly lower in injured runners than in uninjured runners. Similarly, pre-activation of the tibialis anterior was lower for injured runners than uninjured runners. Rectus femoris and gluteus medius activity after heel strike was also lower in the injured group. However, impact forces were not different between the two groups.16
Pertinent Pointers On The Diagnostic Workup
The differential diagnosis of insertional Achilles tendinopathy may include gout, pseudogout, diffuse idiopathic skeletal hyperostosis, seronegative spondyloarthropathies, inflammatory bowel disease and pain due to ill-fitting shoes, industrial work boots, ice skates or ski boots.
The diagnosis of insertional Achilles tendinopathy is a clinical one based on the location of the pain and the patient’s presenting history. An examination will reveal tenderness and edema at the insertion site of the Achilles tendon into the posterior calcaneus. Localized erythema with hypertrophic changes of the distal Achilles tendon is a common feature. There may be erythema and warmth in the region of the retrocalcaneal bursa if this structure is inflamed.
Enlargement of the posterior calcaneus is quite common in the sedentary population but not that common in athletes with posterior heel pain. There may be erythema and inflamed adventitious bursa overlying the posterior superior osseous protuberance of the calcaneus, which is often largest on the lateral side. Dorsiflexion of the ankle is often restricted due to a tight gastroc-soleus complex and this maneuver may also reproduce pain.
Radiographs are usually the only diagnostic imaging modality required when evaluating posterior heel pain. A lateral radiograph will demonstrate calcification within the Achilles tendon insertion and a prominent superior calcaneal prominence.
Magnetic resonance imaging (MRI) can evaluate patients who do not adequately respond to non-operative management. Nicholson and colleagues demonstrated that MRI can be a useful tool in determining if patients will respond to non-operative treatment.17 They found that patients are not likely to respond to non-operative treatment if they have tenderness of the Achilles tendon insertion without obvious signs of inflammation and demonstrate confluent areas of intrasubstance signal changes on MRI. They suggest that early identification of these patients and surgery may lead to an earlier return to function.
If there appears to be something unusual about the patient’s history or presentation, then aspirating the retrocalcaneal bursa may be useful in determining if an underlying inflammatory condition is responsible for the patient’s symptoms.18
Keys To Conservative Management In Sedentary Patients And Athletes
In the sedentary group, non-operative management consists of rest, ice and physiotherapy. As far as footwear goes, management includes heel lifts; heel cups; and a change in footwear to a soft heel counter, open heeled shoes or sandals. Other treatments include topical anti-inflammatory medication, laser therapy and night splints. Extracorporeal shockwave therapy has demonstrated promising results in the management of insertional Achilles tendinopathy.19,20
In this sedentary group, weight loss plays an important role in the management of the condition and consultations with a personal trainer and dietician can be very helpful. Many patients with this condition cite the inability to walk along with their weight gain, not knowing there are many other exercise options available that will help them reach their goal.
The non-operative management in the athletic group consists of rest, ice, cross-friction massage, the Graston technique, rehabilitation exercises and addressing the biomechanical factors that have contributed to the condition. Altered knee kinematics and reduced muscle activity have been associated with Achilles tendinopathy in runners. Rehabilitation exercises and the appropriate use of orthotics to control the abnormal biomechanical influences that affect kinematics and muscle activity would be beneficial in the treatment of runners with Achilles tendinopathy.21
Modification of footwear or appropriate footwear selection is extremely important and one can do this in consultation with a local running shoe store with experienced staff. Changes in training routine may be necessary as well and patients can achieve this by working with a running coach and physiotherapist.
For other sports, alterations to hockey skates, figure skates and ski boots will often eliminate the pain, which is due to external pressure.
Assessing The Benefits Of Different Surgical Approaches
If non-operative management has failed to relieve the pain and allow the patient to resume normal activities, then consider surgery. Researchers have described a number of surgical approaches for this procedure. They include a medial incision, a medial-J incision, a combined medial and lateral incision, a step down incision and a posterior midline incision.1,17,22-25
Consider a medial incision if it is necessary to harvest an adjacent tendon for augmentation. However, with the advent of regenerative tissue matrix products, one can often avoid this. The medial-J incision will provide exposure to the Achilles tendon, the retrocalcaneal bursa, the posterior calcaneus and adjacent tendons if augmentation is required.
The lateral incision is an option when the main area of concern is the posterior superior calcaneal protuberance and/or retrocalcaneal bursa with no intratendinous spurring or calcification present. Take care to identify and protect the sural nerve during this approach.
A Closer Look At The Author’s Surgical Technique
The following is a guide to the author’s surgical technique. After anesthetizing the patient, apply a thigh tourniquet and ensure the patient is in the prone position on the operating table. Exsanguinate the leg to ensure good visualization. The surgeon would utilize either a step down incision or a posterior midline incision depending on the width of the posterior calcaneal involvement. One can modify the step down incision to provide greater exposure to the posterior calcaneus, allowing for full resection of the osseous protuberance and remodeling of the medial and lateral edges.
Once one has reflected the overlying soft tissue off the Achilles tendon, employ a central tendon splitting approach. The extent of the tendon detached depends on the size of the osseous structure one is removing. After reflecting the overlying soft tissue, excise any intratendinous calcification and degenerative tendinosis from the healthy tendon. Then carefully excise the retrocalcaneal bursa from the surrounding structures. Using a saw, rongeur and rasp, one would remove the posterior spur and posterior superior osseous prominence. Remodel the calcaneus and remove any sharp or rough edges. Lavage the area to remove all loose resected bone.
After determining that adequate soft tissue and osseous debridement is complete, reattach the detached Achilles tendon using suture anchor systems. One would first use an absorbable suture to repair any frayed tendon edges. Then reattach the tendon using the suture anchor system. If you have carried out a smaller area of detachment, you can use two single suture anchor systems. If a larger area of exposure necessitates a more aggressive tendon detachment, one can use a bridging suture technique.
Place bone wax on the exposed bone to control postoperative hematoma formation and scar tissue formation. Then repair the split tendon by using a running buried absorbable suture. Perform further repair of the medial and lateral tendon slips to the calcaneal periosteum as needed. Carry out the subcutaneous closure with an absorbable suture and close the skin with staples or a non-absorbable suture. If an equinus contracture still exists that is contributory to the condition, the surgeon can carry out a gastroc slide as an adjunctive procedure.
What You Should Know About Post-Op Management
At the completion of the procedure, apply a compression dressing/posterior slab to the lower leg with the foot sitting at approximately 10 degrees of plantarflexion. At two weeks, remove the posterior slab and dressing, inspect the surgical site and remove the sutures or skin staples.
Then place the patient in a walking cast and continue immobilization for another two to four weeks. At the end of this stage of immobilization, initiate range of motion exercises. At eight weeks, discontinue the walking cast and have the patient start wearing a supportive shoe with a heel lift for another eight weeks.
Physiotherapy starts at week 10 and this should include range of motion, plantarflexion strengthening exercises, gait training and edema reduction as necessary. The patient continues home rehabilitation exercises provided by the physiotherapist. Once the strength has improved, one can initiate orthotic therapy in those patients who require biomechanical support.
In the obese, sedentary population, consider the appropriate anticoagulation regimen to prevent deep venous thrombosis.
Complications may include infection, skin edge necrosis, hypertrophic scar formation, sural neuritis or hyperesthesia along the scar. Recurrent pain may occur if the surgeon does not resect an adequate amount of bone.
Surgical management of insertional Achilles tendinopathy can provide an excellent outcome in patients with recalcitrant posterior heel pain who have not responded to non-operative management. There are a number of approaches available to the surgeon as well as techniques for tendon reattachment. One must spend time educating the patient regarding the postoperative course of recovery. Complete healing and resumption of pain-free activity can take up to 12 months.
Dr. Haverstock is an Assistant Clinical Professor of Surgery and the Chief of the Division of Podiatric Surgery in the Department of Surgery at the University of Calgary.
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