The back of the heel (posterior heel) can become painful for many reasons. It is a particularly important area because this is where the Achilles tendon inserts. The Achilles tendon is the largest and strongest tendon in the body and responsible for lifting the entire body weight with every step. Pain can develop at the back of the heel from……
Insertional Achilles Tendinosis
Achilles Tendon Rupture
Bursas are small sacks of fluid located all over the body that are designed to cushion and reduce friction between anatomical moving parts. They tend to be located around joints and where tendons insert into bone. If a bursa is damaged or becomes over stressed it can become inflamed and painful. When a bursa becomes inflamed it is called bursitis.
Achilles bursitis, also called retrocalcaneal bursitis, affects a bursa that can develop at the back of the heel due to irritation of the Achilles tendon against the heel bone. There is a small space between the upper third of the heel bone and the Achilles tendon that can become irritated leading to the development of the bursa. The irritation can be a result of activity or type of shoes. Certain types of bony anatomy can be a cause such as a “Hagland’s Deformity.” Less commonly, a bursa can develop just under the skin on top of the Achilles tendon. This type of bursa is called a subcutaneous calcaneal bursa.
To test for Achilles bursitis, pinch the back of the heel on either side of the Achilles tendon at the superior edge of the heel bone. This will compress the bursa between your fingers and cause pain.
Treatment for Achilles bursitis is much the same as for other ailments we are discussing for posterior heel pain. It includes: rest, walking boot, night splints, physical therapy, ice, NSAIDS, and stretching. Cortisone injections can be used in certain situations.
If conservative treatment fails there are several surgical options. Recently, a new minimally invasive surgery has become available called the Tenex procedure. The Tenex procedure uses ultrasound to break up the bursa. The ultrasonic probe also has a suction collar on it through which the bursa is removed. As a second option, the bursa can be removed endoscopically with a scope. This technique uses similar instruments used in knee and shoulder scopes. As a third option, the bursa can be surgically excised. Regardless of which procedure is performed, the recovery is relatively quick because the Achilles tendon is not disturbed. Due to the bursa’s location it can be accessed with little trauma to surrounding structures. Patients are usually able to weight bear in a post-op boot within a week. Sports can be resumed in 4-6 weeks.
Insertional Achilles tendinosis is often confused with Achilles tendonitis. Tendonitis is an acute inflammatory process of a tendon, but the tendon is anatomically and histologically intact. Tendinosis is more of a chronic pathology that involves a destructive process of a tendon. The heel bone is also affected with tendinosis and often develops spurs and calcifications. Calcifications can extend into the tendon itself.
Insertional Achilles tendinosis often begins with a bone spur at the back of the heel. The spur causes inflammation that extends into the Achilles tendon. Patients usually complain of a painful large “bump” on the back of their heel. Pain may increase when the back of their shoe presses on the area.
While Achilles bursitis is described as a separate entity above, it is very commonly associated with and seen with insertional Achilles tendinosis. Pain is often worse when wearing a shoe that presses on the back of the heel. Many patients with insertional Achilles tendinosis get in the habit of wearing backless shoes to alleviate anything pressing on the area. Pain is usually directly over the back of the heel bone. This is where the Achilles tendon inserts and where the spur and/or bursitis is located.
Insertional Achilles tendinosis most commonly develops as a result of abnormal biomechanical forces in the foot. These abnormal biomechanical forces can be from trauma or chronic overuse.
Treatment for insertional Achilles tendinosis is much the same as for other ailments we are discussing for posterior heel pain. It includes: rest, walking boot, night splints, physical therapy, ice, NSAIDS, and stretching. Cortisone injections can be used in certain situations. Some patients find tremendous relief simply by switching to backless shoes. The back of shoes, or heel counter, can cause a lot of pain because it usually falls directly over the insertion of the Achilles tendon and directly over the spur.
Another important aspect to managing insertional Achilles tendinosis is early recognition. Insertional Achilles tendinosis is a chronic condition and takes years to develop. If the condition is addressed early, custom molded orthotics can be fabricated to negate the abnormal biomechanical forces and arrest the progression of the disease.
Unfortunately, insertional Achilles tendinosis does not usually respond well to conservative care. Once the disease has progressed to the point where the tendon exhibits degenerative changes and spurs have formed, conservative care is temporary at best.
If conservative treatment fails there is a new minimally invasive treatment available, the Tenex procedure. The Tenex procedure is a minimally invasive procedure that uses ultrasound to break up and removed the damaged portions of the tendon. The ultrasonic probe also has suction collar on it through which the bursa is removed. This treatment works wonders for patients whose pain is from the damaged tendon and bursitis. If the pain is caused by a bone spur or calcifications the Tenex procedure will not be effective.
Insertional Achilles tendinosis is difficult to manage conservatively and many patients ultimately end up requiring surgery. Surgery involves excision of all damaged portions of the Achilles tendon and removal of the bone spurs from the back of the heel. Removing the bone spur requires detaching a large portion of the Achilles tendon for access. Once the spur is removed the Achilles tendon must be reattached to the heel bone. This reattachment process requires 12 weeks of non-weight bearing which is usually the biggest drawback for patients.
There is often an associated Achilles bursitis associated with this condition that is excised as well.
If the Achilles tendon has deteriorated significantly from the disease, a second tendon may be transferred to assist the Achilles tendon’s function. The Flexor Hallucis Longus(FHL) tendon is a strong tendon located deep to the Achilles tendon. This tendon provides an excellent source for a transfer. The FHL tendon is transferred into the back of the heel bone just behind the Achilles tendon insertion. This tendon transfer provides reinforcement to the Achilles tendon as well as increased healing capacity, circulation, durability, and ultimate strength to the Achilles tendon.
Surgical correction of insertional Achilles tendinosis begins with removing any damaged portions of tendon. The Achilles tendon is then detached from the back of the heel and the bone spur and bursa are excised.
Next, the flexor hallucis longus tendon is harvested from deep in the ankle.
The flexor hallucis longus tendon is then transferred into the back of the heel close to where the Achilles tendon inserts using a bone anchor (white arrow). This transferred tendon will act to assist the Achilles tendon and provide additional strength to the Achilles tendon. It also balances the abnormal biomechanical forces that caused the condition to develop and prevents recurrence.
Once the procedure is complete the Achilles tendon is reattached to the back of the heel bone.
Postoperative recovery usually involves 12 weeks with non-weight on the affected foot, followed by progressive rehabilitation focused on strengthening, gait mechanics, and proprioception conditioning.
Achilles tendonitis is inflammation of the Achilles tendon. Achilles tendonitis is surprisingly uncommon compared to the other ailments described above. Many conditions that occur at the back of the heel are incorrectly termed Achilles tendonitis when in fact they are one of the other ailments described above.
Achilles tendonitis usually affects the middle portion of the tendon above the heel bone. It is more common in young active patients. Excessive exercise or walking are the most common causes of Achilles tendonitis. Any repetitive activity can strain the Achilles tendon leading to the condition. It is important to see your doctor if you suspect you have Achilles tendonitis because chronic inflammation can lead to an Achilles tendon rupture.
For those who have repetitive bouts of Achilles tendonitis and do not want to give up their active lifestyle, there are a few things to keep in mind.
Achilles tendonitis is an overuse injury, so treatment focuses on resting the area. This will include a walking boot that does not allow the ankle to move. Oral anti-inflammatory medications and ice are helpful as is physical therapy.
Hagland’s deformity is a bony prominence/spur at the back of the heel, usually laterally. We use the term bony prominence because often the bone is normal with no spurring, but the biomechanics of the foot have caused the site to stick our more than it should. This prominent area of bone begins to rub on surrounding structures. Clinically, there is usually a red “bump” at the back of the heel that is painful. Pain is worse with pressure or shoes that press on the site. Hagland’s deformity is also called a “pump bump” because the rigid back of a pump-style shoe tends to cause pressure directly on the area.
Haglund’s deformity is difficult to distinguish from insertional Achilles tendinosis because they both present with pain directly over the back of the heel bone. Haglund’s deformity pain is more confined to a relatively small area at the back of the heel. Insertional Achilles tendinosis tends to be painful over the entire back of the heel. Haglund’s deformity will usually present with a small (1-inch diameter) red bump at the back of the heel. Insertional Achilles tendinosis may have a bony prominence, but it will be less defined, and sometimes the entire back of the heel looks like one big “bump.”
The goal of conservative treatment for a Haglund’s deformity is to protect the bony prominence at the back of the heel. This is achieved by padding the area and wearing shoes that do not press directly on the site.
Pads come in all shapes and sizes. The aperture pads or “doughnut pads” are ideal because they transfer any pressure away from the tender spot onto the surrounding pad. Shoes should have a soft counter. Backless shoes are ideal because they exert zero pressure on the back of the heel. Additional conservative treatment may include rest, walking boot, night splints, physical therapy, ice, NSAIDS, and stretching. Cortisone injections can be used in certain situations. Custom molded orthotics are also very effective in the treatment of Haglund’s deformity. Orthotics can change the biomechanical forces that are causing the prominence to be accentuated.
Surgical correction for a Haglund’s deformity involves removing the underlying bony prominence and any associated bursa. The surgery is performed through a 2-inch incision over the bump. The bursa is removed along with the underlying bone. Usually, this surgery can be accomplished with minimal disruption of the Achilles tendon because the offending bony prominence is located above the insertion of the tendon. There is also an endoscopic option which is even less invasive. Recovery is usually quick. Patients can bear weight within a week and are back in regular shoes in 3 to 4 weeks.