Heel pain is a frequent problem for orthopaedic surgeons. Successful treatment relies on a careful review of the history and systematic examination for proper identification of the cause of the pain and subsequent initiation of an appropriate treatment plan. Patients should be informed that it is unrealistic to continue activity while being treated. Both patients and physicians often feel frustrated due to the length of time it takes for symptoms to resolve. Most experts recommend conservative treatment for 6 to 12 months before considering surgical treatment. Heel pain can be divided into two types: subacromial pain and posterior heel pain syndrome. Although all orthopedic surgeons are familiar with the term heel pain syndrome, they often do not fully understand the difference. I. Etiology The enlarged posterior superior heel process (Haglund deformity) impinges on the fibers at the Achilles tendon stop, causing irritation of the bony process and Achilles tendon fibers. The enlargement of the posterior bony process of the heel triggers tendinitis at the stop, posterior heel bursitis, and posterior Achilles bursitis, which together constitute Haglund’s syndrome. The Achilles tendinitis that accompanies Haglund syndrome is usually located just at or slightly above the stop of the Achilles tendon at the posterior aspect of the heel and not closer to the end. Calcification of the Achilles tendon in this region is representative of calcification of the degenerative tendon. Achilles tendinopathy can be divided into stopping point dysfunction and non-stopping point dysfunction. Stopping Achilles tendinitis occurs in and around the Achilles tendon attachment and may be associated with Haglund’s deformity or with the formation of internal Achilles tendon osteophytes. Biological disturbances of the Achilles tendon due to constant intrinsic loading may be the cause of stopping Achilles tendonitis, whereas posterior Achilles bursitis arises from impingement of the posterior heel process with the Achilles tendon. Posterior Achilles subcutaneous bursitis, an inflammation of the bursa between the Achilles tendon and its surface skin, is often caused by friction between the shoe upper and the posterior heel process. It is more common in women and less common in athletes. Epidemiology Posterior Achilles bursitis is more common in young people (around 30 years old), while stopping Achilles tendonitis with bone formation is more common in people of older age. Anatomy The Achilles tendon ends at the posterior medial part of the posterior aspect of the heel bone. The posterior Achilles bursa is located between the Achilles tendon and the posterior superior calcaneal tuberosity and is in a constant position. The pressure on the posterior heel bursa increases during dorsiflexion of the ankle and decreases during plantarflexion. Anatomically, the fibrocartilage on the posterior surface of the heel constitutes the anterior wall of the posterior heel bursa, which is indistinguishable from the thin tendon sheath of the Achilles tendon. The posterior heel bursa is a disc-like structure located posteriorly over the heel bone, which is concave anteriorly and covers the heel bone like a cap. The posterior Achilles bursa is located at a relatively constant distance between the axis of the ankle joint and the stop of the Achilles tendon. If the posterior heel bursa is absent, then the distance between the ankle axis and the Achilles tendon stop is shortened during dorsiflexion of the ankle joint. This results in a shortening of the force arm and thus affects gastrocnemius function. Therefore, the posterior heel process is similar to a lever fulcrum that ensures that the tension of the gastrocnemius muscle group acting on the Achilles tendon remains stable during dorsiflexion or plantarflexion of the foot. The morphology of the posterior superior heel tuberosity may be over-, normal-, or under-projected. The following anatomical landmarks of the lateral view exist in the heel x-ray anatomy: 1. The heel talar articular surface of the heel bone marks the most proximal end of the posterior aspect of the heel. 2, The bursal projection is in the area above the posterior heel tuberosity. 3, The posterior aspect of the posterior heel tuberosity is the stop of the Achilles tendon. 4.The medial heel node is the stop of the central bundle of the metatarsal tendon membrane. IV. Pathophysiology The posterior heel pain syndrome is usually associated with a high arched foot with internal rotation of the heel bone. The combination of these factors causes the foot to fail to extend dorsally as normal. The presence of the posterior heel bulge increases the pressure between the Achilles tendon and the upper of the shoe, thus making it more likely that pain will occur. Posterior heel bursitis is usually seen in cases of compensatory hindfoot pronation, compensatory forefoot valgus, and first metatarsal row plantarflexion deformity due to abnormal movement of the subtalar joint and abnormal coronal and sagittal plane relationships. Hindfoot inversion makes the heel bone more vertical and therefore makes the posterosuperior heel node more prominent. Achilles tendon rupture often occurs in the area of lack of blood supply and nutrition 2 to 6 cm proximal to the Achilles tendon stop. This is a very important finding in relation to posterior Achilles bursa syndrome, as this type of typical Achilles tendonitis tends to occur proximal to the site of posterior Achilles bursa syndrome. This also suggests that stopping Achilles tendonitis is produced by impingement due to deformity of the foot or enlargement of the posterior heel bulge rather than ischemia. The history usually includes the following: 1. slow onset of dull pain at the posterior aspect of the heel, aggravated after exercise or after wearing specific shoes; 2. pain after rising from a sitting position, or after waking up in the early morning; 3. gradual swelling at the Achilles tendon stop. Clinical manifestations 1. Careful palpation along the Achilles tendon down to its stopping point can help the diagnosis of stopping point Achilles tendonitis. 2.There may be increased skin temperature, swelling or tenderness at the stopping point of Achilles tendon. 3, If the Achilles tendon itself is neither swollen nor tender, palpation of the medial and lateral aspects of the anterior border of the Achilles tendon can help to diagnose retrocalcaneal bursitis. 4, In some cases, percussive palpation of the bursa can help in the diagnosis. 5, For posterior Achilles bursitis, the pain is increased during dorsiflexion of the foot due to increased pressure on the bursa between the Achilles tendon and the heel bone. 6, This condition can coexist with stopping Achilles tendonitis that combines Achilles tendon thickening and swelling. 7, The subcutaneous inflammatory bursa is located between the skin and the Achilles tendon, rather than in the deeper layers of the Achilles tendon. 8, There may be increased skin temperature at the posterior heel ridge, and the skin on its surface may be thickened and inflamed. 9.The presence of Haglund’s deformity can be determined by palpating the skin over the posterior heel bone, and the local skin may be accompanied by callus formation. 10, Localized periostitis may be present as a scattered, limited area of pressure pain in the heel bone. It is usually found on the lateral aspect of the posterior aspect of the heel bone, mostly due to long-term compression of the shoe upper. 11, Passive dorsiflexion of the ankle joint can be used to assess for the presence of Achilles tendon contracture, resulting in increased tension at the Achilles tendon stop. 12.The knee joint should be examined in extension and flexion and forefoot abduction and adduction positions respectively to differentiate simple gastrocnemius tension.