Heel Pain – Heel Pain Syndrome Heel pain is a frequent problem for orthopedic surgeons. Successful treatment relies on the correct identification of the cause of the pain after a careful review of the history and systematic examination, and the subsequent initiation of an appropriate treatment program. The patient should be informed that it is not practical to continue activity in conjunction with treatment. Both the patient and the physician often feel frustrated due to the length of time it takes for symptoms to resolve. Etiology The enlarged posterior supraspinatus of the heel bone (Haglund deformity) impinges on the fibers at the Achilles tendon stop, causing agitation of the bony prominence against the Achilles tendon fibers. The enlarged posterior bony prominence of the Achilles bone causes Achilles tendinitis at the stop, posterior Achilles bursitis, and posterior Achilles bursitis, which together constitute Haglund syndrome. The Achilles tendonitis that accompanies Haglund’s syndrome is usually located at or slightly above the stopping point of the Achilles tendon at the back of the Achilles bone, rather than closer to the end. Calcification of the Achilles tendon within this area is representative of calcification of degenerative tendon changes. Achilles tendinopathy can be categorized as either a stopping point dysfunction or a non-stopping point dysfunction. Stopping point Achilles tendonitis occurs in and around the Achilles tendon attachment and may be associated with Haglund’s deformity or the formation of an internal Achilles tendon osteophyte. Disturbances in the biology of the Achilles tendon due to sustained intrinsic loading may be the cause of stopping point Achilles tendonitis, whereas posterior Achilles bursitis arises from impingement of the posterior eminence of the Achilles tendon on the Achilles tendon. Posterior subcutaneous bursitis, an inflammation of the bursa between the Achilles tendon and its surface skin, is often caused by friction between the shoe insert and the posterior malleolus of the Achilles. It is more common in women and less common in athletes. Epidemiology Posterior Achilles bursitis occurs in young people (around 30 years of age), whereas stopping point Achilles tendonitis, with the formation of bony encumbrances, occurs in people of a more advanced age. Anatomy The Achilles tendon stops at the posterior medial aspect of the posterior surface of the Achilles bone. The posterior bursa of the Achilles is located between the Achilles tendon and the posterior superior tubercle of the Achilles in a constant position. Pressure on the posterior Achilles bursa increases with dorsiflexion of the ankle and decreases with plantarflexion. Anatomically, the fibrocartilage on the posterior surface of the Achilles bone forms the anterior capsule wall of the posterior bursa, which is indistinguishable from the thin tendon sheath of the Achilles tendon. The posterior bursa of the heel bone is a disk-like structure located on the posterior superior surface of the heel bone that is concave anteriorly and covers the heel bone like a cap. The posterior bursa of the Achilles lies at a relatively constant distance between the axis of the ankle joint and the stopping point of the Achilles tendon. If the posterior bursa of the heel bone is absent, the distance between the ankle joint axis and the Achilles tendon stop is shortened during dorsiflexion of the ankle. This causes a shortening of the force arm, which affects gastrocnemius function. Thus, the posterior process of the Achilles 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. Pathophysiology Posterior Achilles pain syndrome is usually associated with a high arched foot accompanied by heel pronation. The combination of these factors results in an inability to dorsiflex the foot as normal. The presence of a posterior calcaneal tuberosity increases the pressure between the Achilles tendon and the upper of the shoe, thus making the pain more likely to occur. Posterior heel bursitis is usually seen in the setting of compensatory rearfoot pronation, compensatory forefoot valgus, and first metatarsal column plantarflexion deformity due to abnormal talonavicular joint motion and abnormal coronal and sagittal plane relationships. Hindfoot inversion makes the heel bone more vertical and therefore makes the posterior superior calcaneal tuberosity more prominent. Achilles tendon rupture often occurs in the area of lack of blood supply and nutrition 2-6 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 tendinitis occurs proximally to the site of the posterior Achilles bursa syndrome. It also suggests that stopping point Achilles tendinitis is produced by impingement due to deformity of the foot or enlargement of the posterior calcaneal eminence, rather than ischemia.