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. Introduction to posterior heel pain
There are many causes of posterior heel pain, which should be distinguished from subacromial pain by history taking and physical examination. Pain over the posterior heel can be caused by the following factors.
1, posterior heel bursitis
enlargement of the posterior superior heel bursa, the so-called Haglund deformity.
2. Achilles tendinitis at the stop
an inflammatory bursa between the skin and the Achilles tendon.
Any of the above factors may be present alone or may manifest as a syndrome in combination with each other. Careful analysis of the patient’s complaints and objective findings is the key to arriving at a correct diagnosis.
II. Pathogenesis
1. 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 associated with Haglund’s 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 area 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.
2. 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 higher age.
3. 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 anatomic landmarks of lateral views exist in the heel bone 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.
(4) Pathophysiology: Posterior heel pain syndrome is usually associated with a high arched foot with inversion 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 the stopping point Achilles tendonitis is due to impingement caused by deformity of the foot or enlargement of the posterior heel bursa, rather than ischemia.
Diagnosis
1.History and physical examination
The medical history usually includes the following items.
(1) A slow onset of dull pain behind the heel bone, 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 stop of the Achilles tendon.
2.Clinical manifestations
(1) Careful palpation along the Achilles tendon down to its stopping point is helpful for the diagnosis of stopping point Achilles tendonitis.
(2) There may be increased skin temperature, swelling or tenderness at the stopping point of the Achilles tendon.
(3) If the Achilles tendon itself is neither swollen nor painful to palpate, palpation of the medial and lateral aspects of the anterior border of the Achilles tendon may help diagnose posterior Achilles bursitis.
(4) In some cases, percussive palpation of the bursa may help in the diagnosis.
(5) In 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 tendinitis that combines with thickening and swelling of the Achilles tendon.
(7) The subcutaneous inflammatory bursa is located between the skin and the Achilles tendon rather than deep in 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 palpation of the skin over the posterior heel and may be accompanied by callus formation.
(10) Localized osteochondritis may be present as a scattered, limited area of pressure pain on the heel bone. It is usually found posteriorly on the lateral 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) It should be examined in knee extension and flexion and forefoot abduction and adduction positions respectively to distinguish simple gastrocnemius tension.
3.Imaging features
(1) Lateral films of the foot should be taken in the standing position. The biomechanics of the foot and the specific area behind the heel bone can be evaluated. The reference points are as follows.
(2) The posterior edge of the posterior aspect of the heel bone at the projection of the superior bursa.
(3) The posterior heel node at the Achilles tendon stop.
(4) The medial tuberosity and anterior tuberosity.
The morphology and presentation of the posterior superior heel process should be noted: evaluation of the lateral radiograph should include measurement of the posterior heel angle, which is considered to be overprojected if it is greater than 75°. In patients with symptomatic Haglund’s syndrome, this is most often accompanied by a posterior heel angle greater than 75° and a heel inclination angle greater than 90°. A straight line can also be made along the medial and anterior nodes of the heel and then a parallel line through the posterior lip of the heel-tarsiflexion surface, and if the bursa protrudes beyond this line it is considered abnormal. Other imaging manifestations are described as follows.
(1) posterior heel bursitis (disappearance of the translucent posterior heel recess between the Achilles tendon and bursal projection).
(2) Achilles tendinitis (the width of the Achilles tendon exceeds 9 mm at 2 cm proximal to the bursal projection).
(iii) Posterior subcutaneous bursitis of the Achilles tendon (soft tissue bulge behind the Achilles tendon stop).
(iv) Cortical integrity but protruding from the bursal projection line.
Some experts believe that x-ray measurements are not useful for clinical decision making and therefore focus more on history taking and physical examination. Magnetic resonance imaging (MRI) can visualize the Achilles tendon and bursa and show any bony abnormalities over the posterior aspect of the heel. MRI can also visualize the extent of Achilles tendinitis and differentiate it from simple bursitis.
4. Laboratory tests
Posterior heel bursitis can sometimes be a manifestation of systemic arthritis or gout. Specific laboratory tests can be used to exclude these diseases. It has been found that heel pain caused by metatarsal tenosynovitis or Achilles tendinitis can be seen in patients with seronegative ankylosing spondylitis, but is rare in patients with rheumatoid arthritis.
Treatment
1.Non-surgical treatment
Conservative treatment for posterior heel pain includes the following.
(1) change the movement to reduce the load on the Achilles tendon.
(2) alternating elliptical bike and stationary bike training.
(3) Stretching exercises to pull the gastrocnemius-fibularis muscle complex.
(4) Change shoes to avoid direct compression of the posterior aspect of the heel by the shoe upper.
(5) Add padding to the area to reduce pressure.
(6) Adjust the material and height of the upper.
(7) Slight padding at the heel can elevate the heel to reduce the heel tilt angle and allow the bony prominence to move forward relative to the upper.
(8) Apply non-steroidal anti-inflammatory drugs.
(9) If local injection of steroids is required, extreme caution should be exercised as they can lead to tendon rupture.
(10) Night brace immobilization can reduce morning pain and help improve flexibility of the Achilles tendon.
(11) For athletes, especially runners, who are seen for acute or chronic Achilles pain, training may be modified in one or more of the following ways to achieve a non-surgical cure.
(12) Reducing or stopping the usual weekly training mileage routine.
(13) Temporarily stopping interval training and hill climbing training.
(14) Changing from a hard training surface to a soft surface
(15) Flexibility and strength training for the gastrocnemius-fibularis complex.
(16) For patients with severe pain, significant Achilles tendinitis, or failed conservative treatment, cast immobilization may be used. The affected limb is immobilized in a short leg walkable cast for 4-8 weeks until the local pressure pain disappears. For patients with combined Achilles tendinitis, the application of molded ankle orthoses to extend the braking time can lead to cure after 6 to 9 months.
(17) In child athletes, achilles pain can be caused by osteochondritis of the heel ridge (Sever’s disease) or Achilles tendinitis, which is characterized by positive pressure pain at the Achilles tendon stop. In severe cases, localized twisting of the Achilles tendon is possible. Treatment includes rest and the application of anti-inflammatory medications. The difference between the two types of heel pain is that in osteochondritis the pressure pain appears below the Achilles node, while in Achilles tendinitis the pressure pain is located proximal to the Achilles tendon stop.
2.Surgical treatment
Surgical treatment is indicated in cases where conservative treatment has failed and there is no systemic disease, or in cases of tendon rupture. Surgery should be performed to find the specific cause of symptoms in each patient and, guided by clinical and imaging findings, may include combined debridement of the Achilles tendon, posterior Achilles bursa, subcutaneous bursa of the Achilles tendon, posterior Achilles nodal bursa, and tendon transposition.
To reduce impingement between the bursa and the Achilles tendon stop, a dorsal closed wedge osteotomy has been proposed to reduce soft tissue loading during dorsal extension. However, there is insufficient follow-up data to demonstrate the efficacy of this procedure. In patients with Haglund’s node and posterior heel bursitis, the procedure should be performed in the prone position with the assistance of a tourniquet. A simple postero-lateral or combined postero-lateral and postero-medial incision is usually used, taking care to avoid the peroneal nerve. Careful retraction of the Achilles tendon stop is required to avoid damage to it.
(1) Excise the posterior heel bursa and expose all the bony tuberosities.
(2) Resect the posterior superior process of the heel, preserving the integrity of the subtalar joint and the Achilles tendon stop.
(3) Smooth the posterior border of the Achilles with a bone file and may require anchor nailing to secure the Achilles tendon to the bone surface.
(4) The chronic degenerative tissue of Achilles tendinitis has a different histologic pattern than an acutely ruptured Achilles tendon.
(5) If both Achilles tendinitis and calcification are present, a bunion flexor tendon transposition may be required, aimed at strengthening the Achilles tendon and improving blood flow.