The “Other” Heel Pain
Pain on the back side of the heel at the insertion of the Achilles tendon is a commonly seen disorder in our practice. Research into the development of a spur in this area has been inconclusive as to what exactly is causing this to happen. Traditionally, this was thought to develop due to overuse, such that certain, repetitive, activities induced microtrauma at the insertion of the Achilles tendon which then lead to inflammation and development of the spur. However, individuals who have a relatively sedentary lifestyle also commonly develop these spurs. It is generally accepted that the spur forms on the back of the heel as a result of excess stress from tight muscles/tendons in the back of the foot/leg. There may also be a slightly higher incidence of this condition in females caused by wearing shoes with heels with a very rigid heel counter.
The diagnosis of this problem is relatively straightforward, and generally can be obtained from the patient’s history of present illness. They will often complain of pain in the back of the heel, pain with any type of shoe that has a closed-back, and they can often feel a bump. The pain is usually made better with rest, ice, and oral anti-inflammatories. Physical and radiographic examination often confirm the patient’s symptoms which again include a painful palpable bump on the back of the heel, excessively tight posterior leg musculature, and radiographs which show a spur formation on the back of the calcaneus (heel bone). Very rarely is an MRI necessary, but can be helpful in cases where there is a similar presentation but no obvious bony spur on physical exam or x-ray. This would likely then be an inflamed bursa and/or an acute or chronically inflamed Achilles tendon.
Conservative treatments for the heel spur include rest, ice, stretching of the posterior leg muscles, physical therapy, wearing open-back shoes, adding a heel lift to prevent rubbing in closed-back shoes, and/or avoiding activities that aggravate the spur/pain. Frequently, we see patients who are frustrated with the limited available conservative therapies and surgical intervention is requested.
Surgical intervention requires incising the Achilles tendon, and reflecting it from its insertion on the heel bone. This allows access to the spur which is removed with a bone saw and rasp to make for a smooth, contoured heel bone. Commonly, an inflamed bursa or a thickened Achilles tendon is encountered and these can also be repaired at this time. Finally, the Achilles tendon is reattached to the heel bone utilizing a bone anchor. Post-operatively, the patient is non-weightbearing in a removable boot for approximately 3 weeks. This allows time for the tendon to strengthen its attachment to the heel bone. The patient is then transitioned to walking in the removable boot for another 3-4 weeks. Physical therapy may be implemented, if necessary. Foot orthotics or arch supports may be used afterwards to help prevent recurrence of the condition. Overall, the success of surgery is high. Most studies show greater than 90% of the patients would recommend this surgery for treatment when nonsurgical methods aren’t effective.