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The Journal of Bone and Joint Surgery 80:1814-24 (1998)
© 1998 The Journal of Bone and Joint Surgery, Inc.

Instructional Course Lecture

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Disorders of the Insertion of the Achilles Tendon and Achilles Tendinitis*{dagger}

MARK S. MYERSON, M.D.{ddagger}, BALTIMORE, MARYLAND and WILLIAM McGARVEY, M.D.§, HOUSTON, TEXAS

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons


   Introduction
Top
 Introduction
Functional and Gross Anatomy
 Achilles Tendinitis
 References
 
Because of its size and unique functional anatomy, the Achilles tendon is susceptible to both acute and chronic injury. This paper addresses some of these injuries, including the various forms of tendinitis as well as the various pain syndromes of the retrocalcaneal space, such as retrocalcaneal bursitis and Haglund deformity.


   Functional and Gross Anatomy
Top
 Introduction
 Functional and Gross Anatomy
Achilles Tendinitis
 References
 
The Achilles tendon is the continuation of the triceps surae, which originates from the medial and lateral femoral condyles as the two heads of the gastrocnemius and continues as the gastrocnemius blends with the soleus distally. The Achilles tendon inserts onto the middle third of the posterior tuberosity of the calcaneus. At the bone-tendon junction, the enthesis is composed of calcified and noncalcified cartilage. Paratenon surrounds the tendon and is able to stretch two to three centimeters with movement of the tendon, thereby allowing the Achilles tendon to glide smoothly. The tendon is vascularized by anterior muscular branches as well as osseous and periosteal vessels near the site of insertion. Although there is both a proximal and a distal intratendinous vascular supply, there are considerably fewer vessels four centimeters proximal to the calcaneus than anywhere else in the tendon5,27,44. Thus, the region of the tendon three to five centimeters proximal to the insertion is a relatively avascular zone and is the area most prone to various pathological problems, including chronic tendinitis and rupture. It is assumed that this hypovascularity is one of the causes of rupture.

The anatomical structures that make up the posterior aspect of the heel are the Achilles tendon, the posterior aspect of the calcaneus, the retrocalcaneal bursa, and the pretendinous bursa. The retrocalcaneal bursa lies anterior to the posterosuperior calcaneal tuberosity and lubricates the anterior aspect of the tendon as well as the superior aspect of the calcaneus14. It is important to recognize that there is a normal communication between the posterior aspect of the Achilles tendon and the retrocalcaneal bursa, and retrocalcaneal injection of steroids may adversely affect the insertion of the tendon. If the posterosuperior and lateral process of the calcaneus is enlarged, it is referred to as a Haglund deformity18. The enthesis, the bursa, and the bursal walls form a complex insertional region that protects the Achilles tendon and the posterior aspect of the heel from wear and tear. The insertional region of the tendon was well studied histopathologically in cadaver specimens by Rufai et al.40. They found that, in the specimens that had a prominent superior tuberosity, the walls of the bursa were fibrocartilaginous and replaced the calcaneal periosteum. Because the bursal fibrocartilage was absent when the tuberosity was not prominent, Rufai et al. concluded that the fibrocartilage could be implicated in retrocalcaneal bursitis.

From a functional standpoint, the gastrocnemius and the soleus are important, strong muscles involved in plantar flexion of the foot; the gastrocnemius also flexes the knee by virtue of its origin on the femoral condyles. The gastrocnemius supplies the power for propulsion in walking, running, and jumping, whereas the soleus stabilizes the leg on the foot through its proprioceptive function. The soleus is far more susceptible to immobilization by disuse atrophy. During running, the Achilles tendon is subject to forces that are six to eight times body weight48. Therefore, running may aggravate any underlying biomechanical problems, such as hyperpronation. Because the Achilles tendon inserts onto the calcaneus, subtalar motion can subject the tendon fibers to an uneven rotational force, which can lead to an imbalance at the insertion of the tendon, especially with overuse. This is particularly noticeable in runners whose feet hyperpronate because excessive pronation during midstance causes an internal rotational force on the tibia. However, with extension of the knee, there is an external rotational force on the tibia, and these contradictory forces impart high stresses on the insertion of the Achilles tendon20.


   Achilles Tendinitis
Top
 Introduction
 Functional and Gross Anatomy
 Achilles Tendinitis
References
 
Overuse injury of the Achilles tendon commonly occurs in individuals who are active and who subject the tendon to repetitive forces beyond its ability to heal. This injury has been noted in all types of athletes, not just runners. Individuals who regularly engage in jumping activities subject the tendon to forces that may be of normal magnitude, but the forces are more frequently applied, which increases the likelihood of injury. Although there may be acute and chronic inflammation, it is more logical from a functional perspective to classify these disorders as those that occur at the insertion of the tendon (insertional tendinitis) and those that occur more proximally (noninsertional tendinitis).

The prevalence of noninsertional Achilles tendinitis in runners is high: approximately 10 percent of 109 active runners8,9,23,28. The pathogenesis of tendinitis associated with running is probably different from that associated with other athletic activities, such as ballet, tennis, soccer, and basketball26. Noninsertional tendinitis occurs in more active athletes probably as a result of the repetitive stress of activities involving jumping, pushing off, and cutting. This is in contrast to insertional tendinitis, which occurs in older, less athletic, and overweight individuals.

Noninsertional Achilles Tendinitis
We have found the histopathological classification system for noninsertional Achilles tendinitis that was developed by Puddu et al.39 to be quite useful. Those authors classified tendinitis into three subgroups: paratendinitis, paratendinitis with tendinosis, and tendinosis. Paratendinitis is characterized by inflammation of only the lining of the tendon. Tendinosis is a more advanced condition with inflammation of the paratenon and noninflammatory, atrophic, intratendinous degeneration due to aging, microtrauma, or a decrease in the vascular supply to the tendon. Noninsertional Achilles tendinitis generally occurs in the hypovascular zone, four centimeters proximal to the calcaneus, and the pathological changes are the result of repetitive microtears that produce degeneration of the collagen, fibrosis, or even heterotopic ossification within the tendon13,17,30.

Perhaps the simplest explanation for the development of Achilles tendinitis is overuse associated with excessive forces on the tendon. There is a direct association between the prevalence of Achilles tendinitis and the intensity of training and running activities4,46. Most athletes report a recent change in the duration, intensity, or frequency of their activities. However, there may not always be a marked alteration of physical activity because the changes causing the inflammation may be the result of variations in the running surface or the type of shoes. When the tendinitis is acute, there is pain associated with swelling, warmth, and tenderness three to five centimeters proximal to the insertion.

With acute paratendinitis, there is diffuse fusiform swelling and the tenderness is present during active and passive dorsiflexion and plantar flexion. The pain is exacerbated by rubbing the tendon between the thumb and forefinger, and in doing so the examiner notes thickening (Fig. 1) associated with crepitus when the skin is glided over the tendon. An imaging study is rarely necessary, although a magnetic resonance imaging scan may be performed if there is doubt regarding the diagnosis. The findings are either normal or associated with slight thickening. With paratendinitis with tendinosis, there is more irregularity within the tendon and the thickening is diffuse and visible (Fig. 2). There is marked pain, particularly when the tendon is squeezed. With chronic tendinosis, there is marked weakness and a decrease in push-off strength in addition to an area of pain and thickening of the tendon. As a result of the chronic degeneration, the tendon elongates and is no longer in functional continuity and there is commonly an increase in the passive range of dorsiflexion. Magnetic resonance imaging is not necessary to make the diagnosis, but it may be of some benefit in the planning of operative treatment (Fig. 3).



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  		Fig. 1 Photograph showing mild thickening (arrow) of the distal end of the Achilles tendon four centimeters proximal to the insertion, a finding typical of paratendinitis.

 


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  		Fig. 2 Magnetic resonance image of the ankle in Fig. 1, demonstrating mild thickening of the paratenon and slight intrasubstance degeneration of the tendon.

 


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  		Fig. 3 Coronal magnetic resonance image demonstrating marked thickening of the tendon six centimeters proximal to the insertion, a finding typical of chronic tendinosis.

 
The initial treatment consists of a modification of both activity level and shoewear. If there is acute inflammation of the tendon, running should be discontinued. When activities are resumed, it is important to avoid climbing or running up hills. Sprinting and interval training should be discontinued temporarily. Stretching exercises are important and are performed by leaning forward and maintaining the stretch for thirty seconds. Modifications of shoewear (such as use of 1.5-centimeter heel-lift) and use of ice and nonsteroidal anti-inflammatory medication are important. In severe cases, ultrasound and electrical stimulation, as well as a walking boot with a rocker-bottom sole worn for six weeks, are helpful. If the range of passive dorsiflexion is limited, a night splint, used in addition to stretching of the tendon complex, is useful to maintain and enhance passive stretching of the tendon. The injection of corticosteroids is contraindicated. Once the acute phase resolves, the individual should gradually return to running and an orthotic can be prescribed if there is a problem with hyperpronation32. During the ensuing phase of recovery, it is important to avoid reinjury, which can occur with overtraining. Cross-training with swimming and bicycling is helpful.

Before operative treatment is considered for chronic refractory paratendinitis, patients may be managed with the injection of two milliliters of sterile saline solution into the tendon sheath, with the goal of lifting the inflamed and adherent paratenon away from the tendon. If the inflammation persists for more than six months, operative treatment may be indicated. The operation is planned according to the extent of the pathological process because the technical aspects of the procedure for paratendinitis, and the recovery after it, are considerably different from those for chronic tendinosis. For operative treatment of paratendinitis, the diseased and thickened paratenon is excised through a four-centimeter-long medial incision centered over the area of maximum tenderness. The thickened paratenon is identified (Fig. 4), and all adhesions are removed. A posterior splint is applied to maintain the foot in neutral dorsiflexion. No weight-bearing is permitted for ten days, at which time rehabilitation is begun. Instead of open removal of the inflamed paratenon, percutaneous vertical tenotomies may be performed. A number-15 knife blade is introduced into the tendon percutaneously in four positions (proximal, distal, medial, and lateral), and the ankle is passively plantar flexed and dorsiflexed with each introduction of the knife. Maffulli et al.31 reported the results of percutaneous tenotomy in fifty-two feet; the result was good for thirty-seven of the forty-eight patients.



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  		Fig. 4 Photograph showing an inflamed paratenon enveloping the tendon, which is characteristic of acute paratendinitis.

 
Operative treatment of chronic tendinosis consists of débridement of the paratenon and removal of any degenerative necrotic tissue3,25. If only minimum degeneration of the tendon is evident after débridement, multiple five-millimeter longitudinal fish-mouth incisions are made in the tendon to stimulate revascularization and healing. If there is more extensive degeneration, the central fusiform thickened portion of the tendon must be excised and the defect is closed primarily with a running 4-0 absorbable suture. If there is very extensive degeneration of the tendon, most of the central portion of the tendon may need to be excised. If this is the case, there will not be sufficient tendon left for adequate healing or function; therefore, the tendon defect must be augmented with additional tissue. For selected patients, not only does the addition of a tendon transfer with the flexor hallucis longus improve the strength of the deficient tendon but also the proximity of the flexor hallucis longus muscle to the Achilles tendon probably improves the blood supply to the degenerated tendon (Fig. 5).



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  		Fig. 5 Photograph showing chronic tendinosis after excision of the central portion of the tendon. The flexor hallucis longus tendon (extending outside of the wound) has been obtained distally for transfer.

 
After the débridement for the treatment of tendinosis (with or without a tendon transfer), the patient is not permitted to bear weight for ten days; after ten days, the patient is allowed to walk with a walker boot and to begin early range-of-motion exercises and progressive weight-bearing. The rehabilitation focuses on a gradual, progressive resumption of sports activity similar to that after acute rupture.

The results of these procedures have been quite favorable, although the results reported after treatment of chronic paratendinitis have been better than those after treatment of tendinosis24,33,42,43, perhaps because of the ischemia and degeneration of the tendon in tendinosis. Kvist and Kvist24 reported a good or excellent result in 96 percent of 182 patients who had had operative treatment of chronic paratendinitis; nineteen of the patients had had a bilateral procedure. The final result of operative treatment of chronic Achilles tendinitis is not noted soon after the operation; patients are not expected to regain full function until a year has passed, particularly if there was more advanced degeneration of the tendon. Alfredson et al.1 found that the affected limb was still substantially weaker than the contralateral, normal limb six months after treatment of Achilles tendinitis. Although their patients wore a below-the-knee cast for six weeks after the procedure and although weight-bearing and a functional stepwise recovery program were initiated immediately after removal of the sutures, recovery was not as rapid as expected.

Insertional Achilles Tendinitis
The symptoms of insertional Achilles tendinitis are quite specific and are related to pain at the bone-tendon junction that is frequently worse after exercise but may ultimately become constant. Although this is a fairly common finding in athletes, other conditions and medications that cause pain in the posterior aspect of the heel should be considered, including the various causes of insertional enthesopathy, seronegative spondyloarthropathies, gout, systemic corticosteroids, orally administered fluoroquinolones, familial hyperlipidemia, sarcoidosis, and diffuse idiopathic skeletal hyperostosis.

Insertional Achilles tendinitis can be aggravated by running uphill or by activities performed on a hard surface. Frequently, the patient reports a history of poor stretching, running on the heels or over an excessive distance, or a sudden increase in training intensity. The tenderness is specifically located either directly posterior or posterolateral to the insertion of the Achilles tendon. As degeneration of the tendon increases, a palpable defect may be detected in the substance of the tendon. Dorsiflexion is limited compared with that of the uninvolved ankle because of the relative tightness of the triceps surae. Pain in the heel is the cardinal symptom, and it is increased by prolonged standing, walking, running uphill, or running on a hard surface. The pain generally emanates from the posterior aspect of the heel and is aggravated by active or passive motion. Radiographs often demonstrate ossification in the most proximal extent of the insertion of the tendon or as a spur off the superior portion of the calcaneus (Fig. 6). The size of the osteophyte cannot be accurately determined on radiographs because the structure has a very broad surface that extends across the central half of the insertion of the tendon. Although radiographically it appears that the osteophyte is located in the tendon that envelops it, the tendon is not actually attached to the spur and the insertion of the tendon is continuous with the posterior wall of the calcaneus. Secondary imaging studies, such as magnetic resonance imaging and ultrasonography, are not necessary to make the diagnosis or to plan treatment. Rarely, magnetic resonance imaging may be helpful if there is extensive degeneration because the extent of the degeneration may have some bearing on the choice of the reconstructive procedure.



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  		Fig. 6 Radiograph showing ossification of the posterior aspect of the calcaneus, which is characteristic of insertional Achilles tendinitis.

 
Most patients can be managed successfully with non-operative means7,36,45. Although many patients who have insertional Achilles tendinitis either are sedentary or are recreational athletes, those who are more active or who are competitive athletes should persevere with non-operative management. Modifications in training and the use of ice, nonsteroidal anti-inflammatory medication, and heel-lifts in conjunction with stretching and strengthening exercises are effective for athletes. Other simple measures, such as widening or deepening the heel-counter of the shoe or distribution of pressure with use of a silicone sleeve or pad, may also be effective for active or athletic patients. Various pads should be used to take pressure off the insertion of the Achilles tendon. A quarter-inch to half-inch (0.64 to 1.3-centimeter) felt heel-lift can be incorporated inside the shoe, although this tends to lift the heel out of the shoe. When this happens, a heel-wedge is added to the sole of the running shoe. A horseshoe-shaped felt pad is most effective and may be applied to either the shoe or the posterior aspect of the heel. If these modalities are not effective, more intensive stretching of the Achilles tendon should be performed with use of a night splint to hold the foot in maximum dorsiflexion. If the condition is refractory, the leg may be immobilized in a below-the-knee weight-bearing walking cast or a walker boot for six weeks.

After a period of rest from exercise, activities are gradually resumed with incorporation of a good flexibility program that includes correction of any biomechanical abnormalities. Rest may be achieved not only by cessation, but also by diminution, of the repetitive impact loading of the Achilles tendon. Cross-training may be useful after the acute phase subsides. The introduction of nonloading-type activities, such as swimming, bicycling, aqua jogging, or open-chain kinetic-type weight-lifting exercises, to the management program permits the athlete to stay conditioned. An added advantage is better compliance on the part of the athlete because he or she has a training alternative. As always, ice, compression, and elevation, as well as use of non-steroidal anti-inflammatory medication for a short period, are helpful in the early phases of this condition. Physical therapy is sometimes used for more resistant cases, with a focus on flexibility of the hamstrings and the gastrocnemius-soleus complex as well as the use of modalities such as ultrasound and contrast baths to help to control pain and inflammation at the site of the insertion. Ultimately, when activity (particularly running) is resumed, the distance should be decreased compared with that before the injury and the running surface should be soft. Occasionally, a biomechanical abnormality, such as hyperpronation, is identified. A semirigid orthosis can help to control such a problem. It should be noted that slight undercorrection of a pronated foot with use of an orthosis is better tolerated by runners than is complete correction and that over-correction is frequently intolerable. Again, the injection of corticosteroids is contraindicated.

If the symptoms persist after all nonoperative modalities have been tried, operative intervention is indicated. We have found that a central heel-splitting incision is ideal for patients who have degeneration of the insertion associated with ossification because the pathological process is easy to identify and treat. However, this condition can be treated with numerous operative approaches, including an isolated medial or lateral incision, concurrent medial and lateral incisions, posterior central splitting, and a hockey-stick or transverse incision11,41,42. Therefore, the choice of the operative approach for the treatment of this entity can be confusing because of the plethora of underlying diseases involving the insertion of the Achilles tendon as well as the various incisions that can be used. Common to all procedures, however, is resection of the inflamed retro-calcaneal bursa, removal of the prominent posterolateral bone, and débridement of the calcific and diseased insertion. If débridement of the tibial insertion is done in such a manner that the surgeon believes that complete rupture of the tendon may occur, it is necessary to reattach or augment the tendon.

As noted previously, advantages of the central heel-splitting incision are direct visualization of the pathological process, ease of dissection of the torn portion of the tendon, and removal of the bone spur (Fig. 7-A). However, if the site of the most pain is not located directly posteriorly, the incision should be located either medially or laterally because the torn portion of the tendon may not be visualized from the posterior incision. For any of these incisions, particularly the central vertical incision, the skin should be free of abnormalities, there should be a normal potential for soft-tissue healing, and there should be no scars that could create a hypertrophic scar. The potential for problems with wound-healing and for the formation of a painful posterior scar directly over the heel, which will make it difficult to wear shoes, must be taken into consideration.



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  		Figs. 7-A through 7-E: Photographs showing the stages of the operation for the treatment of insertional Achilles tendinitis. Fig. 7-A: A central heel-splitting incision for resection of the ossification.

 
The procedure is performed with local ankle-block anesthesia and the patient in the prone position. A four-centimeter vertical incision is made directly over the tendon, extending toward the plantar skin surface. The tendon is split longitudinally, with the full thickness of the incision maintained down to bone inferiorly. Usually, the central portion of the tendon has the greatest degeneration and is therefore excised as a longitudinal ellipse (Fig. 7-B). The hypertrophied osteophyte is identified anterior to the tendon and is removed completely with an osteotome (Fig. 7-C). The posterior edge of the bone must be smoothed so that there is no potential source of irritation of the Achilles tendon (Fig. 7-D). Depending on the extent of the degeneration and the amount of tendon that is resected, the tendon split is left open or repaired or, if the surgeons believe that it is warranted, the tendon is reattached to the calcaneus with a suture anchor (Fig. 7-E). It is possible to remove one-third of the insertion of the tendon without reattachment to the calcaneus, although the exact extent of dissection that is possible before rupture is not known.



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  		Fig. 7-B: The necrotic portion of the tendon is excised, and the margins of the tendon are retracted.

 


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  		Fig. 7-C: An osteotome is used to resect the bone spur.

 


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  		Fig. 7-D: After the excision.

 


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  		Fig. 7-E: Because of the extensive degeneration of the Achilles tendon and the resection of the central portion of the tendon, a bone-suture anchor (PBA; Orthopedic Biosystems, Phoenix, Arizona) is used.

 
No weight-bearing is permitted postoperatively until there is complete wound-healing and perfect apposition of the skin edges. By three weeks postoperatively, most patients are fully weight-bearing while wearing either a below-the-knee cast or a removable walker boot positioned in slight equinus. The duration of immobilization, as determined by the extent of the débridement, ranges from four to eight weeks. This is followed by an intensive course of therapy and rehabilitation, the goal of which is improved strength and decreased swelling and inflammation. Recovery is slow, and it may take as long as twelve months to return to normal function, particularly when a patient has seronegative spondylo-arthropathy or insertional enthesopathy. The extent of the disease and the degree of the involvement of the tendon is much greater in patients who are more than fifty years old16. The reported results of treatment of insertional tendinitis have been satisfactory16,29,43.

Haglund Deformity
The function of the retrocalcaneal bursa is primarily to lubricate the tendon during walking or running. The bursa may become irritated by an osseous prominence and become enlarged, and this is followed by impingement on the anterior aspect of the tendon (Fig. 8). The enlarged posterosuperior and lateral calcaneal tuberosity was originally described by Patrick Haglund18 in 1928; it has since been associated with various types of shoes, as reflected by the names pump bump10, high heel12, and winter heel35. Haglund deformity occurs when the bursal projection is compressed by a poorly fitting heel-counter, leading to subcutaneous irritation and bursitis of the adventitial bursa. If the bursal projection is excessively large, reactive inflammation may develop in the retrocalcaneal bursal space, exacerbating pain in the posterior aspect of the heel. It should be emphasized that, although Haglund deformity is common in patients who have insertional Achilles tendinitis, it typically does not involve the Achilles tendon. The pump bump has a fairly innocuous presentation (Fig. 9) and, if symptomatic, usually responds well to basic intervention such as shoe modifications and the use of pads, ice, and anti-inflammatory medication.



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  		Fig. 8 Photograph showing prominence of the posterosuperior and lateral aspect of the calcaneus, a finding typical of a Haglund deformity.

 


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  		Fig. 9 Radiograph of a Haglund deformity, demonstrating a normal clear space between the bone and the tendon, a finding that indicates the absence of retrocalcaneal bursitis.

 
Patients who are managed for Haglund deformity are typically younger (between fifteen and thirty years old). The presentation is different from that of retrocalcaneal bursitis, although, as noted, these patients may have acute retrocalcaneal bursitis in addition to the symptoms resulting from pressure from the shoe. Symptoms arise from the osseous prominence along the posterosuperior and lateral margin of the calcaneus rubbing against the heel-counter of the shoe. Skin irritation occurs, and these patients, who are often young women, are seen because of localized erythema and focal swelling. The etiology of this condition is usually developmental and is aggravated by certain types of shoes. Although trauma to the apophysis in childhood may lead to the development of an osseous prominence, this is unusual. Most likely, Haglund deformity has a biochemical etiology that leads to mechanically induced inflammation of the posterior aspect of the heel. Difficulties related to the diagnosis and treatment of retrocalcaneal pain are inconsistencies in the nomenclature, anatomical discrepancies, and the fact that little has been written to describe how to verify the exact cause of pain accurately. Even if it is assumed that the posterosuperior and lateral osseous prominence is pathological, there is no accurate and reproducible way of determining the extent of the deformity or how much bone should be resected.

One should not be confused by the nomenclature of the numerous bumps on the posterior aspect of the heel. As stated, Haglund18 described the painful condition caused by an osseous prominence on the posterosuperior and lateral aspect of the calcaneus. Enlargement of the entire posterior aspect of the calcaneus may occur, either directly posterior or slightly more inferior to the insertion of the Achilles tendon. A patient who has a symptomatic Haglund deformity typically has a painful, red, irritated heel with a palpable and visible osseous prominence on the posterosuperior and lateral aspect. Frequently, a patient has a high arched cavus foot with a particularly narrow heel. The condition is often worse when certain shoes are worn, especially those that have a hard or irregularly shaped heel-counter. There is a large, tender prominence on the lateral side of the insertion of the Achilles tendon but not directly on the central portion of the posterior tuberosity.

Many radiographic measurements can be used in an attempt to identify the extent of a Haglund deformity, but we have not found any to be reliable or even helpful in the planning of treatment. Although many angles and lines may be used to determine the presence of abnormal bone superiorly, none adequately portray lateral osseous prominences. The various measurements include those described by Fowler and Philip12, Steffensen and Evensen49, Pavlov et al.38, Chauveaux et al.6, and Sella et al.47 (Fig. 10). A Fowler-Philip angle of more than 75 degrees is supposedly diagnostic of enlargement of the posterior aspect of the calcaneus, although most authors have found no association between the size of the angle and symptoms15,19,52. Pavlov et al. believed that the height of the superior aspect of the calcaneus and not the angular relationships of the posterior aspect was related to the symptoms. Those authors developed a technique involving parallel pitch lines. They drew a line from the posterosuperior articular facet to the posterior aspect of the calcaneus, noting that the postero-superior aspect of the calcaneus should be inferior to the superior line. The problem with this technique is that it does not measure the length or the inclination of the calcaneus (the angle between the plantar surface of the calcaneus and the floor on a lateral radiograph made with the patient standing). Because pain may occur at the insertion of the Achilles tendon, Chauveaux et al. described an alternate measurement. This angle is more relevant to other forms of pain in the posterior aspect of the heel than it is to Haglund deformity because the inclination and length of the calcaneus are measured.



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  		Fig. 10 Angles and lines used to measure abnormal bone on the superior surface of the calcaneus and to determine the position of the calcaneus.

 
The nonoperative treatment of Haglund deformity is similar to that of insertional Achilles tendinitis and is based on the relief of friction between the heel-counter, the heel, and particularly the inflamed bursa. Adjustments in shoewear can be made, with particular attention directed to the height of the heel and the rigidity and shape of the heel-counter. The use of a close-fitting rigid heel-counter should be avoided so as to prevent irritation of the bursal projection. A heel-insert elevates the heel from the shoe and may change the area of mechanical irritation at the upper edge of the heel-counter. A moderate-to-high heel can sometimes be beneficial by decreasing the angle of inclination of the calcaneus, which essentially alleviates the irritation caused by the bursal projection by forcing the foot downward and displacing the heel from the counter of the shoe. When these measures as well as the use of nonsteroidal anti-inflammatory medications, stretching exercises, and other therapeutic modalities fail, the patient should be considered a candidate for operative intervention.

Operative intervention falls into two broad categories: resection of the osseous prominence and displacement osteotomy. Resection of the prominent bone is performed most often and is the most reliable form of treatment. The key to a successful result is resection of an appropriate amount of bone, which should include the entire bursal projection and an additional 0.5 centimeter. We recommend a lateral incision immediately anterior to the insertion of the Achilles tendon because the tendon itself is usually not involved in this condition and the bursal projection is almost invariably on the lateral side50. If the symptoms warrant it, the retrocalcaneal bursa can be excised, although this is not usually necessary. The extent of the ostectomy depends on the size of the osseous prominence, although removal of a large amount of bone is not necessary. It is important to use the described short, vertical, lateral incision for excision of a Haglund deformity immediately anterior to the Achilles tendon because there is less likelihood of injury to the sural nerve or the Achilles tendon. Other incisions that have been described for the treatment of pain in the posterior aspect of the heel are not indicated for a resection of a posterosuperior and lateral osseous prominence.

The second method of treatment involves a dorsal closing-wedge osteotomy, which realigns the prominent bursa by displacing it from the Achilles tendon. Zadek53 as well as Keck and Kelly22 reported the results of a dorsally based osteotomy at the posterior aspect of the calcaneus. Zadek believed that removal of the Achilles bursa alone was not adequate and recommended calcaneal osteotomy to decrease the pressure on the posterior-central aspect of the heel without disrupting the insertion of the Achilles tendon. That author recommended removal of a 0.6-centimeter-wide wedge through the body of the calcaneus, leaving a plantar hinge intact, and use of chromic sutures to secure the osteotomy site. We perform this osteotomy, with use of rigid internal fixation, for patients who have an abnormally prominent posterior tuberosity, but the osteotomy should be performed as a greenstick fracture of the interior cortex without complete detachment of the bone. In this manner, there is less likelihood of any shift of the posterior tuberosity. The position of the closing-wedge osteotomy is also critical because placement too far anterior or posterior compromises either the subtalar joint or the posterior attachment of the Achilles tendon. A more difficult problem, however, is the occurrence of a sharp osseous projection on the posteroinferior aspect of the calcaneus as a result of the heel-pad shifting slightly posteriorly and superiorly. This causes a very painful prominence that is not easily treated with padding and may necessitate a second operation. It should be noted, however, that this osteotomy changes the shape of the posterior aspect of the heel and that, in our experience, the heel widens slightly even though the posterior osseous prominence is decreased in size. Theoretically, as a result of the change in the position of the insertion of the Achilles tendon, the kinematics of the posterior aspect of the ankle may change; however, we have not found this to be clinically important. Although there are certain patients for whom this procedure may be indicated because of an abnormally shaped posterior aspect of the heel, this procedure should not be performed routinely due to the increased morbidity compared with that of more simple superolateral resection.

The results after resection of a Haglund deformity have not always been favorable. Nesse and Finsen34 noted that pain persisted in twelve of thirty-five heels and that additional complications and symptoms related to the leg were associated with twenty-two heels. Those authors noted that the degree of relief of pain in the heel was independent of the amount of bone that had been resected but that stiffness and pain in the ankle were much more commonly associated with large, rather than small, resections. For this reason, Nesse and Finsen as well as Taylor51 recommended nonoperative treatment whenever possible. Other authors37 reported more favorable results after operative treatment, finding (as we have) that resection of the bursa is not necessary and that preoperative planning is important in order to remove an adequate amount of bone, which is the key to a successful result. It has been our experience that failure after excision of a Haglund deformity is due either to insufficient resection of bone or to injury of a branch of the sural nerve, which can be avoided by making the incision posterior to the sural nerve.

Retrocalcaneal Bursitis
Patients who have retrocalcaneal bursitis are generally in the fifth or sixth decade of life. They are usually low-level recreational athletes or sedentary and often are obese. The onset of retrocalcaneal bursitis is typically acute, with deep pain and swelling of the posterior soft tissues. This swelling may be noticeable, with a bulge of the soft tissues medial and lateral to the tendon, and it may be associated with warmth and increased pain with range-of-motion maneuvers. In particular, passive dorsiflexion is uncomfortable, and there is medial or lateral tenderness, or both, just anterior to the Achilles tendon. Although lateral radiographs of the calcaneus can demonstrate the characteristically prominent superior calcaneal deformity, they are generally not helpful and the clinical findings remain diagnostic. The lateral radiograph may show obliteration of the normal soft-tissue shadow of the retrocalcaneal space; in addition, this radiograph shows the osseous projection superiorly and posteriorly.

Nonoperative treatment consists of rest as well as the use of ice, a heel-lift, and, in particular, an open-back shoe, which is similar to the treatment of other problems in the region of the insertion of the Achilles tendon. If the symptoms are refractory, a single injection of corticosteroids may be used; however, the potential for rupture of the tendon with repeated injections should be noted. If steroids are injected, the leg may be temporarily immobilized in a weight-bearing cast or a walker boot to protect the tendon. If these measures fail, an operation may be indicated and is easily performed through a short vertical lateral incision. Some surgeons prefer to use a medial incision instead of, or in addition to, the vertical lateral incision if the osseous prominence is particularly large. If the lateral incision is used, it should be made immediately anterior to the tendon to avoid the sural nerve, which is located more anteriorly. Generally, it is possible to resect the lateral portion of the posterosuperior aspect of the calcaneus with an ostectomy performed through the lateral incision; a medial incision should be used when bone that cannot be resected through the lateral incision is still present medially. There should be no osseous impingement and the retrocalcaneal space should be decompressed by the ostectomy after resection of the inflamed bursa. The patient is non-weight-bearing for one week postoperatively, followed by activity as tolerated and use of a below-the-knee weight-bearing cast or a walker boot for four weeks.

The reported results of resection of the bursa and the posterior aspect of the calcaneus for correction of refractory bursitis have varied. Some authors21,50 have had good results provided that sufficient bone was resected and there were no neurological complications. However, Angermann2 reported what he called a cure rate of only twenty (50 percent) of forty heels that had had resection of the posterosuperior aspect of the calcaneus to treat chronic retrocalcaneal bursitis. Interestingly, Angermann did not find any association between the size of the resection and the result of the procedure.


   Footnotes
 
*Printed with permission of the American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 48, American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 1999.

{dagger}No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

{ddagger}Union Memorial Orthopaedics, The Johnston Professional Building, Suite 400, 3333 North Calvert Street, Baltimore, Maryland 21218.

§University of Texas Health Science Center, 6431 Fannin Street, Houston, Texas 77030.


   References
Top
 Introduction
 Functional and Gross Anatomy
 Achilles Tendinitis
 References
 

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