- Email: [email protected]
Posterior heel pain
FOOT AND ANKLE
Posterior heel pain
common. The Achilles tendon is formed by the soleus and gastrocnemius muscles which unite to form a conjoint tendon which inserts distally onto the middle third of the os calcis (Figure 1). This area, known as the enthesis or transition zone, acts to evenly distribute the mechanical load transmitted from the soft tissues to the calcaneum.3 The tendon itself is composed of mostly type I collagen fibres, which are well organized longitudinally and surrounded by an extracellular matrix.4 The term ‘tendinitis’, in relation to disorders of the Achilles, has been discredited.5 Inflammatory cells such as macrophages and neutrophils are absent on histological examination. Instead abnormal tenocytes predominate, with disorganization of the collagen fibres.6,7 The tenocytes are subsequently prone to apoptosis, and there is evidence of neovascularization whereas, conversely, healthy tendon will be avascular. These characteristics in the thickened tendon are classic of degeneration secondary to overuse and a failed healing response, rather than an inflammatory process.5,6 Degeneration of the tendon can also be associated with a prominent postero-superior projection of the calcaneum, otherwise known as Haglund’s deformity.8 This variant can cause impingement of bone against the Achilles tendon. Irritation of the soft tissues frequently leads to inflammation of the bursa within the retrocalcaneal recess (retrocalcaneal bursitis).9 Microtrauma or increased activity levels have been linked to calcific deposition within the Achilles tendon.10 A bony spur then projects from the os calcis and this is evident radiologically. The spur is also known as an enthesophyte.
Christopher P Jukes Georgia Scott Matthew C Solan
Abstract Heel pain at or around the insertion of the Achilles tendon is a common presenting complaint affecting both young, active patients and those who are older and more sedentary. So-called posterior heel pain is often presumed to run a self-limiting course over a few months, resolving with rest, weight loss and stretching exercises. However, a small number of patients suffer with increasingly disabling symptoms that are refractory to this regimen. Posterior heel pain is classically split into insertional and non-insertional types, and in order to select an appropriate management plan the diagnosis must be precise. Further management without a clear understanding of the pathology is potentially detrimental to the patient. This review aims to provide a structured approach to careful clinical and radiological assessment and treatment of this condition.
Keywords gastrocnemius release; heel pain; insertional; non-insertional; tendinopathy
Introduction Heel pain, classified as either posterior or plantar, can be a troublesome complaint posing a diagnostic challenge for the physician.1 Often it resolves after a period of time with analgesia and tailored physiotherapy. However, a small number of patients go on to suffer chronic, debilitating symptoms. Choosing the correct treatment can be confusing given the number of different pathologies involved. A variety of different non-operative treatments are available. This attests to the absence of one reliable treatment. Where non-operative treatments fail there are surgical options to consider, but only as a last resort. This article focuses on the diagnosis and management of posterior heel pain, including Achilles tendinopathy of the insertional and non-insertional (main body) types.2 Plantar heel pain and Achilles tendon rupture are not discussed here.
Terminology The term tendinitis, implying inflammation of the tendon, should be abandoned. As discussed above, there is no evidence of inflammatory exudate on histological examination. There is mucoid change instead of granulation tissue formation in those who suffer with chronic pathology.5,6 Tendinosis is therefore the appropriate term for this degenerative change, without evidence of attempted healing. Maffulli described the triad of pain, swelling (diffuse or localized) and impaired function as characteristic of Achilles tendinopathy.11 A streamlined classification system was proposed in order to clarify the nomenclature relating to Achilles tendon pathologies (Table 1). Demographics Achilles tendinopathy is often perceived as a problem presenting in the young athletic person, related to excessive strain. The demographics are more complex, and insertional tendinopathy is more common in the older, sedentary population.12 The likelihood of developing symptomatic tendinopathy increases with body mass index (BMI) and age.13 It is believed that, in an era of increasing health awareness, activity and lifespan, the incidence of Achilles tendinopathy is rising. However, reliable epidemiological data are not readily available to substantiate that claim.14
Pathophysiology Achilles tendinopathy may be classified by its anatomical location as insertional or non-insertional, with the latter being more
Christopher P Jukes MRCS BSc(Hons), Orthopaedic Registrar, Trauma and Orthopaedics Department, Royal Surrey County Hospital, Guildford, UK. Conflicts of interest: none declared. Georgia Scott MRCS, Core Surgical Trainee, Trauma and Orthopaedics Department, Royal Surrey County Hospital, Guildford, UK. Conflicts of interest: none declared.
Clinical presentation
Matthew C Solan FRCS (Tr&Orth), Consultant Foot & Ankle Surgeon, Trauma and Orthopaedics Department, Royal Surrey County Hospital, Guildford, UK. Conflicts of interest: none declared.
History The primary symptom is pain, commonly presenting as ‘start-up’ pain and stiffness affecting the first steps in the morning or after a
ORTHOPAEDICS AND TRAUMA xxx:xxx
1
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
Figure 1 Posterior heel anatomy.
period of rest. This classically is relieved by gentle activity but then exacerbated again by exercise. Patients are often frustrated by an inability to walk long distances or to take part in sport or fitness activities. Symptoms are usually insidious in onset, but may coincide with altered activity levels (such as longer periods of standing), new sports footwear, or increased body weight. Establishing the duration of symptoms is important. It is well documented that most cases of posterior heel pain with a recent onset are self-limiting, and many will improve without intervention. Chronic cases require more consideration, especially when first-line treatments have already been unsuccessful. Since posterior heel pain is closely associated with adverse biomechanics, particularly isolated gastrocnemius tightness, symptoms of other conditions that are associated with this should be considered when taking a history (Figure 2).
performed with the talonavicular joint held in the reduced position. If not performed properly the heel can escape into valgus, thus shortening the distance between the knee and the heel, resulting in masking of any gastrocnemius contracture.15 Failure to appreciate this will result in a false-negative test. The Achilles tendon and its insertion can be examined conveniently with the patient kneeling on a couch or chair, as one would when performing Simmonds’ calf squeeze test for Achilles tendon rupture. This allows a good view of the heel, as well as accurate palpation of the tendon from the musculotendinous junction to the calcaneum. It is key to differentiate between non-insertional and insertional disease, as the treatment for each will differ. Non-insertional Achilles tendon disease may produce a discrete swelling and localized tenderness, or involve a longer portion of the tendon (without involving the insertion). Tenderness and swelling here is most commonly from tendinosis, with paratenon thickening a relatively uncommon variant. It is possible to differentiate these two pathologies clinically with the Royal London Hospital Test. Discrete areas of tendinosis will move with the tendon as the foot moves from plantar to dorsiflexion, whereas if the painful area remains static with ankle movements then inflammation of the paratenon is the cause. The insertional portion of the Achilles tendon is relatively complex anatomically (Figure 1), and it is not uncommon for a number of different structures to be involved. If pain on palpation is on the medial and/or lateral sides of the tendon, then retrocalcaneal bursitis is most likely. Midline posterior tenderness is due to calcific tendinopathy. Other causes of insertional pain can include a bursal projection, the superficial (or retroachilles) bursa, or the Achilles tendon itself.
Clinical examination Observing the patient walk may reveal a painful limp in moderate to severe cases. Raised BMI may be evident. Calf contracture can give rise to a planovalgus foot posture when standing, as well as difficulty in performing heel walking. A positive Silfver€ld’s test will confirm (but not reliably quantify) gastrocneskio mius contracture (Figure 3). However, this test must be
Appropriate nomenclature relating to clinical and histological findings as per Maffulli et al Clinical diagnosis 1. Tendinopathy
Conditions relating to overuse of tendon. Pain, swelling and limited function 2. Paratenonopathy Paratenon only 3. Paratendinopathy Both tendon and paratenon affected Histological diagnosis 1. Tendinosis Degeneration with collagen deposition. No clinical or histological signs of inflammation 2. Paratenonitis Acute oedema and hyperaemia with inflammatory cell infiltration
Imaging A standing lateral plain radiograph of the foot and ankle may be useful in assessment of posterior heel pain. Radiographs identify posterior enthesophytes, a prominent calcaneal tuberosity, and an increased calcaneal pitch. Antero-posterior (AP) weightbearing views of both feet help to assess any degree of planovalgus deformity (dorsolateral peritalar subluxation). Calcification at the insertion of the Achilles tendon can be demonstrated
Table 1
ORTHOPAEDICS AND TRAUMA xxx:xxx
2
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
-
Calf muscle cramps Medial gastrocnemius tear (tennis leg)
-
Posterior heel pain (insertional and non-insertional) Plantar fasciitis
-
Posteromedial pain/swelling with an acquired flat foot Forefoot overload Hallux valgus Difficulty wearing shoes
Figure 2 Signs and symptoms of gastrocnemius contracture.
quite readily on plain films, but the medio-lateral extent of the ‘spur’ is not easily assessed. Further imaging with a computed tomography (CT) scan is most useful to determine breadth of the spur, for surgical planning (Figure 4). A weight-bearing CT scan provides CT images with low radiation dose and is therefore particularly useful. Magnetic resonance imaging (MRI) is less helpful in demonstrating calcification around the insertion, but
serves to highlight tendon thickening and the retroachilles and retrocalcaneal bursae. Our initial choice of imaging for Achilles tendinopathy is with ultrasound scanning (USS). This can provide immediate and useful information about the tendon (such as the degree of any neovascularity), its insertion, and the surrounding bursae. Pathology amenable to injection treatment can also be addressed at the same time.
Treatment Since posterior heel pain is self-limiting for the vast majority of patients we suggest the following protocol as a pragmatic way of approaching this common condition, without overloading health resources or over-investigation. Less than 3 months of symptoms: Simple ‘home stretches’, as well as advice on activity modification, rest and weight loss, should ensure resolution for many patients. Stretching should focus on the calf muscle, such as lowering the heel over the edge of a step, which is an easy exercise to understand. 3e6 months’ duration: Formal calf-stretching programmes are widely considered to be the best treatment for non-insertional Achilles tendinopathy.16 Therefore, patients with ongoing symptoms should be referred for physiotherapy. There is evidence to suggest the Achilles tendon recovers its normal structural architecture after an eccentric calf stretching programme. However, care should be taken to identify and exclude cases of insertional tendinopathy. For those patients, eccentric loading regimes only serve to exacerbate symptoms. Exercises in these cases should be modified (e.g. only lowering the heel to floor rather than over a step). More than 6 months’ duration: Detailed clinical examination with radiological investigation in order to determine best treatment is required. A heel pain clinic devoted to the investigation and treatment of these difficult cases is efficient for patients who may have suffered for several years with many failed interventions. We have ultrasonography with Doppler capability available in our Heel Pain Clinic,
€ ld’s test displaying increased range of Figure 3 Positive Silfverskio ankle dorsiflexion with knee flexion.
ORTHOPAEDICS AND TRAUMA xxx:xxx
3
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
Figure 4 a) Sagittal view of left ankle CT scan displaying prominent tuberosity and enthesophyte; b) Coronal CT view demonstrating medial position of enthesophyte to aid surgical planning.
contracture. Patient compliance with stretching exercises should be challenged at all stages of their treatment pathway. Steroid injection for non-insertional tendinopathy is not advised due to the risk of tendon rupture, as well as the fact that it does not actually address the underlying pathology of a “failed healing response”. Equally, there is also no evidence for the use of platelet-rich plasma (PRP) injections in the treatment of noninsertional disease.22e24 In cases where there is no neovascularity on Doppler USS, we recommend extracorporeal shock wave therapy (ESWT). Results are pleasing, and once again appear to be improved when used in conjunction with eccentric loading exercises.25,26 A new focused ultrasound treatment (ActiSound) is under evaluation and may prove to have advantages over other non-operative therapies.
which is extremely useful especially since the treating physician is present to review the scan findings. In this setting it is possible to tailor treatment to each recalcitrant case based on their individual needs, biomechanical profile and precise pathology. It is important to examine for and identify calf muscle tightness. In our experience, locally targeted treatments for the heel will be of limited benefit if the adverse biomechanics of gastrocnemius tightness have not been addressed. We prescribe specific physiotherapy to patients, but do take into account previous or failed stretching regimes. If appropriate stretches have really failed we offer a gastrocnemius lengthening procedure. Those who do not exhibit any calf tightness, or remain symptomatic after a surgical gastrocnemius release, are candidates for local therapies to the heel (or occasionally surgical treatment).
Surgical options: the success of less-invasive therapies means that surgery is not as commonly required as it used to be. Limited debridement of areas of tendinosis and stripping the paratenon aims to preserve the native tendon whilst improving pain and function. In severe recalcitrant cases the surgical principles are to remove all pathological tendon tissue and then use reconstructive techniques to augment or bridge the defect. Reconstruction with flexor hallucis longus (FHL) tendon transfer is our preferred salvage procedure. Open surgery comes with risk of complications, and so several minimally invasive procedures have been developed in order to try and minimise these. The rationale behind these techniques is similar to that for the injection therapies (disruption of the neovascularization seen on Doppler). Techniques include ventral scraping or debridement of the paratenon under USS or endoscopic guidance.27,28 Complication rates are, in small series, reported to be lower with minimally invasive techniques than with open surgery, with comparable patient satisfaction.29
Non-insertional Achilles tendinopathy Non-surgical management: good outcomes can be expected with non-operative measures, and so these should always be employed initially. Ninety percent of patients will respond to an appropriate stretching regime, if performed properly and frequently enough.17 Ultrasound assessment of stubborn non-insertional tendinopathy helps to determine which other treatments may be appropriate. Doppler imaging may show neovascularization and hypervascularity on the anterior surface of the tendon. It is believed that new pain-transmitting nerve endings grow along with these vessels. Treatments which aim to disrupt this vascular infiltration are frequently useful.18 These include injection prolotherapy to selectively target areas of neovascularity. Another popular therapy is high-volume injection, with the aim of stripping the paratenon away from the tendon. High-quality evidence to support these treatments is limited, but the literature does indicate that although prolotherapy alone is not more effective than eccentric exercises, it can still help to reduce pain especially when used in combination with an eccentric loading regimen.19 e21 This highlights the importance of addressing a calf
ORTHOPAEDICS AND TRAUMA xxx:xxx
Insertional Achilles tendinopathy Non-operative management: this condition can be difficult to manage non-operatively, since symptoms are likely to be exacerbated by aggressive stretching exercises. It is therefore
4
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
Figure 5 a) Detached and reflected Achilles tendon from its insertion at the calcaneal tuberosity during debridement; b) Calcaneum prepared and drilled to receive suture anchors; c) Suture bridge repair of the Achilles tendon back onto its calcaneal insertion.
suture bridge technique to reattach the Achilles tendon back onto the calcaneum with bone anchors is a good option which facilitates early postoperative weight-bearing34e37 (Figure 5). An FHL transfer may be considered if there is severe distal tendinopathy. Dorsally based closing wedge (‘Zadek’) calcaneal osteotomy is an alternative surgical option, with no requirement to detach the tendon. Improved pain is most likely achieved through reorientation of the tendon insertion, shortening of the tuberosity, reduction of the calcaneal pitch angle, and indirect decompression of the retrocalcaneal bursa and tendon.38 There is currently interest in using minimally invasive osteotomy techniques for this. Anecdotally, the results from both suture-bridge repair techniques and calcaneal osteotomies are promising. As yet there are no high-quality or comparative studies regarding outcomes.
important to identify those patients with insertional pain before referring for physiotherapy. Modified exercises, such as only lowering the heel to the floor rather than full range of motion over a step, may be preferable.30 Shoes with a modest heel are usually more comfortable than flat shoes. Open-backed shoes are ideal, and anything that rubs the heel must be avoided. Compromise regarding shoes and activities are very important strategies. Setting realistic expectations is essential when managing patients with insertional tendinopathy. ESWT has been shown to be more effective than stretching for insertional Achilles tendinopathy, particularly in non-calcified disease.25,30 However, it can be extremely painful and so is not well tolerated. Targeted steroid injections do have a role when there is retrocalcaneal bursitis, but recurrence is common. Steroid injection to the superficial bursa is not recommended due to the risk of skin thinning at a potentially sensitive site.
Gastrocnemius lengthening procedures for recalcitrant Achilles tendinopathy: posterior heel pain is associated with calf contracture, and if physiotherapy stretches fail to improve the biomechanics then surgical lengthening may be beneficial, particularly in non-insertional disease.39 It is important to carefully assess and identify what type of calf contracture is present, as this will affect the choice of lengthening procedure used. €ld’s test will help to differentiate an isolated gastrocSilfverskio nemius contracture from one that includes both the gastrocnemius and soleus.15 Many options exist for surgical release of the gastrocnemius esoleus complex. The plantar forces caused by calf contracture are similar whether they arise from the gastrocnemius, soleus, or both combined.40 In cases of isolated gastrocnemius contracture it is preferential to release only the gastrocnemius portion of the calf, since Achilles tendon lengthening is associated with prolonged rehabilitation and risk of weakness from overlengthening.
Surgical options: insertional disease responds well to surgery, but requires a very long recovery period.1 Retrocalcaneal bursitis and bony prominences can be debrided, in carefully selected patients, via endoscopic techniques. This technique offers high levels of patient satisfaction, rapid return to activities, and fewer complications when compared to open surgery.31,32 Open procedures have the advantage of addressing insertional spurs or tendinopathy of the tendon itself. A para-median incision to remove the ‘Haglund’ and bursitis allows access to debride the tendon, however it will not always be possible to address an enthesophyte. Instead, a midline posterior approach through the tendon will allow good visualization of a central spur, as well as removal of the bursa and bony prominences. Patients can rehabilitate with early active mobilization if less than 50% of the tendon has been excised.33 When a very broad enthesophyte is present, complete excision requires detachment of the tendon. A
ORTHOPAEDICS AND TRAUMA xxx:xxx
5
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
We recommend proximal medial gastrocnemius release (PMGR) for most cases of isolated gastrocnemius contracture. The aponeurosis of the medial head of gastrocnemius has been identified as the main source of tightness, with a cross-sectional area 2.4 times that of the lateral head, so medial release alone is sufficient. The approach is safe with low risk of neurological complication, whereas approaches to the lateral head must be used with care due to the variable anatomy of nerves in that area.41 Another benefit of PMGR is that only the tight aponeurosis is released, leaving the main muscle belly intact. The procedure does require the patient to be positioned either prone or ‘lazy-lateral’, but is conveniently performed as a day case with local anaesthetic and light sedation. Patients are allowed to mobilize immediately, without plaster or boot, and can continue stretching exercises as soon as pain permits. Although there are no reliable methods of measuring the degree of gastrocnemius tightness, where the contracture is deemed ‘bad enough’, it may warrant the more powerful Strayer release. This release is made in the mid-calf allowing the proximal muscle belly to retract before either being re-attached proximally or left without re-attachment. It is important to appreciate that variation in the course of the sural nerve leaves it at risk of iatrogenic injury, since it can be superficial, deep, or closely adherent to the deep fascia at the level of a Strayer release.42 We recommend formally identifying and protecting the nerve. There is usually a period of immobilization for 2e4 weeks in a cast or boot following this procedure, during which time we recommend chemical venous thromboembolism prophylaxis.
either Zadek osteotomy or detachment-reattachment surgery offers good outcomes. However, the lengthy recovery period and the risk of significant complications demand careful consideration. For these reasons, insertional tendinopathy is best managed non-operatively in most patients, accepting the necessary compromises in activity and choice of shoes. A REFERENCES 1 Solan M, Davies M. Management of insertional tendinopathy of the Achilles tendon. Foot Ankle Clin 2007; 12: 597e615. 2 Tu P. Heel pain: diagnosis and management. Am Fam Physician 2018; 97: 86e93. 3 Benjamin M, Ralphs JR. Entheses e the bony attachments of tendons and ligaments. Ital J Anat Embryol 2001; 106: 151e7. 4 Maffuli N, Binfield PM, King JB. Tendon problems in athletic individuals. J Bone Joint Surg Am 1998; 80: 142e4. 5 Khan KM, Cook JL, Kannus P, Maffuli N, Bonar SF. Time to abandon the ‘tendinitis’ myth. BMJ 2002; 324: 626e7. 6 Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sport Med 1999; 27: 393e408. 7 Li HY, Hua YH. Achilles tendinopathy: current concepts about the basic science and clinical treatments. BioMed Res Int, 2016; 6492597. Epub 2016 Nov 3. 8 Haglund P. Beitrag zur Klinik der Achillessehne. Zeitschr Orthop Chir 1928; 49: 49e58. 9 Stephens MM. Haglund’s deformity and retrocalcaneal bursitis. Orthop Clin N Am 1994; 25: 41e6. 10 Krahl H, Pieper HG, Quack G. Bone hypertrophy as a result of training. Der Orthop€ade Sept 1995; 24: 441e5. 11 Maffuli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy 1998; 14: 840e3. 12 Irwin TA. Current concepts review: insertional Achilles tendinopathy. Foot Ankle Int 2010; 31: 933e9. 13 Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res 2008; 1: 2. 14 Maffuli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy. Clin Sports Med 2003; 22: 675e92. 15 Silfverskiold N. Uber die subkutane totale Achillessehnenruptur and deren Behandlung. Acta Chir Scand 1941; 84: 393. 16 Clain MR, Baxter DE. Achilles tendinitis. Foot Ankle 1992; 13: 482e7. 17 Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sport Traumatol Arthrosc 2003; 11: 327e33. 18 Boesen MI, Torp-Pedersen S, Koenig MJ, et al. Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study. Br J Sports Med 2006; 40: 761e6. Epub 2006 Jun 28. 19 Sanderson LM, Bryant A. Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review. J Foot Ankle Res 2015; 8: 57. 20 Coombes BK, Bisset L, Vicenzo B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials Lancet376(9754): 1751e67.
Conclusion Optimal treatment for posterior heel pain requires careful clinical and radiological evaluation. Stretches are a successful first-line treatment, with specialist intervention only considered after 6 months. Most cases resolve with minimal intervention but recalcitrant pain can pose a significant problem that is often overlooked. It is important to differentiate non-insertional from insertional tendinopathy. Careful clinical assessment by a specialist and ultrasound examination can be conveniently combined in a dedicated heel pain clinic. The use of Doppler ultrasound can confirm clinical diagnosis and, if appropriate, injection treatments can be offered all in one hospital visit. Addressing adverse biomechanics, particularly gastrocnemius tightness, is necessary prior to any local heel treatments since they are unlikely to be successful otherwise. When calf stretching regimes have not worked, we recommend a proximal medial gastrocnemius release as a simple and well-tolerated day case procedure. For non-insertional tendinopathy, with neovascularity we recommend prolotherapy alongside stretching regimes. Shockwave (ESWT) can be helpful for cases without neovascularity if stretching alone has failed. Surgery is only required for a very small minority of cases. Insertional disease is frequently exacerbated by stretching regimes, and so these should be modified. ESWT, if tolerated, is helpful for a proportion of patients. Careful steroid injections can help with retrocalcaneal bursitis. Minimally invasive surgery has a role in selected cases. Surgery with
ORTHOPAEDICS AND TRAUMA xxx:xxx
6
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
32 Zwiers R, Wiegerinck JI, Murawski CD, Smyth NA, Kennedy JG, van Dijk CN. Surgical treatment for posterior ankle impingement. Arthroscopy 2013; 29: 1263e70. 33 Calder JD, Saxby TS. Surgical treatment of insertional Achilles tendinosis. Foot Ankle Int Am Orthop Foot Ankle Soc Swiss Foot Ankle Soc 2003; 24: 119e21. 34 Witt BL, Hyer CF. Achilles tendon reattachment after surgical treatment of insertional tendinosis using the suture bridge technique: a case series. J Foot Ankle Surg 2012; 51: 487e93. 35 Rigby RB, Cottom JM, Vora A. Early weight-bearing using Achilles suture bridge technique for insertional Achilles tendinosis: a review of 43 patients. J Foot Ankle Surg 2013; 52: 575e9. 36 McAlister JE, Hyer CF. Safety of achilles detachment and reattachment using a standard midline approach to insertional enthesophytes. J Foot Ankle Surg 2015; 54: 214e9. 37 Greenhagen RM, Shinabarger AB, Pearson KT, Burns PR. Intermediate and long-term outcomes of the suture bridge technique for the management of insertional achilles tendinopathy. Foot Ankle Spec 2013; 6: 185e90. 38 Georgiannos D, Lampridis V, Vasiliadis A, Bisbinas I. Treatment of insertional achilles pathology with dorsal wedge calcaneal osteotomy in athletes. Foot Ankle Int 2017; 38: 381e7. 39 Gurdezi S, Kohls-Gatzoulis J, Solan M. Results of proximal medial gastrocnemius release for achilles tendinopathy. Foot Ankle Int 2013 Oct; 34: 1364e9. 40 Aronow MS, Diaz-Doran V, Sullivan RJ, Adams DJ. The effect of triceps surae contracture force on plantar foot pressure distribution. Foot Ankle Int 2006; 27: 43e52. 41 Hamilton PD, Brown M, Ferguson N, Adebibe M, Maggs J, Solan M. Surgical anatomy of the proximal release of the gastrocnemius: a cadaveric study. Foot Ankle Int 2009; 30: 1202e6. 42 Pinney SJ, Sangeorzan BJ, Hansen Jr ST. Surgical anatomy of the gastrocnemius recession (Strayer procedure). Foot Ankle Int 2004; 25: 247e50.
21 Yelland MJ, Sweeting KR, Lyftogt JA, Ng SK, Sciffham PA, Ebans KA. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med 2011; 45: 421e8. https://doi.org/10.1136/bjsm.2009. 057968. Epub 2009 Jun 22. 22 De Jonge S, de Vos RJ, Weir A, et al. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med 2011; 39: 1623e9. 23 Bell KJ. Impact of autologous blood injections in treatment of midportion Achilles tendinopathy: double blind randomised controlled trial. Br Med J 2013; 346: f2310. €de, 2019; https://doi.org/ 24 Wang Y, Han C, Hao J, et al. Der Orthopa 10.1007/s00132-019-03711-y. 25 Mani-Babu S, Morrissey D, Waugh C, et al. The effectiveness of extracorporeal shock wave therapy in lower limb tendinopathy: a systematic review. Am J Sports Med 2015 Mar; 43: 752e761. 26 Al-Abbad H, Simon JV. The effectiveness of extracorporeal shock wave therapy on chronic achilles tendinopathy: a systematic review. Foot Ankle Int 2013; 34: 33e41. 27 Alfredson H. Ultrasound and Doppler-guided mini-surgery to treat midportion Achilles tendinosis: results of a large material and a randomised study comparing two scraping techniques. Br J Sports Med 2011; 45: 407e10. 28 Maquirriain J. Surgical treatment of chronic Achilles tendinopathy: long-term results of the endoscopic technique. J Foot Ankle Surg 2013; 52: 451e5. 29 Baites TPA, Zwiers R, Wiegerinck JI, van Dijk CN. Surgical treatment for midportion Achilles tendinopathy: a systematic review. Knee Surg Sport Traumatol Arthrosc 2017; 25: 1817e38. 30 Wiegerinck JI, Kerkhoffs GM, van Sterkenburg MN, Sierevelt IN, van Dijk CN. Treatment for insertional Achilles tendinopathy: a systematic review. Knee Surg Sport Traumatol Arthrosc 2013; 21: 1345e55. 31 JIp Wiegerinck, Kok ACp, van Dijk CNp. Surgical treatment of chronic retrocalcaneal bursitis. Arthroscopy 2012; 28: 283e93.
ORTHOPAEDICS AND TRAUMA xxx:xxx
7
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
Posterior heel pain
common. The Achilles tendon is formed by the soleus and gastrocnemius muscles which unite to form a conjoint tendon which inserts distally onto the middle third of the os calcis (Figure 1). This area, known as the enthesis or transition zone, acts to evenly distribute the mechanical load transmitted from the soft tissues to the calcaneum.3 The tendon itself is composed of mostly type I collagen fibres, which are well organized longitudinally and surrounded by an extracellular matrix.4 The term ‘tendinitis’, in relation to disorders of the Achilles, has been discredited.5 Inflammatory cells such as macrophages and neutrophils are absent on histological examination. Instead abnormal tenocytes predominate, with disorganization of the collagen fibres.6,7 The tenocytes are subsequently prone to apoptosis, and there is evidence of neovascularization whereas, conversely, healthy tendon will be avascular. These characteristics in the thickened tendon are classic of degeneration secondary to overuse and a failed healing response, rather than an inflammatory process.5,6 Degeneration of the tendon can also be associated with a prominent postero-superior projection of the calcaneum, otherwise known as Haglund’s deformity.8 This variant can cause impingement of bone against the Achilles tendon. Irritation of the soft tissues frequently leads to inflammation of the bursa within the retrocalcaneal recess (retrocalcaneal bursitis).9 Microtrauma or increased activity levels have been linked to calcific deposition within the Achilles tendon.10 A bony spur then projects from the os calcis and this is evident radiologically. The spur is also known as an enthesophyte.
Christopher P Jukes Georgia Scott Matthew C Solan
Abstract Heel pain at or around the insertion of the Achilles tendon is a common presenting complaint affecting both young, active patients and those who are older and more sedentary. So-called posterior heel pain is often presumed to run a self-limiting course over a few months, resolving with rest, weight loss and stretching exercises. However, a small number of patients suffer with increasingly disabling symptoms that are refractory to this regimen. Posterior heel pain is classically split into insertional and non-insertional types, and in order to select an appropriate management plan the diagnosis must be precise. Further management without a clear understanding of the pathology is potentially detrimental to the patient. This review aims to provide a structured approach to careful clinical and radiological assessment and treatment of this condition.
Keywords gastrocnemius release; heel pain; insertional; non-insertional; tendinopathy
Introduction Heel pain, classified as either posterior or plantar, can be a troublesome complaint posing a diagnostic challenge for the physician.1 Often it resolves after a period of time with analgesia and tailored physiotherapy. However, a small number of patients go on to suffer chronic, debilitating symptoms. Choosing the correct treatment can be confusing given the number of different pathologies involved. A variety of different non-operative treatments are available. This attests to the absence of one reliable treatment. Where non-operative treatments fail there are surgical options to consider, but only as a last resort. This article focuses on the diagnosis and management of posterior heel pain, including Achilles tendinopathy of the insertional and non-insertional (main body) types.2 Plantar heel pain and Achilles tendon rupture are not discussed here.
Terminology The term tendinitis, implying inflammation of the tendon, should be abandoned. As discussed above, there is no evidence of inflammatory exudate on histological examination. There is mucoid change instead of granulation tissue formation in those who suffer with chronic pathology.5,6 Tendinosis is therefore the appropriate term for this degenerative change, without evidence of attempted healing. Maffulli described the triad of pain, swelling (diffuse or localized) and impaired function as characteristic of Achilles tendinopathy.11 A streamlined classification system was proposed in order to clarify the nomenclature relating to Achilles tendon pathologies (Table 1). Demographics Achilles tendinopathy is often perceived as a problem presenting in the young athletic person, related to excessive strain. The demographics are more complex, and insertional tendinopathy is more common in the older, sedentary population.12 The likelihood of developing symptomatic tendinopathy increases with body mass index (BMI) and age.13 It is believed that, in an era of increasing health awareness, activity and lifespan, the incidence of Achilles tendinopathy is rising. However, reliable epidemiological data are not readily available to substantiate that claim.14
Pathophysiology Achilles tendinopathy may be classified by its anatomical location as insertional or non-insertional, with the latter being more
Christopher P Jukes MRCS BSc(Hons), Orthopaedic Registrar, Trauma and Orthopaedics Department, Royal Surrey County Hospital, Guildford, UK. Conflicts of interest: none declared. Georgia Scott MRCS, Core Surgical Trainee, Trauma and Orthopaedics Department, Royal Surrey County Hospital, Guildford, UK. Conflicts of interest: none declared.
Clinical presentation
Matthew C Solan FRCS (Tr&Orth), Consultant Foot & Ankle Surgeon, Trauma and Orthopaedics Department, Royal Surrey County Hospital, Guildford, UK. Conflicts of interest: none declared.
History The primary symptom is pain, commonly presenting as ‘start-up’ pain and stiffness affecting the first steps in the morning or after a
ORTHOPAEDICS AND TRAUMA xxx:xxx
1
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
Figure 1 Posterior heel anatomy.
period of rest. This classically is relieved by gentle activity but then exacerbated again by exercise. Patients are often frustrated by an inability to walk long distances or to take part in sport or fitness activities. Symptoms are usually insidious in onset, but may coincide with altered activity levels (such as longer periods of standing), new sports footwear, or increased body weight. Establishing the duration of symptoms is important. It is well documented that most cases of posterior heel pain with a recent onset are self-limiting, and many will improve without intervention. Chronic cases require more consideration, especially when first-line treatments have already been unsuccessful. Since posterior heel pain is closely associated with adverse biomechanics, particularly isolated gastrocnemius tightness, symptoms of other conditions that are associated with this should be considered when taking a history (Figure 2).
performed with the talonavicular joint held in the reduced position. If not performed properly the heel can escape into valgus, thus shortening the distance between the knee and the heel, resulting in masking of any gastrocnemius contracture.15 Failure to appreciate this will result in a false-negative test. The Achilles tendon and its insertion can be examined conveniently with the patient kneeling on a couch or chair, as one would when performing Simmonds’ calf squeeze test for Achilles tendon rupture. This allows a good view of the heel, as well as accurate palpation of the tendon from the musculotendinous junction to the calcaneum. It is key to differentiate between non-insertional and insertional disease, as the treatment for each will differ. Non-insertional Achilles tendon disease may produce a discrete swelling and localized tenderness, or involve a longer portion of the tendon (without involving the insertion). Tenderness and swelling here is most commonly from tendinosis, with paratenon thickening a relatively uncommon variant. It is possible to differentiate these two pathologies clinically with the Royal London Hospital Test. Discrete areas of tendinosis will move with the tendon as the foot moves from plantar to dorsiflexion, whereas if the painful area remains static with ankle movements then inflammation of the paratenon is the cause. The insertional portion of the Achilles tendon is relatively complex anatomically (Figure 1), and it is not uncommon for a number of different structures to be involved. If pain on palpation is on the medial and/or lateral sides of the tendon, then retrocalcaneal bursitis is most likely. Midline posterior tenderness is due to calcific tendinopathy. Other causes of insertional pain can include a bursal projection, the superficial (or retroachilles) bursa, or the Achilles tendon itself.
Clinical examination Observing the patient walk may reveal a painful limp in moderate to severe cases. Raised BMI may be evident. Calf contracture can give rise to a planovalgus foot posture when standing, as well as difficulty in performing heel walking. A positive Silfver€ld’s test will confirm (but not reliably quantify) gastrocneskio mius contracture (Figure 3). However, this test must be
Appropriate nomenclature relating to clinical and histological findings as per Maffulli et al Clinical diagnosis 1. Tendinopathy
Conditions relating to overuse of tendon. Pain, swelling and limited function 2. Paratenonopathy Paratenon only 3. Paratendinopathy Both tendon and paratenon affected Histological diagnosis 1. Tendinosis Degeneration with collagen deposition. No clinical or histological signs of inflammation 2. Paratenonitis Acute oedema and hyperaemia with inflammatory cell infiltration
Imaging A standing lateral plain radiograph of the foot and ankle may be useful in assessment of posterior heel pain. Radiographs identify posterior enthesophytes, a prominent calcaneal tuberosity, and an increased calcaneal pitch. Antero-posterior (AP) weightbearing views of both feet help to assess any degree of planovalgus deformity (dorsolateral peritalar subluxation). Calcification at the insertion of the Achilles tendon can be demonstrated
Table 1
ORTHOPAEDICS AND TRAUMA xxx:xxx
2
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
-
Calf muscle cramps Medial gastrocnemius tear (tennis leg)
-
Posterior heel pain (insertional and non-insertional) Plantar fasciitis
-
Posteromedial pain/swelling with an acquired flat foot Forefoot overload Hallux valgus Difficulty wearing shoes
Figure 2 Signs and symptoms of gastrocnemius contracture.
quite readily on plain films, but the medio-lateral extent of the ‘spur’ is not easily assessed. Further imaging with a computed tomography (CT) scan is most useful to determine breadth of the spur, for surgical planning (Figure 4). A weight-bearing CT scan provides CT images with low radiation dose and is therefore particularly useful. Magnetic resonance imaging (MRI) is less helpful in demonstrating calcification around the insertion, but
serves to highlight tendon thickening and the retroachilles and retrocalcaneal bursae. Our initial choice of imaging for Achilles tendinopathy is with ultrasound scanning (USS). This can provide immediate and useful information about the tendon (such as the degree of any neovascularity), its insertion, and the surrounding bursae. Pathology amenable to injection treatment can also be addressed at the same time.
Treatment Since posterior heel pain is self-limiting for the vast majority of patients we suggest the following protocol as a pragmatic way of approaching this common condition, without overloading health resources or over-investigation. Less than 3 months of symptoms: Simple ‘home stretches’, as well as advice on activity modification, rest and weight loss, should ensure resolution for many patients. Stretching should focus on the calf muscle, such as lowering the heel over the edge of a step, which is an easy exercise to understand. 3e6 months’ duration: Formal calf-stretching programmes are widely considered to be the best treatment for non-insertional Achilles tendinopathy.16 Therefore, patients with ongoing symptoms should be referred for physiotherapy. There is evidence to suggest the Achilles tendon recovers its normal structural architecture after an eccentric calf stretching programme. However, care should be taken to identify and exclude cases of insertional tendinopathy. For those patients, eccentric loading regimes only serve to exacerbate symptoms. Exercises in these cases should be modified (e.g. only lowering the heel to floor rather than over a step). More than 6 months’ duration: Detailed clinical examination with radiological investigation in order to determine best treatment is required. A heel pain clinic devoted to the investigation and treatment of these difficult cases is efficient for patients who may have suffered for several years with many failed interventions. We have ultrasonography with Doppler capability available in our Heel Pain Clinic,
€ ld’s test displaying increased range of Figure 3 Positive Silfverskio ankle dorsiflexion with knee flexion.
ORTHOPAEDICS AND TRAUMA xxx:xxx
3
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
Figure 4 a) Sagittal view of left ankle CT scan displaying prominent tuberosity and enthesophyte; b) Coronal CT view demonstrating medial position of enthesophyte to aid surgical planning.
contracture. Patient compliance with stretching exercises should be challenged at all stages of their treatment pathway. Steroid injection for non-insertional tendinopathy is not advised due to the risk of tendon rupture, as well as the fact that it does not actually address the underlying pathology of a “failed healing response”. Equally, there is also no evidence for the use of platelet-rich plasma (PRP) injections in the treatment of noninsertional disease.22e24 In cases where there is no neovascularity on Doppler USS, we recommend extracorporeal shock wave therapy (ESWT). Results are pleasing, and once again appear to be improved when used in conjunction with eccentric loading exercises.25,26 A new focused ultrasound treatment (ActiSound) is under evaluation and may prove to have advantages over other non-operative therapies.
which is extremely useful especially since the treating physician is present to review the scan findings. In this setting it is possible to tailor treatment to each recalcitrant case based on their individual needs, biomechanical profile and precise pathology. It is important to examine for and identify calf muscle tightness. In our experience, locally targeted treatments for the heel will be of limited benefit if the adverse biomechanics of gastrocnemius tightness have not been addressed. We prescribe specific physiotherapy to patients, but do take into account previous or failed stretching regimes. If appropriate stretches have really failed we offer a gastrocnemius lengthening procedure. Those who do not exhibit any calf tightness, or remain symptomatic after a surgical gastrocnemius release, are candidates for local therapies to the heel (or occasionally surgical treatment).
Surgical options: the success of less-invasive therapies means that surgery is not as commonly required as it used to be. Limited debridement of areas of tendinosis and stripping the paratenon aims to preserve the native tendon whilst improving pain and function. In severe recalcitrant cases the surgical principles are to remove all pathological tendon tissue and then use reconstructive techniques to augment or bridge the defect. Reconstruction with flexor hallucis longus (FHL) tendon transfer is our preferred salvage procedure. Open surgery comes with risk of complications, and so several minimally invasive procedures have been developed in order to try and minimise these. The rationale behind these techniques is similar to that for the injection therapies (disruption of the neovascularization seen on Doppler). Techniques include ventral scraping or debridement of the paratenon under USS or endoscopic guidance.27,28 Complication rates are, in small series, reported to be lower with minimally invasive techniques than with open surgery, with comparable patient satisfaction.29
Non-insertional Achilles tendinopathy Non-surgical management: good outcomes can be expected with non-operative measures, and so these should always be employed initially. Ninety percent of patients will respond to an appropriate stretching regime, if performed properly and frequently enough.17 Ultrasound assessment of stubborn non-insertional tendinopathy helps to determine which other treatments may be appropriate. Doppler imaging may show neovascularization and hypervascularity on the anterior surface of the tendon. It is believed that new pain-transmitting nerve endings grow along with these vessels. Treatments which aim to disrupt this vascular infiltration are frequently useful.18 These include injection prolotherapy to selectively target areas of neovascularity. Another popular therapy is high-volume injection, with the aim of stripping the paratenon away from the tendon. High-quality evidence to support these treatments is limited, but the literature does indicate that although prolotherapy alone is not more effective than eccentric exercises, it can still help to reduce pain especially when used in combination with an eccentric loading regimen.19 e21 This highlights the importance of addressing a calf
ORTHOPAEDICS AND TRAUMA xxx:xxx
Insertional Achilles tendinopathy Non-operative management: this condition can be difficult to manage non-operatively, since symptoms are likely to be exacerbated by aggressive stretching exercises. It is therefore
4
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
Figure 5 a) Detached and reflected Achilles tendon from its insertion at the calcaneal tuberosity during debridement; b) Calcaneum prepared and drilled to receive suture anchors; c) Suture bridge repair of the Achilles tendon back onto its calcaneal insertion.
suture bridge technique to reattach the Achilles tendon back onto the calcaneum with bone anchors is a good option which facilitates early postoperative weight-bearing34e37 (Figure 5). An FHL transfer may be considered if there is severe distal tendinopathy. Dorsally based closing wedge (‘Zadek’) calcaneal osteotomy is an alternative surgical option, with no requirement to detach the tendon. Improved pain is most likely achieved through reorientation of the tendon insertion, shortening of the tuberosity, reduction of the calcaneal pitch angle, and indirect decompression of the retrocalcaneal bursa and tendon.38 There is currently interest in using minimally invasive osteotomy techniques for this. Anecdotally, the results from both suture-bridge repair techniques and calcaneal osteotomies are promising. As yet there are no high-quality or comparative studies regarding outcomes.
important to identify those patients with insertional pain before referring for physiotherapy. Modified exercises, such as only lowering the heel to the floor rather than full range of motion over a step, may be preferable.30 Shoes with a modest heel are usually more comfortable than flat shoes. Open-backed shoes are ideal, and anything that rubs the heel must be avoided. Compromise regarding shoes and activities are very important strategies. Setting realistic expectations is essential when managing patients with insertional tendinopathy. ESWT has been shown to be more effective than stretching for insertional Achilles tendinopathy, particularly in non-calcified disease.25,30 However, it can be extremely painful and so is not well tolerated. Targeted steroid injections do have a role when there is retrocalcaneal bursitis, but recurrence is common. Steroid injection to the superficial bursa is not recommended due to the risk of skin thinning at a potentially sensitive site.
Gastrocnemius lengthening procedures for recalcitrant Achilles tendinopathy: posterior heel pain is associated with calf contracture, and if physiotherapy stretches fail to improve the biomechanics then surgical lengthening may be beneficial, particularly in non-insertional disease.39 It is important to carefully assess and identify what type of calf contracture is present, as this will affect the choice of lengthening procedure used. €ld’s test will help to differentiate an isolated gastrocSilfverskio nemius contracture from one that includes both the gastrocnemius and soleus.15 Many options exist for surgical release of the gastrocnemius esoleus complex. The plantar forces caused by calf contracture are similar whether they arise from the gastrocnemius, soleus, or both combined.40 In cases of isolated gastrocnemius contracture it is preferential to release only the gastrocnemius portion of the calf, since Achilles tendon lengthening is associated with prolonged rehabilitation and risk of weakness from overlengthening.
Surgical options: insertional disease responds well to surgery, but requires a very long recovery period.1 Retrocalcaneal bursitis and bony prominences can be debrided, in carefully selected patients, via endoscopic techniques. This technique offers high levels of patient satisfaction, rapid return to activities, and fewer complications when compared to open surgery.31,32 Open procedures have the advantage of addressing insertional spurs or tendinopathy of the tendon itself. A para-median incision to remove the ‘Haglund’ and bursitis allows access to debride the tendon, however it will not always be possible to address an enthesophyte. Instead, a midline posterior approach through the tendon will allow good visualization of a central spur, as well as removal of the bursa and bony prominences. Patients can rehabilitate with early active mobilization if less than 50% of the tendon has been excised.33 When a very broad enthesophyte is present, complete excision requires detachment of the tendon. A
ORTHOPAEDICS AND TRAUMA xxx:xxx
5
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
We recommend proximal medial gastrocnemius release (PMGR) for most cases of isolated gastrocnemius contracture. The aponeurosis of the medial head of gastrocnemius has been identified as the main source of tightness, with a cross-sectional area 2.4 times that of the lateral head, so medial release alone is sufficient. The approach is safe with low risk of neurological complication, whereas approaches to the lateral head must be used with care due to the variable anatomy of nerves in that area.41 Another benefit of PMGR is that only the tight aponeurosis is released, leaving the main muscle belly intact. The procedure does require the patient to be positioned either prone or ‘lazy-lateral’, but is conveniently performed as a day case with local anaesthetic and light sedation. Patients are allowed to mobilize immediately, without plaster or boot, and can continue stretching exercises as soon as pain permits. Although there are no reliable methods of measuring the degree of gastrocnemius tightness, where the contracture is deemed ‘bad enough’, it may warrant the more powerful Strayer release. This release is made in the mid-calf allowing the proximal muscle belly to retract before either being re-attached proximally or left without re-attachment. It is important to appreciate that variation in the course of the sural nerve leaves it at risk of iatrogenic injury, since it can be superficial, deep, or closely adherent to the deep fascia at the level of a Strayer release.42 We recommend formally identifying and protecting the nerve. There is usually a period of immobilization for 2e4 weeks in a cast or boot following this procedure, during which time we recommend chemical venous thromboembolism prophylaxis.
either Zadek osteotomy or detachment-reattachment surgery offers good outcomes. However, the lengthy recovery period and the risk of significant complications demand careful consideration. For these reasons, insertional tendinopathy is best managed non-operatively in most patients, accepting the necessary compromises in activity and choice of shoes. A REFERENCES 1 Solan M, Davies M. Management of insertional tendinopathy of the Achilles tendon. Foot Ankle Clin 2007; 12: 597e615. 2 Tu P. Heel pain: diagnosis and management. Am Fam Physician 2018; 97: 86e93. 3 Benjamin M, Ralphs JR. Entheses e the bony attachments of tendons and ligaments. Ital J Anat Embryol 2001; 106: 151e7. 4 Maffuli N, Binfield PM, King JB. Tendon problems in athletic individuals. J Bone Joint Surg Am 1998; 80: 142e4. 5 Khan KM, Cook JL, Kannus P, Maffuli N, Bonar SF. Time to abandon the ‘tendinitis’ myth. BMJ 2002; 324: 626e7. 6 Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sport Med 1999; 27: 393e408. 7 Li HY, Hua YH. Achilles tendinopathy: current concepts about the basic science and clinical treatments. BioMed Res Int, 2016; 6492597. Epub 2016 Nov 3. 8 Haglund P. Beitrag zur Klinik der Achillessehne. Zeitschr Orthop Chir 1928; 49: 49e58. 9 Stephens MM. Haglund’s deformity and retrocalcaneal bursitis. Orthop Clin N Am 1994; 25: 41e6. 10 Krahl H, Pieper HG, Quack G. Bone hypertrophy as a result of training. Der Orthop€ade Sept 1995; 24: 441e5. 11 Maffuli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy 1998; 14: 840e3. 12 Irwin TA. Current concepts review: insertional Achilles tendinopathy. Foot Ankle Int 2010; 31: 933e9. 13 Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res 2008; 1: 2. 14 Maffuli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy. Clin Sports Med 2003; 22: 675e92. 15 Silfverskiold N. Uber die subkutane totale Achillessehnenruptur and deren Behandlung. Acta Chir Scand 1941; 84: 393. 16 Clain MR, Baxter DE. Achilles tendinitis. Foot Ankle 1992; 13: 482e7. 17 Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sport Traumatol Arthrosc 2003; 11: 327e33. 18 Boesen MI, Torp-Pedersen S, Koenig MJ, et al. Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study. Br J Sports Med 2006; 40: 761e6. Epub 2006 Jun 28. 19 Sanderson LM, Bryant A. Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review. J Foot Ankle Res 2015; 8: 57. 20 Coombes BK, Bisset L, Vicenzo B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials Lancet376(9754): 1751e67.
Conclusion Optimal treatment for posterior heel pain requires careful clinical and radiological evaluation. Stretches are a successful first-line treatment, with specialist intervention only considered after 6 months. Most cases resolve with minimal intervention but recalcitrant pain can pose a significant problem that is often overlooked. It is important to differentiate non-insertional from insertional tendinopathy. Careful clinical assessment by a specialist and ultrasound examination can be conveniently combined in a dedicated heel pain clinic. The use of Doppler ultrasound can confirm clinical diagnosis and, if appropriate, injection treatments can be offered all in one hospital visit. Addressing adverse biomechanics, particularly gastrocnemius tightness, is necessary prior to any local heel treatments since they are unlikely to be successful otherwise. When calf stretching regimes have not worked, we recommend a proximal medial gastrocnemius release as a simple and well-tolerated day case procedure. For non-insertional tendinopathy, with neovascularity we recommend prolotherapy alongside stretching regimes. Shockwave (ESWT) can be helpful for cases without neovascularity if stretching alone has failed. Surgery is only required for a very small minority of cases. Insertional disease is frequently exacerbated by stretching regimes, and so these should be modified. ESWT, if tolerated, is helpful for a proportion of patients. Careful steroid injections can help with retrocalcaneal bursitis. Minimally invasive surgery has a role in selected cases. Surgery with
ORTHOPAEDICS AND TRAUMA xxx:xxx
6
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001
FOOT AND ANKLE
32 Zwiers R, Wiegerinck JI, Murawski CD, Smyth NA, Kennedy JG, van Dijk CN. Surgical treatment for posterior ankle impingement. Arthroscopy 2013; 29: 1263e70. 33 Calder JD, Saxby TS. Surgical treatment of insertional Achilles tendinosis. Foot Ankle Int Am Orthop Foot Ankle Soc Swiss Foot Ankle Soc 2003; 24: 119e21. 34 Witt BL, Hyer CF. Achilles tendon reattachment after surgical treatment of insertional tendinosis using the suture bridge technique: a case series. J Foot Ankle Surg 2012; 51: 487e93. 35 Rigby RB, Cottom JM, Vora A. Early weight-bearing using Achilles suture bridge technique for insertional Achilles tendinosis: a review of 43 patients. J Foot Ankle Surg 2013; 52: 575e9. 36 McAlister JE, Hyer CF. Safety of achilles detachment and reattachment using a standard midline approach to insertional enthesophytes. J Foot Ankle Surg 2015; 54: 214e9. 37 Greenhagen RM, Shinabarger AB, Pearson KT, Burns PR. Intermediate and long-term outcomes of the suture bridge technique for the management of insertional achilles tendinopathy. Foot Ankle Spec 2013; 6: 185e90. 38 Georgiannos D, Lampridis V, Vasiliadis A, Bisbinas I. Treatment of insertional achilles pathology with dorsal wedge calcaneal osteotomy in athletes. Foot Ankle Int 2017; 38: 381e7. 39 Gurdezi S, Kohls-Gatzoulis J, Solan M. Results of proximal medial gastrocnemius release for achilles tendinopathy. Foot Ankle Int 2013 Oct; 34: 1364e9. 40 Aronow MS, Diaz-Doran V, Sullivan RJ, Adams DJ. The effect of triceps surae contracture force on plantar foot pressure distribution. Foot Ankle Int 2006; 27: 43e52. 41 Hamilton PD, Brown M, Ferguson N, Adebibe M, Maggs J, Solan M. Surgical anatomy of the proximal release of the gastrocnemius: a cadaveric study. Foot Ankle Int 2009; 30: 1202e6. 42 Pinney SJ, Sangeorzan BJ, Hansen Jr ST. Surgical anatomy of the gastrocnemius recession (Strayer procedure). Foot Ankle Int 2004; 25: 247e50.
21 Yelland MJ, Sweeting KR, Lyftogt JA, Ng SK, Sciffham PA, Ebans KA. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med 2011; 45: 421e8. https://doi.org/10.1136/bjsm.2009. 057968. Epub 2009 Jun 22. 22 De Jonge S, de Vos RJ, Weir A, et al. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med 2011; 39: 1623e9. 23 Bell KJ. Impact of autologous blood injections in treatment of midportion Achilles tendinopathy: double blind randomised controlled trial. Br Med J 2013; 346: f2310. €de, 2019; https://doi.org/ 24 Wang Y, Han C, Hao J, et al. Der Orthopa 10.1007/s00132-019-03711-y. 25 Mani-Babu S, Morrissey D, Waugh C, et al. The effectiveness of extracorporeal shock wave therapy in lower limb tendinopathy: a systematic review. Am J Sports Med 2015 Mar; 43: 752e761. 26 Al-Abbad H, Simon JV. The effectiveness of extracorporeal shock wave therapy on chronic achilles tendinopathy: a systematic review. Foot Ankle Int 2013; 34: 33e41. 27 Alfredson H. Ultrasound and Doppler-guided mini-surgery to treat midportion Achilles tendinosis: results of a large material and a randomised study comparing two scraping techniques. Br J Sports Med 2011; 45: 407e10. 28 Maquirriain J. Surgical treatment of chronic Achilles tendinopathy: long-term results of the endoscopic technique. J Foot Ankle Surg 2013; 52: 451e5. 29 Baites TPA, Zwiers R, Wiegerinck JI, van Dijk CN. Surgical treatment for midportion Achilles tendinopathy: a systematic review. Knee Surg Sport Traumatol Arthrosc 2017; 25: 1817e38. 30 Wiegerinck JI, Kerkhoffs GM, van Sterkenburg MN, Sierevelt IN, van Dijk CN. Treatment for insertional Achilles tendinopathy: a systematic review. Knee Surg Sport Traumatol Arthrosc 2013; 21: 1345e55. 31 JIp Wiegerinck, Kok ACp, van Dijk CNp. Surgical treatment of chronic retrocalcaneal bursitis. Arthroscopy 2012; 28: 283e93.
ORTHOPAEDICS AND TRAUMA xxx:xxx
7
Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Jukes CP et al., Posterior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.001