The Achilles tendon connects the calf muscle to the heel bone. It is a consolidation of the gastrocnemius and soleus muscles and acts to plantarflex the ankle. It inserts broadly over the posterosuperior calcaneal tuberosity and has two bursae. As the strongest and largest tendon in the body, the Achilles tendon is regularly subjected to forces that are 2-4 times greater than a person’s body weight. The forces are even stronger during athletic participation, which means the Achilles bears an immense amount of stress on a regular basis.
Over time, these repetitive loads can lead to degenerative wear and tear, specifically where the tendon inserts into the heel bone (calcaneus). This degeneration incites an inflammatory response and produces pain at the back of the heel. Eventually, the inflamed Achilles tendon may become calcified, forming bone-like fragments in the tendon.
Wherever tissues rub against one another, a bursa forms to allow for smooth gliding of tissues. A bursa is a sac filled with lubricating fluid, which occurs normally throughout the body. Although it is only a few cell layers thick, when irritated, a bursa can become markedly thickened, inflamed and painful. This is often referred to as bursitis.
The retrocalcaneal bursa is positioned to allow the Achilles tendon to glide over the back part (posterior aspect) of the heel bone. When this bone becomes enlarged, inflammation of the retrocalcaneal bursa occurs. This inflammation results in exquisite tenderness along the posterior aspect of the heel.
In the early stages, patients will have pain in the distal Achilles just proximal to the insertion. The pain may increase with activity and as it progresses, pain can be associated with lesser levels of activity. Patients may complain of thickening or swelling along the tendon as well as weakness or loss of motion.
Initial treatment for posterior heel pain starts with non-operative treatment. Traditional non-operative treatment includes the following:
- Rest. Avoiding movements that exacerbate your pain.
- Heat and Ice can be applied to reduce pain and swelling. Apply for 20 minutes at a time, several times a day, to keep swelling down. Do not apply directly to the skin.
- Weight Loss: Many patients with posterior heel pain are overweight. A concerted effort to lose substantial weight may be one of the most effective ways to manage this condition. The Achilles tendon is often subjected to forces equivalent to many times a person’s body weight during regular, daily activities (i.e. walking and standing). Therefore, losing weight (even as little as 5-10 pounds) can be very helpful.
- Nonsteroidal anti-inflammatory medicines. Drugs like ibuprofen and naproxen reduce pain and swelling. Like any over the counter medication, please read and follow the label. If you have a history of stomach ulcers, bleeding ulcers or heart conditions, these medications might not be right for you. Consult your physician if you have any questions.
- Physiotherapy and home exercises
- Calf Stretching: Regular calf stretching can help improve the compliance and length of the Achilles tendon. This makes it more resilient to wear and tear due to the repetitive loading associated with standing and walking.
- Heel Lift or the Use of a Shoe with a Moderate Heel: Walking barefoot, or in a flat-soled shoe, increases the tension on the insertion of the Achilles tendon. Using a heel lift or a shoe with a moderate heel can help both reduce the stress on the tendon, and decrease the irritation caused by this condition.
- Air-cast boot: Wearing a removable air-cast boot for 4-8 weeks may permit healing of the degenerative tendon tearing. This is often successful initially, but if the cause of the microscopic tendon tearing is not addressed, the symptoms may recur.
- Topical anti-inflammatories
- Compound Topical Creams
- Injections under Ultrasound Guidance
- Steroid (Depo-Medrol, Kenalog, Decadron)
- Blood (PRP – Platelet Rich Plasma)
Due to the lengthy recovery associated with surgery, along with the relatively unpredictable postoperative outcome, non-operative management should be exhausted before surgery is contemplated.