Retrocalcaneal Spurs/Pain
What are Retrocalcaneal Spurs (RS)?
Retro-meaning backward, or back + Calcaneal-meaning heel bone + Spurs-meaning growths of bone = Growths of bone at the back of the heel.
RS are portions of calcified bone that form within the insertion (attachment) of the achilles tendon at the back of the heel bone (calcaneus). They can be considered ‘heel spurs’ but are
not to be confused with ‘typical’ heel spurs which occur on the bottom of the heel and are referred to as plantar heel spurs. For more information regarding plantar heel spurs, or heel spur syndrome, please visit our website page at: http://www.drtompkins.com/conditions/heel_pain.htm
We do not see RS is children, and very rarely in adolescents. This is due to the fact RS develop over time. Continued and excessive pressure at the attachment of the achilles tendon to the calcaneus initially causes irritation and/or inflammation. This inflammation can be the result of either insertional achilles tendonitis, which is inflammation of the tendon itself; or retrocalcaneal periostitis, which is inflammation of the layer of tissue covering the back of the heel bone (periosteum).
Continued and progressive pressure and inflammation of these tissues can cause progressive calcification within the attachment of the achilles tendon and lead to chronic pain from RS.
What causes RS and what can be done to prevent them?
The primary cause of RS is hereditary in nature. However, a number of environmental factors play an important role in the progression of RS.
Lower extremity, and predominantly foot, anatomical structure (and function to a certain degree) are something that we inherit from our parents. Various foot anomalies, combined with leg and/or lower leg functional limitations, highly predispose certain individuals to develop RS.
The most common anatomical condition that increases the risk of developing RS is referred to as equinus. Equinus deformity is a lack of motion of the ankle joint that allows (or doesn’t allow) the foot to dorsi-flex (move upward) on the ankle. This puts a tremendous force and pressure at the back of the heel-at the insertion of the achilles tendon with the heel bone-with every step taken. Over-pronation (biomechanical) anomalies within the bones/joints of the foot also predispose individuals to RS. For more information regarding various biomechanical factors which affect the foot, visit our webpage site at: http://www.drtompkins.com/conditions/metatarsalgia.htm
Certain environmental factors can also increase the probability of developing RS….the most important being physical weight. Increased weight, combined with the above anomalies, are the most common denominators in people who develop chronic pain associated with RS.
There are a number of things that can be done to lower the propensity of developing chronic pain from RS. Early recognition, and appropriate treatment, of foot and/or leg/lower leg anomalies is paramount. Shoe modification and orthotic therapy, along with rigorous stretching/strengthening exercises, will go a long way in slowing the development of RS. It goes without saying; maintenance of an appropriate weight to height ratio will also greatly reduce the progression of RS.
What can be done to treat RS?
Again, early recognition of RS symptoms and appropriate treatment is the most important factor in preventing, and limiting, the progression of calcification within the attachment of the achilles tendon.
If chronic irritation and pain at the back of the heel exists/persists, professional treatment is warranted. Professional treatment is based upon the severity of the symptoms of individual patients. I categorize conditions as
mild, moderate, or severe.
Mild cases of RS can normally be treated by a combination of shoe modification, insert (orthotic) therapy and/or heel lifts, stretching/strengthening exercises, OTC and/or prescription-strength oral anti-inflammatories, physical therapy, and weight reduction (if applicable).
Moderate cases of RS are typically treated by a combination of the above noted methods, with the addition of corticosteroid injections and various levels of immobilization. However, it must be noted that injection therapy for RS is of limited long-term value. This is due to the fact that multiple steroid injections into the attachment of the achilles tendon can lead to significant weakening of the tendon/attachment and possible rupture. Immobilization may include a hard-soled trauma shoe, various types of cam-walkers or an AFO’s (ankle-foot-orthosis), or BK (below-the-knee) fiberglass/plaster casting.
Severe cases of RS, again, are treated with a combination of the above noted methods as for mild and moderate conditions. If continued and progressive pain persists at a level which causes significant alterations in the patient’s gait pattern, shoe wear, and life-style, surgical intervention is a viable alternative.
Surgical treatment for severe cases of RS is an extremely gratifying procedure for patients who have been through the above noted treatments and continue to experience considerable pain and problems. However, the procedure requires a significant amount of healing time and patient inconvenience.
The surgery is typically performed in an out-patient facility under general anesthesia. Surgical time varies on the severity of the condition but rarely is longer than 45 minutes to 1 hour. The surgery involves the partial detachment of the achilles tendon, resection of the RS and any calcified tendon, and reattachment of the achilles. Additionally, if there is a severe, symptomatic, equinus deformity (as noted above) present, I will also perform some type of achilles tendon lengthening procedure-referred to as a TAL.
The patient is placed in a BK (below the knee) cast and is required to be NWB (no-weight on foot) for anywhere from 4 to 12 weeks depending on the severity of the condition, level of detachment-and reattachment of the achilles, and/or the type of TAL procedure performed. At that time, progression into an AFO (ankle-foot-orthosis) for 2-4 weeks; this is followed by a surgical shoe. Physical therapy is typically recommended and rehabilitation of the calf muscle and achilles can take a number of weeks to months. As one can see, the surgery if fairly involved, and should be limited to the most severe conditions. However; long-term results are extremely favorable, and reoccurrence is limited.
RS is a relatively frequent condition seen in my office and can be managed very successfully if diagnosed early. It is important to remember that RS is a distinctly different condition than plantar heel spurs, frequently referred to as plantar fasciitis.
|
