Bursitis
Bursitis is inflammation of a bursa or fluid filled sac. Bursae develop at areas of increased friction, pressure or stress. Although found on the foot, they are normally found at the knee, elbow and hip. There are essentially 3 different areas on the heel for bursae to develop and become problematic.
The first area in which bursae can develop is on the bottom of the heel. This bursa is called an adventitial bursa. It is usually located between the calcaneus and the fat tissue. It can become prominent. It may feel as though the patient is walking on a pillow or fluid filled sac. It creates pain due to the vast amount of inflammatory cells located within the sac and from increased pressure from swelling. It may occur in conjunction with plantar fasciitis or with an infracalcaneal exostosis.
The second and third types of bursae that can form on the heel are located on the back or posterior aspect of the heel. Although they are both on the back of the heel the location is slightly different for each. The first bursa is called a retrocalcaneal bursa and the second is called a pre-achilles bursa. The pre-achilles bursa is located in front of the achilles tendon and the retrocalcaneal bursa is located behind or posterior to the achilles tendon just under the surface of the skin.
The retrocalcaneal bursa usually forms due to increased pressure from a retrocalcaneal exostosis or heel spur on the back of the heel bone.
The pre-achilles bursa usually forms in conjunction or simultaneously with a Haglund’s deformity.
Bursae are typically treated initially with NSAIDS or topical anti-inflamatory gels or creams. Immobilization is typically incorporated in the treatment regimen. Injection therapy with corticosteroids may also be implemented.
If the previous mentioned conservative therapies fail and no relief is achieved, then surgical removal of the bursa is performed.
If you feel you may have a inflamed bursa on the heel, please call 972-542-2155 today.
Haglund’s Deformity / Retrocalcaneal Exostosis
Retrocalcaneal exostosis is a term to describe a bone spur on the back central portion of the heel bone or calcaneus. Haglund’s deformity is a term to describe a bone spur on the superior-lateral aspect of the heel bone or calcaneus. Although both entities are stemming from the same bone and almost the same location, they are different.
First, retrocalcaneal exostoses are located directly at the insertion site or just above the insertion site of the achilles tendon on the back of the calcaneus or heel bone. This bone spur usually occurs in conjunction with insertional achilles tendonitis, but not always. There are many people who have retrocalcaneal exostoses and no pain.
Second, Haglund’s deformities or “pump bumps” are located just above and lateral to the insertion of the achilles tendon on the posterior aspect of the heel bone. To differentiate a Haglund’s deformity from a retrocalcaneal exostoses, an x-ray is typically required. Prominence of the posterior aspect of the calcaneus predisposes to the development of bursa or inflamed fluid-filled sac on on the back of the heel. The reason this entity is called a “pump bump” is that most individuals who develop this deformity are women who wear pumps.
Pain at the site of the bone spur is aggravated by pressure from shoe gear. Oftentimes, the skin overlying the spur can become thin, blistered, or callused from increased pressure from the shoe gear.
X-rays will often reveal a large bony prominence on the back of the heel just above the insertion site of the achilles tendon if a Haglund’s deformity is present, and directly at the insertion site of the achilles tendon if a retrocalcaneal exostosis is present. Most heel bones normally have a tapered or rounded posterior aspect. If the posterior aspect of the calcaneus is “squared off” then a Haglund’s deformity is present. If a retrocalcaneal exostosis is present, the bone spur is primarily located on the back center portion of the heel bone. If the retrocalcaneal exostosis is large enough, it may also involve calcification or hardening of the achilles tendon. Calcification essentially means that the achilles is turning into bone.
Initial treatment centers around reducing pressure to the back of the heel. This includes wearing open-backed shoes such as flips-flops, sandals, clogs and mules. Heel lifts are often worn inside the shoe to raise the heel up and prevent pressure by the back of the shoe while also decreasing tension or strain of the achilles tendon on the posterior aspect of the heel.
Resistant cases may require immobilization in devices such as a walking boot, below-the-knee casts and even a short period of complete non-weightbearing.
Treatment for Haglund’s deformity and retrocalcaneal exostoses are very similar. If treating a Haglund’s deformity, the “squared off” corner of the posterior superior calcaneus is removed and smoothed to make a rounded and less prominent bony prominence. Depending on how large the Haglund’s deformity is, detachment and re-attachment of the achilles tendon may be warranted.
Treating a retrocalcaneal exostosis surgically usually requires detachment of the achilles to gain access to the bone spur on the back of the heel bone. The achilles tendon most commonly inserts on and around the bone spur. Once the achilles tendon is detached from the back of the heel, the spur is resected or removed and smoothed with instrumentation. It is then customary to use tendon-bone anchors to re-attach the achilles tendon to the back of the calcaneus.
Recovery for detachment – re-attachment of the achilles tendon requires 6-12 weeks of non-weightbearing on the foot. It is important to prevent early weightbearing due to risk of tearing the achilles tendon away from the back of the heel or calcaneus.
If you have a retrocalcaneal exostosis or Haglund’s deformity, please feel free to call our offices today at 972-542-2155. Dr. Eric Silvers is a highly trained foot and ankle surgeon waiting to help you with your pain. Offices are located in both McKinney, TX and Prosper, TX.
Insertional Achilles Tendonitis
Insertional achilles tendonitis (IAT) is inflammation of the achilles tendon as it inserts on the back of the heel bone or posterior aspect of the calcaneus. IAT most commonly presents with a sudden or gradual onset often leading to chronic posterior heel pain and swelling. The back of the heel becomes very tender, puffy, and intolerable to shoes with a back or heel counter.
Pain is aggravated by increased activity (walking or running) and pressure from shoe gear. Oftentimes, a bony prominence is appreciated both medially and laterally to the insertion of the achilles tendon. Tenderness can be central within the achilles tendon or globally encompassing the entire posterior aspect of the heel.
X-rays often, but not always, may show bone spurs at the insertion site of the achilles tendon or may show erosion of the bone at the area where the achilles tendon inserts.
Initial treatment centers around reducing pressure to the area. This includes wearing open-backed shoes such as flips-flops, sandals, clogs and mules. Non-steroidal anti-inflammatory, steroid therapy, and various physical therapy modalities such as stretching, ultrasound and iontophoresis can be involved with initial treatment. Heel lifts are often incorporated to lift the heel and decrease tension or strain of the achilles tendon on the posterior aspect of the heel.
Corticosteroid injections are not a viable treatment option. There is increased risk of achilles tendon rupture if corticosteroid is injected in or around the achilles tendon.
Resistant cases of insertional achilles tendonitis may require immobilization in devices such as a walking boot, below-the-knee casts and even a short period of complete non-weightbearing.
If no relief is accomplished with the previously mentioned conservative options, surgery may be indicated. If the tendon is diseased and nonviable, or if a tear or partial rupture of the tendon is noted, then repair of the tendon is performed. If the a secondary bone spur or bursa is present, it is usually resected or removed as well.
Surgical repair of the achilles tendon involves a rigorous and prolonged post-operative recovery and should only be considered as a final option.
If you have insertional achilles tendonitis, please visit our office for a clinical and radiographical evaluation and let us begin your road to recovery and relief as soon as possible. Call 972-542-2155 to schedule an appointment today.
Infracalcaneal Exostosis
An infracalcaneal exostosis is a term that describes a large bony prominence or spur on the bottom of the heel bone or calcaneus. In some patients, this bone spur can actually be large enough to be felt on the bottom of the heel.
The bone spur is caused by traction or pulling on the heel bone or calcaneus by tiny muscles on the bottom of the foot. Many people correlate “heel spurs” with plantar fasciitis. This is a false statement. The plantar fascia in actuality, inserts just lateral to the plantar heel spur.
Most patients have 1 – 1.5 inches of fat pad on the bottom of the heel that aids in cushioning and shock absorption for the calcaneus. In older patients who have experienced atrophy or thinning of the fat pad, the bone spur can be prominent and very painful.
Treatment includes cushioning of the infracalcaneal exostosis, wearing appropriate shoe gear to soften the impact of the heel with walking or running.
For those patient who cannot find relief cushioning, padding or shoe therapy, surgery is a viable option. Surgery involves removing the plantar heel spur or infracalcaneal exostosis and making the bottom surface of the heel bone flat and smooth. A extended period of non-weightbearing is suggested due to possible risk of stress fracture with early weight bearing following the surgery.
If you have a prominent heel spur on the bottom of the heel, please visit our office for a clinical evaluation. Call 972-542-2155 for an appointment today.
Traumatic Heel Pain
If you have had trauma to the heel, please click on the following link to read more:
Traumatic Heel Pain
Neurologic Heel Pain
Please click the following link to read about the various causes of heel pain caused by nerve disorders.
