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Achilles Tendonitis and Posterior Heel Pain

Achilles tendonitis presents as a painful bump on the lateral border of their heel just adjacent to the attachment of the Achilles tendon to the calcaneus.. It can be just a bony prominence, it can be a red, hot swollen hot spot if they have been wearing shoes that have been rubbing.

There is also pain and stiffness and swelling in this region, the Achilles tendon might be a bit contracted or have tendonitis, there can also be pain at the bursa between the Achilles tendon and the calcaneus, and they may have a lot of morning start up pain and stiffness, and they sort of work it out as the day goes along, and certainly, if this is a big, red hot swollen bump here, they are having a hard time wearing shoes. They may be the person that comes in wearing sandals or some backless shoe, so it doesn’t rub.

So what’s going on here? There may be some component of insertional Achilles tendonitis, retrocalcaneal bursitis and that’s the sac between the anterior aspect of the Achilles tendon and the posterior aspect of the calcaneus sort of a bump cushion there to prevent rubbing. So what do we do for these problems? Well, we need to reduce the local inflammation, that can be oral anti-inflammatories, that can be local treatment such as iontophoresis or a steroid gel or cream that we try to rub into this area here to quiet down the inflammation. I don’t inject this, I don’t like to do steroid injections, I think if you inject in this region, you run the risk, in the worse severe case, cause iatrogenic rupture of the Achilles tendon. Some people say I’m not injecting the tendon, IM’s injecting the bursa, but there have been anatomic studies that show there are communications between the two, so if people say their injecting in front of the Achilles tendon to quiet down this hot bursa, you still run the possibility that you are directly infusing steroid right into the tendon. They need to have physical therapy, as this has become inflamed , it becomes less compliant, has less elasticity, it’s right and it hurts, so we need to work on first getting rid of the inflammation, and then working on getting rid of some of the contracture, increasing the compliance or elasticity.

Another thing that is going to help them in the short term, they need a padded shoe counter, so where that shoe rubs back here, they need a nice padding on that so it doesn’t rub so hard on the pump bump, but another thing that is going to help is giving them a heel lift.

When I look at someone who presents to me with a foot complaint, I try to break it up into what the primary pathology is, and what are the secondary manifestations that they are coming to me to complain about? The foot is a complex weight bearing surface. There re 28 bones and nearly 60 articulating surfaces.

There are the seven tarsal bones in the hindfoot region, we have that defined as the calcaneus, and the talus, that separates the hindfoot from the midfoot through the transverse tarsal joint. The remaining five tarsal bones are the middle, medial and lateral cuneiform, the cuboid bone, and the navicular. Then you enter into the forefoot which has the five metatarsal bones and the 14 phalanges. As you know, in the hallux, there are only two phalanges, whereas in the lesser toes, there are three, and then the two sesamoids that are under the first metatarsal head. Ligaments are important for static stabilization of the arch of the foot, both it’s longitudinal arch and the transverse arch. The spring ligament, if you look on the slide here, again we are looking up under the foot, here is the calcaneus.

Another concept that I use frequently when I am looking at foot problems, is that the foot should have an axis of balance. That axis of balance runs along the sagittal plane. It goes from the center of the calcaneus, to the center of the midfoot, and runs between the second and third metatarsals in the forefoot. Weight bearing forces are balanced across that access medially and laterally, in fact, minimal muscle activity is required for quiet standing. The muscle forces, or the dynamic forces during the phases of gait are also balanced across this access for dorsiflexion, plantar flexion, but mostly for inversion and eversion of the foot to stabilize and square the