Use steroid injections with extreme caution due to the theoretical risk of tendon rupture.20 Injections are effective when directed at concomitant inflammation of the retrocalcaneal bursa, but accurate positioning and careful postinjection care are paramount. After an injection, a patient may need absolute rest or even immobilization to protect from tendon rupture. Emphasize a careful return to activity or athletic training.
Retrocalcaneal bursitis: Look for subtle swelling
The retrocalcaneal bursa lies between the Achilles tendon and the calcaneus near the tendon’s insertion. This bursa may become inflamed with repetitive stress or with insertional Achilles tendinopathy.
Evaluation. Swelling is usually present but may be subtle. Pain is located just lateral to the midline of the posterior heel at the superior angle of the calcaneus, and it may also be medial to the tendon opposite the lateral location.
Treatment. The bursitis often responds to icing and ice massage, shoe-fit adjustments, heel lifts, Achilles stretching programs, and systemic or topical NSAIDs.2 Steroid injections are likely beneficial, but use them with caution and take care to avoid the Achilles tendon insertion.
Calcaneal apophysitis affects highly active kids
Calcaneal apophysitis (Sever’s disease) is a painful inflammation in the heels of skeletally immature children where the Achilles tendon inserts in the calcaneus apophysis.
Evaluation. Associated with peak growth rate and high activity level, this inflammatory process usually occurs in boys between the ages of 10 and 12 years, and in girls between the ages of 8 and 10 years.21 The process is similar to that occurring at other sites of traction apophysitis, such as Osgood-Schlatter disease at the tibial tuberosity. Children most susceptible are highly active, wear poorly fitting footwear, run frequently on hard surfaces, and have tight Achilles tendons. Clinical diagnosis usually suffices, although plain x-ray films can verify an active apophysis and rule out other sources of pain, such as tarsal coalition, calcaneal stress fractures, or infection.22
Treatment. Calcaneal apophysitis is typically self-limiting, and the mainstay of treatment is rest. Heel lifts, stretching programs, icing, gel heel cups, and anti-inflammatory agents may also be used.23
Posterior impingement: Pain with full plantar flexion
Posterior impingement at the ankle joint may be self-originating or arise as a consequence of an os trigonum, a posterior sesamoid bone of the talus that exists as a normal variant. In some cases, this bone creates a barrier to full plantar flexion at the ankle joint and creates pain at the posterior heel.
Evaluation. Pain with full plantar flexion is a critical distinguishing feature, because most other pathologies in the posterior heel cause pain with dorsiflexion at the ankle.24,25 Patients often are involved in activities that require forced plantar flexion, such as gymnastics or dancing. Diagnosis is clinical for the most part, but plain x-ray films may confirm the presence of an os trigonum. Magnetic resonance imaging (MRI) is warranted for patients with persistent symptoms; it may reveal a hypertrophied synovial lining or other pathology (such as osteochondritis). MRI is also indicated before more invasive therapies, such as steroid injections or surgery.
Treatment. Advise rest with or without immobilization, NSAIDs, or local steroid injections. Severe impingement or recalcitrant cases may require surgical release of the posterior synovium or removal of an os trigonum.24,25
Achilles strain and rupture: Middle-aged men are susceptible
The Achilles tendon is most susceptible to injury in middle-aged men who are active in sports requiring loading and sudden contraction of the calf muscles, such as basketball or football, although injuries may occur in a variety of other settings. A strain of the Achilles tendon should be carefully differentiated from a complete rupture. While strains can be treated similarly to Achilles tendinopathy, complete rupture is a much larger concern.
Evaluation. When the Achilles tendon ruptures, patients describe sudden pain and a pop that is often audible. Poor plantar flexion of the foot ensues.26 Telltale signs on examination are a positive Thompson’s test (little or no plantar flexion with a calf squeeze) and a visible defect in the tendon. The rupture site is usually 1 to 2 inches proximal to its insertion on the calcaneus.
Treatment. Most of these patients should be seen by an orthopedic surgeon as soon as possible. For active and younger adults, treatment is almost always early surgical repair.27 For some older individuals who are less active, nonsurgical management includes graduated casting, which progressively lessens plantar flexion over 6 to 10 weeks, followed by physical therapy.