This is a degeneration of the fibers of the Achilles tendon directly at its insertion into the heel bone. It may be associated with inflammation of a (retrocalcaneal) bursa or tendon sheath in the same area.
The cause is primarily a degeneration of the tendon. The average patient is in their 40s. Conditions associated with increased risk include psoriasis and Reiter’s syndrome, spondyloarthropathy, gout, familial hyperlipidemia, sarcoidosis as well as the use of medications such as steroids and fluoroquinolone antibiotics.
Most patients report the gradual onset of pain and swelling at the Achilles tendon insertion into the back of the heel bone without specific injury. At first, the pain is noted after activity alone, but becomes more constant over time. The pain is made worse by jumping or running and especially with sports requiring short bursts of these activities. There is tenderness directly over the back of the heel bone and often there is a bone prominence at this area. Positioning the ankle above a 90 degree position is limited by pain.
This remains primarily a clinical diagnosis. X-rays may show calcification deposits within the tendon at its insertion into the heel approximately 60 percent of the time and their presence is associated with a more guarded success rate for nonsurgical treatment and a much longer recovery time if surgery is performed. X-rays may also demonstrate the Haglund’s deformity.
Magnetic resonance imaging (MRI) remains the imaging option of choice because it can determine the extent of tendon degeneration as well as other factors such as bursitis, which may contribute to posterior heel pain.
Conservative non-surgical treatment remains effective in the majority of patients with liberal use of nonsteroidal anti-inflammatory drugs, heel lifts, stretching and shoes that do not provide pressure over this area. If symptoms persist, then night splints, arch supports and physical therapy may be of benefit.
Surgical treatment is indicated if there is failure of several months of nonsurgical treatment. Surgery removes the degenerative portions of the tendon, any bone which is irritating the tendon, and any inflamed bursa tissue. The tendon attachment to the heel bone may need to be strengthened with sutures that attach directly into the bone.