Chronic Achilles Tendon Disorders Posterior Heel Spurs
Haglund’s Deformity
Diagnosis and Management

Overview
Chronic Achilles tendon disorders are a common cause of posterior heel pain, often overlapping with conditions like posterior heel spurs and Haglund’s deformity. These entities can coexist or contribute to a cycle of inflammation, degeneration, and impaired function. Understanding the anatomy and pathophysiology is key to effective diagnosis and treatment.
Key Definitions
  • Chronic Achilles Tendinopathy: Degeneration of the Achilles tendon due to overuse, often without inflammation, characterized by pain, thickening, and reduced function.
  • Posterior Heel Spur (Insertional Calcific Tendinopathy): A bony growth at the Achilles insertion on the calcaneus that can irritate the tendon or bursa.
  • Haglund’s Deformity: A bony enlargement of the posterosuperior calcaneus that impinges on the Achilles tendon and retrocalcaneal bursa.

These conditions can occur independently but often coexist, complicating both diagnosis and treatment.

Etiology and Risk Factors
  • Overuse or repetitive strain (e.g., running, jumping)
  • Poor biomechanics (e.g., high arches, tight calf muscles)
  • Improper footwear (rigid heel counters, tight shoes)
  • Age-related degeneration
  • Systemic conditions (e.g., diabetes, inflammatory arthritis)

Clinical Presentation
  • Posterior heel pain, especially with activity or direct pressure
  • Swelling, tenderness, and thickening over the Achilles tendon
  • Palpable bump at the back of the heel (especially in Haglund’s deformity)
  • Decreased ankle range of motion and stiffness in the morning
  • Difficulty wearing closed-back shoes

Diagnostic Evaluation
  1. Physical Examination
    • Palpation of Achilles insertion and retrocalcaneal space
    • Heel rise testing for function
    • Gait assessment
  2. Imaging
    • X-rays: Show calcaneal spurs and bony prominence
    • Ultrasound: Evaluates tendon thickening, neovascularity, and bursitis
    • MRI: Best for assessing chronic tendinosis, partial tears, and bursae

Non-Surgical Management

Most cases respond well to conservative care, which should be attempted for at least 3–6 months.
  • Activity Modification: Reduce aggravating activities such as running or incline walking.
  • Footwear Changes: Use open-heel or cushioned heel shoes. Avoid rigid heel counters.
  • Heel Lifts: Temporarily reduce strain on the Achilles tendon.
  • Orthotics: Address underlying biomechanical contributors.
  • Physical Therapy:
    • Eccentric strengthening programs for the Achilles tendon
    • Calf stretching
    • Soft tissue mobilization and modalities
  • NSAIDs and Ice: Short-term relief for inflammation
  • Immobilization: In cases of severe pain or acute flares

Advanced Non-Surgical Treatments
  • Shockwave Therapy (ESWT): Shown to promote healing in chronic tendinopathies
  • Platelet-Rich Plasma (PRP): Emerging but variable evidence
  • Ultrasound-guided injections: Avoid corticosteroids within the tendon due to rupture risk

Surgical Management

Surgery is considered when conservative care fails after 6–12 months.

Procedures may include:
  • Debridement of diseased tendon tissue
  • Removal of posterior calcaneal spur or Haglund’s deformity
  • Double-row reattachment of Achilles tendon
  • Retrocalcaneal bursa excision

Postoperative recovery typically involves immobilization followed by a structured rehab protocol.

Prognosis

Early intervention and adherence to a structured rehab program improve outcomes. Surgical treatment has a high success rate, although return to high-level activity may take 6–12 months.
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References
  1. Maffulli N, Longo UG, Kadambande S, Spiezia F, Denaro V. Achilles tendinopathy: aetiology and management. J R Soc Med. 2004;97(10):472-476. doi:10.1258/jrsm.97.10.472
  2. Van Dijk CN, van Sterkenburg MN, Wiegerinck JI, Karlsson J, Maffulli N. Terminology for Achilles tendon related disorders. Knee Surg Sports Traumatol Arthrosc. 2011;19(5):835-841. doi:10.1007/s00167-010-1374-z
  3. Lohrer H, David S, Nauck T. Surgical treatment for chronic insertional Achilles tendinopathy: a systematic review. Br J Sports Med. 2011;45(5):407-415. doi:10.1136/bjsm.2009.061952
  4. Wiegerinck JI, Yntema C, van Dijk CN. Treatment of chronic retrocalcaneal bursitis. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1425-1429. doi:10.1007/s00167-012-2015-z
  5. Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med. 2007;41(4):211-216. doi:10.1136/bjsm.2007.035543