Summary
Patients with the terrible triad of posterior heel pain describe pain in the back part of their heel (Figure 1) as their primary symptom. This may be associated with swelling that is quite tender to touch. Standing, walking and constrictive shoe wear typically aggravate symptoms. Many patients with this problem are middle-aged and may be slightly overweight. A second distinctly different group of patients with this condition include active runners who are younger in age.
Figure 1
Clinical Presentation
Haglund’s Deformity
Haglund’s deformity is a bony prominence associated with the upper part of the heel bone (calcaneus). This is sometimes called a “pump bump”. This prominent bone tends to form gradually over many years and creates pain as it rubs on the Achilles tendon and nearby bursa (see below). The bony prominence also creates discomfort by rubbing up against the heel counter of the shoe (the heel counter is at the back of the shoe and provides rigid support for the heel).
Retrocalcaneal Bursitis
Whenever tissues rub across each other, a bursa forms to allow for smooth gliding. A bursa is a fluid-filled sac and occurs normally throughout the body. Only a few cell layers thick, a bursa is filled with a lubricating fluid. However, when irritated, a bursa can become markedly thickened and painful (a bursitis = inflamed bursa). The retrocalcaneal bursa is positioned to allow the Achilles tendon to glide over the back part (posterior aspect) of the heel bone. When this bone becomes enlarged, inflammation of the retrocalcaneal bursa occurs. This inflammation results in exquisite tenderness along the posterior aspect of the heel.
Insertional Achilles Tendonitis
The Achilles tendon connects the calf muscle to the heel bone. As the strongest and largest tendon in the body, it is regularly subjected to forces that are 2 to 4 times body weight (even more with sporting activities). Over time, these repetitive loads can lead to a degenerative wear and tear where the tendon inserts into the calcaneus. This degeneration incites an inflammatory response and produces pain at the back of the heel.
Physical Examination
Patients with posterior heel pain due to the terrible triad have tenderness over the back of the heel where the Achilles tendon inserts into the heel bone. They may have swelling. There may be an increased bony prominence that is particularly irritated with tight shoes. Patients may walk with a limp and they may have difficulty taking a full stride.
Treatment
Non-Operative Treatment
Non-operative treatment is the standard approach to treating posterior heel pain. It is highly desirable to treat this condition non-operatively as operative treatment is often associated with a prolonged recovery. Traditional non-operative treatment includes the following:
- Heel Lift or the Use of a Shoe with a Moderate Heel: Walking in bare feet or a flat-soled shoe increases the tension on the insertion of the Achilles tendon. Using a heel lift, or a shoe with a moderate heel can help reduce the stress on the tendon and decrease the irritation caused by this condition.
Figure 2
- Calf Stretching: Regular calf stretching can help improve the compliance and length of the Achilles tendon. This makes it more resilient to wear and tear due to the repetitive loading associated with standing and walking.
- Anti-inflammatory Medication: Nonsteroidal anti-inflammatories [NSAIDs] can be helpful in decreasing symptoms. These medications do not address the actual underlying pathology. However, they can limit the body’s inflammatory response and therefore, decrease some of the pain associated with the condition. If a patient has a history of stomach problems, such as an ulcer or heartburn, NSAIDs should be avoided.
- Weight Loss: Many patients with posterior heel pain are overweight. A concerted effort to lose substantial weight may be one of the most effective ways to manage this condition. The Achilles tendon is often subject to forces equivalent to many times body weight during regular, daily activities such as walking and standing. Therefore, losing weight (even 5-10 pounds) can be very helpful.
Operative Treatment
Due to the lengthy recovery associated with surgery and a relatively unpredictable postoperative outcome, nonoperative management should be exhausted before surgery is contemplated. However, in high-level athletes that have developed Haglund’s deformity from running, surgery is often indicated. Surgery usually involves:
- Removing the prominent excess bone associated with the Haglund’s deformity
- Removing the thickened inflamed retrocalcaneal bursa and,
- “Cleaning up” (debriding) the Achilles tendon. In some patients where there is excessive degeneration of the tendon, it is necessary to partially or completely remove the tendon and then reattach it. In these instances, it may be necessary to augment the tendon with another tendon such as the flexor hallucis longus.
Recovery from surgery can be prolonged. Initially, the leg is immobilized to allow the wound to heal. Once the wound is healed, gentle range of motion exercises can be started. The patients will have limited or no weightbearing for the first 6 weeks during the healing process. Gradually, activity can be increased. It is not uncommon for a significant improvement to take 6-9 months. The recovery tends to be quicker in younger athletic patients.
Potential Complications
Specific Complications
Complications that are specific to this surgery include the potential for rupture of the Achilles tendon where it attaches (inserts) into the heel bone (calcaneus). If significant removal of damaged Achilles tissue is required, it can weaken the insertion of the tendon into the bone.
General Complications
Wound infection.
Wound breakdown.
Injury to the sural nerve.
Deep vein thrombosis [DVT].
Pulmonary embolism [PE].
Gait asymmetry leading to low back pain or other symptoms.
