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 on that, and exacerbated a bursa that has formed over time. 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 as they are walking.

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 of the tendon.

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. You can imagine, if you put a quarter inch, half inch heel lift here, the ankle is going to plantar flex, the calcaneus is going to rotate up, and you are actually going to increase the space between the front of the Achilles and the back of the calcaneus, so there is going to be less impingement back here when they ambulate.

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