Achilles Tendon Bone Spur Surgery – Everything You Need to Know
People usually associate the pain in the back of the heel with an overuse and think it is an Achilles tendon inflammation. Even though the Achilles tendonitis is primarily an overuse injury, there are other factors that contribute to its development.
One of those factors is retrocalcaneal exostosis which, if not timely and properly treated, can cause chronic pain and problems that can only be solved with a surgical procedure.
What is a retrocalcaneal exostosis?
Extra bone growth on the back of the heel bone is called retrocalcaneal exostosis or Haglund’s deformity. It is also known as Achilles heel spur or heel spur. It is important to differentiate this type of heel spur from the one that is located on the bottom of the heel bone.
Retrocalcaneal exostosis is usually located in the area where the Achilles tendon attaches to the heel bone. This area is particularly vulnerable to stress caused from any physical activity that involves walking, running or jumping.
What is the cause of retrocalcaneal exostosis?
The extra bone growth on the back of the heel is actually a protective response to repeated stress, pressure and friction.
- The basic reason for extra bone growth is a constant pressure and stress on the bone.
With every walk, run or jump there is a certain amount of stress and pressure on the heel bone, especially where it connects with the Achilles tendon and on the bottom of the heel. In order to become more resistant to stress, the heel bone starts to create a new bone. Moreover, overuse makes the bone growth even faster.
- The Achilles tendon and the inflammation at the joint area are other factors that contribute to heel spur formation.
With a contraction of the calf muscles, which is needed for walk, run or jump, the Achilles tendon stretches, causing a friction at the surface of a heel bone. This friction stimulates the heel bone to grow a new bony tissue.
Insertional Achilles tendonitis is another cause of a heel spur. It is an inflammation of the part of the Achilles tendon which connects with the heel bone. Every inflammation of the Achilles tendon leaves a residue in a form of a scar tissue. The scar tissue shortens the Achilles tendon and therefore causes a bigger stress and pressure on the heel bone.
- Unfitting shoes or shoes with stiff backs such as dress shoes, pumps, skates cause pressure at the back of the heel and are one of the major causes for the development of heel spurs.
- People who are born with or develop the shortening of the tendon and muscle over time have a higher risk for retrocalcaneal exostosis.
- People with high arch (pes cavus) have an extra pull of the Achilles tendon and therefore a higher risk for developing the heel spur.
What are the symptoms of a retrocalcaneal exostosis?
Retrocalcaneal exostosis can exist for years and be asymptomatic. That is because the bone spur by itself can’t be the source of the pain. However, when they start to rub on nearby tissues such as Achilles tendon and bursa (the fluid sac between the Achilles tendon and heel bone), they can cause inflammation and all the symptoms that come along with it.
When there is an active inflammation of the Achilles tendon or bursa, patients usually complain of a pain on the back of the heel. The pain is usually more pronounced after the rest, during the first few steps of walking and more intense physical activities. There can even be some pain at rest. Patients usually describe this pain as sharp or dull.
Other symptoms of Achilles tendonitis and/or bursitis like redness, swelling and stiffness are also present.
There is also a noticeable bump on the back of the heel, especially if there is an inflammation of soft tissues.
How is retrocalcaneal exostosis treated?
There are two types of treatment for retrocalcaneal exostosis – non-surgical, conservative treatment and surgical treatment.
The aim of conservative treatment is to resolve the painful symptoms. However, none of these treatments reduce the size retrocalcaneal exostosis.
- RICE therapy is the first step in treating any type of foot injury. RICE therapy consists of rest, ice, compression and elevation.
Rest and elevation are really important parts of the initial therapy. They will reduce the constant stress on the affected area and accelerate the healing process. To reduce swelling, apply a pack of ice to the affected area for 20 minutes. If the pain is to strong, you can also use anti-inflammatory drugs. They will also help with the swelling.
- There are various exercises that can help. Some of them will improve strength of the muscles around the Achilles tendon and therefore reduce the stress even more. There are also stretching exercises that will keep the area flexible and less susceptible to injury.
If you’re not sure what type of exercises you should do, I’ve already picked some of the best Achilles tendon treatment exercises that can also help you with this type of problem.
- Orthotic devices and insoles like heel lifts and heel pads are also helpful, decreasing the pressure and irritation on the back of the heel while walking.
When is the time to consider a surgery?
Conservative treatment is always recommended as a first step in treating this medical condition. However, when retrocalcaneal exostosis becomes chronically painful and limits your everyday activities, surgical therapy may be indicated. Especially when it causes complications like Achilles tendon scarring, rupture or loose bone spur.
Surgical treatment for retrocalcaneal exostosis
Retrocalcaneal exostectomy is a surgical procedure used for retrocalcaneal exostosis. The point of this procedure is to remove the extra bone and repair the Achilles tendon.
The procedure starts with the incision made into the skin on the back of the heel, exposing Achilles tendon and other tissues. Once the Achilles tendon is exposed, surgeon then proceeds with the removal of damaged and scarred parts of the tendon.
The next step is the removal of a bone spur that caused all of these problems.
If Achilles tendon damage is severe or if it is too short, surgeon may perform a flexor hallucis longus tendon transfer. This allows a decreased pull on the Achilles tendon and will reduce stress on it.
Using stitches and anchors, the opened Achilles tendon is then reattached onto the heel bone. After that, the skin is closed using plastic surgery techniques.
Postoperative care and recovery
The recovery from surgical procedures on the back of the heel depends of severity of the problem and type of surgical method that is used.
After the surgery, you will need to wear a cast or removable cast boot. If the tendon was not fully detached from the back of the heel bone, you may walk in the boot for six to eight weeks along with physical therapy.
If the tendon was fully detached from the back of the heel bone or flexor hallucis longus or other tendon was used in the repair, a cast or boot may be used for three months.
For the first six weeks don’t put any stress on the foot. After the initial six weeks, you are allowed to walk in the cast or boot.
After the removal of a cast or boot, shoes with a small heel lift and soft back should be used. In this period, you should also start with the physical therapy. The amount of time needed to return to full activities and sports is depends of the strength of the repaired structures and the speed of recovery with physical therapy. Full recovery can take six to 12 months.
There are several reasons for a long recovery period. The first reason is the poor blood supply of the Achilles tendon. The second reason is immobilization. With every immobilization there is a certain amount of hypotrophy - the reduction of muscle mass and strength. The longer immobilization, the greater loss of muscle mass and strength it is. That is why you need to be patient and follow every single doctor’s order.
Retrocalcaneal exostosis is a condition that is often forgotten as the possible reason for repeated inflammations of Achilles tendon and the pain in the back of the heel. People usually start to worry when the occasional, acute pain that resolves with simple home treatments becomes chronic pain that limits their everyday activities. Unfortunately, sometimes it is already too late for a conservative treatment and surgical procedure is needed.
However, surgical therapy for retrocalcaneal exostosis is not complicated. Maybe the biggest problem is a long recovery period, especially for those who are used to being physically active.
I hope that with this post you’ve learned more about Achilles heel spurs and the advantages and disadvantages of surgical therapy.