Problems of the Insertion of the Achilles Tendon
The Achilles tendon attaches to the
heel bone (the calcaneus) over a very broad area. Although the tendon
is only approximately one-centimeter thick, its attachment spreads
over a three and a half-centimeter area on the calcaneus. Recurrent
stress on the tendon where it attaches (the insertion) leads to inflammation,
microscopic tearing of the tendon, swelling and pain. This can be
associated with inflammation of the space between the tendon and the
calcaneus, called the retrocalcaneal bursa. At times the back of the
heel can begin to enlarge and get quite thick. The thickening is partly
as a result of bone spurs that may develop on the back of the calcaneus.
These can then grow up into the substance of the Achilles tendon causing
further wear and tear of the tendon.
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This is the typical appearance
of a painful heel from a bump on the back of the heel
bone. This is aggravated by rubbing from shoes (in some
countries this condition is called a pump bump because
of the "pump" type of shoe). |
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This is the appearance of the back of
the heel on an XR taken from the side view. The abnormal bone
projecting into the Achilles is easy to see, and the normal
heel bone contour is shown with the dotted line.
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Treatment of the insertion of Achilles tendonitis begins with rest,
elevation of the heel on the sole of the shoe and physical therapy
treatments. All of these are designed to decrease the inflammation
on the tendon. Inflammation occurs with every step we take when walking
because of the stretching of the Achilles tendon. Padding of the shoe,
elevated heels and physical therapy treatments are commonly successful.
Cortisone (steroid injection) should not be used to treat inflammation
of the insertion of the Achilles tendon since this can lead to further
deterioration of the tendon itself.
If conservative treatments are not sufficient, surgery is performed.
The surgical procedures performed are varied and are determined by
the underlying problem. For example, if the bone on the back of the
heel is very prominent and is digging into the Achilles tendon, the
bone is trimmed and shaved.
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Here you see the back of the heel
and the bump on the heel bone shown on the left. Right:
A bone chisel is used to remove the bump completely. |
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The appearance of the heel after the
bone has been cut |
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The bone on the back of the heel
has been removed. On the XR on the right, note a white
object in the bone. This is a small bone screw that is
used at times to re-attach the Achilles in severe cases
where a lot of bone has to be removed. |
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Alternatively, the tendon may need to be repaired if there is tearing
of the tendon where it attaches to the bone. In addition to repairing
the tendon, a transfer of a tendon is used (transferring the tendon
to the big toe, called the flexor hallucis longus). This tendon transfer
adds strength and support to the weakened damaged tendon.
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