Case of the Week #14
72 year old lady with severe insertional achilles tendinopathy and large Haglund's deformity of the calcaneum.
Mrs R is a delightful 72 year old lady who was referred to us by her General Practitioner for intractable heel pain. She had seen a Physiotherapist who had undertaken an appropriate rehabilitation program for insertional achilles tendinopathy (described by Maffulli here). This had helped control her pain, but she was still only able to walk for 10 minutes before having to rest due to her ankle pain. She was also struggling with shoewear due to a prominent, painful bump on the back of her heel.
She was otherwise a very fit, active lady and had recently undergone a successful total knee replacement. She was frustrated that her knee pain had resolved but she was now limited by pain in her achilles tendon.
On examination, she had a prominent, erythematous bump over the posterior aspect of her heel which was extremely tender to palpation. She had significant calf wasting. She was unable to perform a single leg heel raise due to pain in her heel. Her plantar fascia insertion was non-tender (insertional achilles tendinopathy and plantar fasciitis often go together due to a tight posterior chain).
Her initial x-rays demonstrated a moderate sized Haglund's deformity (bump on the back of the calcaneum) as well as calcification within the insertion of the achilles tendon.
We discussed the possibility of an ultrasound guided steroid injection to help settle her symptoms. However, as there is some limited evidence that steroid injections in and around the achilles tendon may cause weakness and rupture (see Juliano 2004), it was decided to avoid the risk of the injection at this stage.
We therefore decided to proceed with surgery. The Haglund's deformity needs to be removed to prevent further irritation and traction on the achilles tendon. The retrocaclaneal bursa, sitting just in front of the Haglund's deformity, also needs to be removed. Then the achilles tendon is debrided and intra-substance calcification removed. As this process involves taking the achilles tendon off the bone, it is repaired back down to the calcaneum using knotless anchors (a technique we borrowed from our shoulder surgeon colleagues!).
Mrs R was placed in a plantarflexed backslab for two weeks and was non-weight bearing while the wound healed. She was reviewed two weeks post-operatively where the sutures were removed and she was fitted with an Air Cast boot and 3cm heel wedge to reduce tension on the achilles tendon and allow for early weight bearing. The heel wedge was reduced by 1cm each fortnight over the following six weeks.
Mrs R was completely pain free and delighted with her surgery at her eight-week post-operative appointment. She made a transition to a normal shoe and started a calf strengthening program, initially performing bilateral heel raises as progressing to single leg heel raises as tolerated.
One year post surgery, she has an unlimited exercise tolerance, can wear all her shoes comfortable and no longer has any night pain. She is very happy with her surgical outcome.
Insertional achilles tendinopathy is relatively common, but fortunately most cases settle with an intensive rehabilitation program. The diagnosis is made by a combination of clinical examination and imaging. A lateral x-ray of the ankle to demonstrate the Haglund's deformity and possible calcification within the tendon is very helpful, and an ultrasound can demonstrate degenerative changes within the tendon at its insertion. An MRI scan is not normally required but may be appropriate if there is concern about fatty atrophy of the calf muscle or another cause for the patient's symptoms. The role of steroid injection is controversial, and the small risk of tendon rupture needs to be discussed with the patient prior to proceeding with an injection. Surgical removal of a Haglund's deformity and careful debridement and reattachment of the achilles tendon is a reliable procedure for patients with intractable insertional achilles tendinopathy not amendable to non-operative measures.