Retrocalcaneal Bursitis / Haglund's Deformity / Insertional Achilles Tendonitis
synonyms: Insertional Achilles Tendonitis, osteochondrosis os tibiale externum
Retrocalcaneal Bursitis ICD-9
- 726.73 = Enthesopathy of ankle and tarsus; calcaneal spur
- 726.91= exostosis of unspecified site; bone spur NOS
Retrocalcaneal Bursitis Etiology / Epidemiology / Natural History
- Insertional Achilles Tendinopathy: an enthesopathy of the Achilles tendon insertion most likely from cumulative traume/repetitive stress. Primarily caused by tendon degeneration.
- Haglund's Deformity: prominent posterior-superior border of the calcaneous which compresses the Achilles tendon and its surrounding bursa against the posterior shoe counter, causing irritation. Typically young (15-30 y/o).
- Retrocalcaneal bursitis: isolated inflammation in the retrocalcaneal bursa without associated Haglund's deformity. Typically older, low activity patients
Retrocalcaneal Bursitis Anatomy
- (Heneghan HO, CORR 1984;187:228)
- Retrocalcaneal bursa lies between the Achilles tendon and the superior tuberosity of the calcaneous.
- Sural nerve lies 6cm anterior to the lateral border of the Achilles tendon.
- The Achilles tendon inserts inferiofly in the apophyseal portion of the calcaneous, not in the posterior-superior angle.
Retrocalcaneal Bursitis Clinical Evaluation
- Pain at the insertion of the Achilles tendon into the calcaneous usually exacerbated during push-off.
- Pain with shoe wear. Symptoms worse walking up inclines.
- Tenderness / swelling at the Achilles tendon insertion into the calcaneous.
- Dorsiflexion of the foot may cause pain by compressing the inflammed bursa.
Retrocalcaneal Bursitis Xray / Diagnositc Tests
- A/P, lateral and mortise ankle and A/P, lateral and oblique weight-bearing views of the foot are indicated.
- Retrocalcaneal burisitis is indicated if the sharp definition of the retrocalcaneal recess is lost and normal lucency in the region of the pre-Achilless fat pad is replaced by a soft tissue density, or if the there is erosion of the posterior-superior calcaneous.
- Evaluate for calcification at the Achilles tendon insertion and prominent posterior calcaneal tuberosity best seen on lateral view.
- Measure posterior calcaneal angle. Normal is <69°, >75° is abnormal. (Fowler A, Br J Surg 1945;32:494).
Retrocalcaneal Bursitis Classification / Treatment
- Nonsurgical treatment: Activity modification, ice, +/- cam walker with posterior heel relief, heel lift, soft heel counters / backless shoes, NSAIDs.
- Surgical: see Haglund's Technique. Achilles tendon insertion and bursa debridement and calcaneal exostectomy indicated for failure of >6months of non-operative treatment. If substantial Achilles debridement is needed repair to the calcaneous with suture anchors, or FHL augmentation is indicated.
- Isolated Retrocalcaneal bursitis which has failed non-op treatment can be treated with resection of inflammed bursal tissue.
- CPT: 28119 (ostectomy calcaneous for spur, with or withou plantar fascial release)
- Cortisone injections into the Achilles tendon are contraindicated because of the risk of rupture. Angermann P: Chronic retrocalcaneal bursitis treated by resection of the calcaneus. Foot Ankle 1990;10:285-287.
Retrocalcaneal Bursitis Associated Injuries / Differential Diagnosis
Retrocalcaneal Bursitis Complications
- Achilles tendon laceration or avulsion
- Persistent posterior heel pain
- Wound breakdown
- Medial calcaneal sensory nerve injury
- Sural nerve injury
- Ankle stiffness
- Insicional neuroma
Retrocalcaneal Bursitis Follow-up Care
- At 1-2 week follow-up: short-leg walking cast in neutral vs mild equines depending on status of Achilles tendon at surgery.
- At 4 weeks: 1/2 inch heel lift, weight-bearing as tolerated with activity limitations
- At 3 months: resume normal activities.
- Full recovery is typically prolonged and takes 6-12 months.
Retrocalcaneal Bursitis Review References
- Clain MR, Baxter DE: Achilles tendinitis. Foot Ankle 1992;13:482-487