The other day a nurse came up to me in the hospital and asked, “Dr. Silverman, the back of my heel hurts. What’s my diagnosis?”
Posterior heel pain is almost always an Insertional Achilles tendon disorder. The anatomy of the back of the heel is pretty simple:
- Skin
- A small layer of tissue
- A tendon that connect the most powerful muscle in the body—the Achilles tendon.
In front of the tendon is often a bony prominence known as a Haglund’s Process.
If there is pain directly on the back of the heel, accompanied by swelling, the problem is likely Insertional Achilles Tendonitis (Degenerative Tearing).
If the pain is in front of the Achilles (you can feel it only on the sides) then the issue is Retrocalcaneal bursitis (inflammation of a space between the Haglund’s Process of the heel and the Achilles tendon.
Initial treatment includes:
- Restriction of aggravating activity
- Avoiding rubbing on the back of the heel
- Immobilization in a cast or boot
Eventually, the above treatment blends into stretching exercises for the calf muscle and a heel lift to diminish the work by the tendon.
Non-surgical treatment isn’t always successful, but it’s always worth a solid try for several weeks to months. Having Achilles Tendon Repair surgery depends on patient age, activity level and percent of degeneration.
Isolated spur excision, excision and repair of the tendon, and reconstruction using another local tendon are reasonable treatment options to discuss.
