What hurts?
Some possible conditions • Heel Pain – Back of Heel
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Haglunds -
Sever’s Apophysitis -
Achilles Tendinitis/Tendinosis
Some possible conditions • Heel Pain – Back of Heel
Haglund’s deformity, also known as retrocalcaneal exostosis or a “pump bump”, is a very common condition of the heel. The deformity is caused by an abnormality of the heel bone, or calcaneus, and soft tissues of the foot. The calcaneus tends to enlarge on the back of the bone causing irritation to the soft tissues near such as the Achilles tendon. Shoe gear often contributes to the pain and irritation if rub begins due to the enlargement of the bone on the heel. The use of high heel shoes coined the term “pump bump” due to the irritation caused from tight stiff shoes and rubbing while walking.
The most common age for presentation is 40-50, and within females more than males. The symptoms are most commonly bilateral with pain at the back of the heel, more pronounced after rest. Limping and swelling are often seen with advanced deformity. History of conditions such as gout, rheumatoid arthritis or seronegative spondyloarthropathies should be ruled out as they can minimic the deformity seen. Patients may present with blistering or bursal sac formation on the back of the heel due to the enlarged bump on the back of the heel and shoe gear rub.
This condition is mostly caused idiopathically, but there are factors that contribute to symptoms that present such as tight or poorly fitting shoes, altered biomechanics, and overuse such as in runners and athletes. A tight Achilles tendon, high arch of the foot, tendency to walk on the outside of the foot, and heredity are also suggested causes of the pain and deformity.
Haglund’s deformities are more often treated conservatively than surgically. Radiographs may be performed in order to fully evaluate the heel bone for enlargement of the posterior aspect. Spurring at the insertion of the Achilles tendon can also be seen on radiographs. Changing the heel height of a shoe, adding orthotics or heel lifts to current footwear, nonsteroidal anti-inflammatory medications and physical therapy are most commonly utilized. An evaluation with a Chiropodist can be performed in order to evaluate shoe gear, gait and Achilles tendon and ankle flexibility. With acute severe pain immobilization may be necessary with a pneumatic walker or cast, in a non-weight bearing position.
In growing children, the most common cause of heel pain is Sever’s Disease, or calcaneal apophysitis. This condition begins when the growth plate that is at the back of the heel or calcaneus becomes inflamed and painful. Children that are active and play sports or exercise regularly have a higher likelihood of developing the condition.
Children often present with pain and swelling to the heel bone on the back of the heel. There can be increased warmth to the area as well. Pain with palpation of the growth plate is often indicative of Sever’s disease. Pain to the sides and bottom of the heel are not uncommon. Limping after running or jumping and stiffness after sitting for long periods or sleeping are typical presentations.
The cause of Sever’s disease is repetitive stress on the growth plate at the back of the heel bone where the achilles tendon attaches and pulls. Since patients undergoing a rapid growth spur are more susceptible to developing inflammation at the growth plate, the typical ages of presentation in girls is 8 to 13 and boys 10 to 15. The growth plate is a soft area of cartilage where bone growth occurs. The achilles tendon connects the calf muscles to the heel bone in the area of the growth plate. Activities that increase the pull of the achilles tendon on the heel such as running and jumping can irritate the heel growth plate. Overuse and improper shoe gear are also causes for possible growth plate injuries.
First and foremost in order to treat Sever’s disease, rest and time off of intense activities is a must. Gentle stretching of the calf muscles can help reduce the stress on the heel, but may not be tolerated when acutely painful. Physical therapy plays a large role in the stretching and strengthening of the leg muscles and tendons. An evaluation with a Chiropodist is recommended due to the development of the child. Icing the heel may be recommended to decrease the present inflammation. A Chiropodist can evaluate the use of over the counter nonsteroidal anti-inflammatory medications to help reduce pain and swelling of the growth plate. A Pedorthotist evaluation is helpful in order to adjust shoe gear, provide heel cups and inserts that will cushion the heel and reduce tension to the achilles tendon.
Achilles tendonitis is a common condition affecting one of the largest tendons in the body. The tendon connects the calf muscles to the heel bone and is vital in the function of walking, running, climbing stairs, jumping, and standing on tiptoes. Tendonitis occurs when the tendon becomes acutely inflamed and irritated. Tendinopathy is often associated with this condition, described as microscopic degeneration due to chronic damage over a period of time. There are two distinct types of Achilles tendonitis, insertional and non-insertional tendonitis. Unfortunately, the two types of Achilles tendonitis can occur separately or succinctly. Non-insertional Achilles tendonitis is characterized by inflammation of the fibers in the middle portion of the tendon, above the attachment to the heel bone. Whereas, insertional Achilles tendonitis involves the lower portion of the tendon as it attaches to the heel bone. The tendon fibers may calcify over time and bone spurs can form on the back of the heel.
The symptoms associated with Achilles tendonitis include pain and stiffness along the Achilles tendon particularly first thing in the morning, pain along the back of the heel that worsens with activity, and thickening of the tendon. Bone spur formation, chronic swelling and pain with shoe wear are also signs and symptoms of tendonitis. Non-insertional Achilles tendonitis is more often found in younger, and active patients. When there is palpation pain in the middle of the tendon for non-insertional or at the back of the heel bone for insertional, it’s associated with limited range-of-motion in your ankle.
Achilles tendonitis, unlike Achilles ruptures, is not usually related to a specific injury. Repetitive stress to the tendon, such as over exertion is the most common cause. Other factors that contribute to the development of Achilles tendonitis include tight calf muscles, haglund’s deformity, or a sudden increase in the intensity or amount of exercise.
Treatment for Achilles tendonitis is aimed at providing pain relief and reducing inflammation. Anti-inflammatory medication, such as ibuprofen, or prescription medication may be used to reduce the inflammation within the tendon. Initial treatment may include rest, icing, footwear modification, orthotics, stretching/physical therapy and oral medications. Physical therapy is aimed at stretching and strengthening the calf muscles and reducing stress on the Achilles tendon. A Pedorthist can fit and dispense a night splint, which holds the foot in place while in a calf stretch position while you sleep. Maintaining healthy calf flexibility will not only help treat Achilles tendonitis but will aid in preventing recurrent issues. Supportive footwear with an open back or soft heel may help to reduce the shearing and irritation of the tendon during healing. A pneumatic walking boot may be necessary for severe pain and inflammation, often a period of non-weight bearing is necessary to reduce the strain to the tendon. More advanced therapies such as extracorporeal shockwave therapy have shown to promote healing of the damaged tendon.
