Posterior heel pain

General

This information booklet aims to provide helpful advice to people who are experiencing pain and swelling at the back of their heel. The underlying cause may be due to the shape of your foot or how it functions, general health problems or overload/overuse injuries, in some cases the cause is unknown. Heel pain commonly produces footwear problems and a reduction in activity levels.

Diagnosis

A diagnosis can often be made by taking a medical history and examining your feet. Generally, an X-ray and an MRI scan are required to help confirm the diagnosis and determine the degree pathology. The treatment options will vary depending on the specific problem and an individual treatment plan will be discussed during your consultation. There is no direct correlation between the size of the deformity and the degree of symptoms experienced.

Inflamed bursa

A bursa is pocket of fluid which is found at the back of your heel. On occasions it can become inflamed and painful, but this rarely happens on its own and is usually associated with a bony problem.

Treatment options

Conservative care

Conservative care is often most helpful in the early stages of the condition. The studies suggest there is limited evidence for long term resolution of pain especially when the condition is severe. However, conservative care is generally recommended initially and some of the options are listed below.

• Pain medication
• Comfortable supportive shoes that don’t put too much pressure on your heel.
• Steroid injection (inflamed bursa)
• Stretch regime for the calf muscles – see calf stretch board below
• Orthotics – depending on your foot type you will be advised regarding a non-bespoke or bespoke insole
• Silicone gel sheeting to protect the soft tissues from footwear irritation
• Extra corporeal shockwave therapy – this treatment aims to improve healing at the tendon bone junction. There are a limited number of studies reporting long term success from this treatment, however it appears to be more helpful when combined with calf stretch exercises.

Surgical management

If the pain continues after trying conservative care then surgery might be considered. The type of surgery will vary depending on your diagnosis. The outcome will depend on the degree of tendon damage and how long the condition has been present for.

Bony exostostectomy

The outgrowth of bone is removed from the back of your heel along with any bone/calcification that has grown into the Achilles tendon. The tendon is reattached to the bone with an anchor suture (a stitch into the bone). The inflamed bursa can be removed at the same time if required. The procedure takes approximately thirty minutes, but would require you being in a below knee cast non-weight bearing for 4-6 weeks. The outcome of the surgery depends on the quality of the Achilles tendon, in severe case some heel pain may persist.

Osteotomy

An incision is made on the side of your heel to expose you’re the bone. The bone will be cut so that a small section of bone can be removed in order to reduce the pressure at the back of your heel. Screws are used to hold the bone together while it heals. Post-surgery weight-bearing in an Aircast Walker is allowed initially with crutches. The screws normally stay in your heel bone unless they cause problems. If they do, the screws can be removed with a small skin incision and a quick recovery. There is a small chance that the bones fail t o unite (heal), but this is highly unlikely.

Removal of bony bump

In case where there is a bony bump but no involvement of the tendon, this can be removed in isolation. An incision is made on the outside of the heel away from the tendon and the bony lump removed. Post-surgery full weight-bearing in an Aircast Walker is allowed.

Bursa removal:

If an inflamed bursa is detected on your scan then it can be removed at the same time as the surgery to treat the bony outgrowth. It is unlikely you will need an inflamed bursa removed in isolation so the recovery time is dependent on the other surgeries performed. This will mean you might be in an Aircast walker or below knee cast after the operation.

Day surgery

These operations are normally carried out on a day care basis. You would be admitted to the hospital on the day of your operation and shown to your room. Professor Tagoe will confirm your consent form and mark the surgical site.

Anaesthesia

You will be put to sleep by the Consultant Anaesthetist for the duration of your operation waking up in recovery. In addition, a local anaesthetic block in the back of your knee (Popliteal block) will be administered by Professor Tagoe. This will numb your foot and lower leg providing pain relief for the 12 to 36 hours following the operation. It will also temporarily block your ability to move your foot and toes. In adult patients the popliteal block is often performed prior to you being put to sleep. As the anatomy behind the knee varies a little from person to person, a nerve stimulator is used to accurately identify the nerves. This sends a small electric current down the needle so that when the nerve is approached it is stimulated. This means that the muscles controlled by that nerve begin to contract and relax causing the foot to ‘flick’. If you are conscious it is a strange sensation, but it helps us to deliver the anaesthetic around the nerve with precision.

Reducing the risk of a blood clot (DVT)

Being in a cast and non-weightbearing places you at an increased risk of developing a DVT, if the clot travels to the lung (pulmonary embolism) this could be fatal. You will be shown how to inject a drug (low molecular weight heparin) using a very small needle into the fat around your tummy. This thins the blood reducing the risk of you developing a DVT. The needle is very fine and for most patients it is not painful, it can leave a bruise, so we recommend that you move the injection sites around your tummy. These injections will need to be continued whilst you are in a cast non weightbearing.

Discharge

When you leave the hospital, you will have a cast on your leg or an Aircast Walker or cast. Depending on the type of operation you had, you will be shown how to non-weight bear or partially weight bear using crutches. The post-operative medications will be dispensed by the nurses, you will need to arrange your next appointment at the clinic. You should arrange to go home by car or taxi with an escort and have someone with you for the first 24 hours in case you feel unwell.

Recovery

You must rest with the leg elevated for the first 48hrs (essential ambulation only). It is important that you keep the cast clean and dry. X-rays for the osteotomy group will be taken to ensure good position and stable internal fixation and again at 12-weeks to confirm bone healing. A Limbo cast cover can be bought to enable bathing without getting the limb wet and increasing the risk of infection. For some patients an additional partial weight bearing cast is applied for 4 weeks. The length of time you are in a cast for depends on the procedure, the degree of pathology affecting the Achilles tendon and how well you are healing.

Returning back to activity and regular footwear is gradual and very much depends on the type of operation, your body’s healing response and the individual’s level of motivation.

Full recovery takes 7-12 months for the retrocalcaneal exostosis.

Possible complications

Most patients have an uneventful recovery. Outlined below are the common problems or those rare complications with serious outcomes. In cases where we don’t have accurate audit, we have used published results from the podiatric literature. These are accompanied by an asterisk *

• Prolonged swelling taking more than 6 months to resolve occurs 1 in every 500 operations*
• Haematoma – a painful accumulation of blood within the operation site. No recorded incidents.
• Thick and or sensitive scar – no audit data is available.
• Screws and plates were removed from 118 patients during a twelve-month period. This is often planned but can occur as a result of irritation.
• Adverse reaction to the post-operative pain killers. 1 in every 50 patients report that the codeine preparations can make them feel sick.*
• Infection of soft tissue. The incidence is 1 in every 83 operations*
• Infection of bone occurred in 3 out of 916 patients.
• Delayed healing of soft tissue or bone. No audit data is available.
• Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10-year period.
• Loss of sensation can occur although this is usually transient but can take up to a year to resolve.
• Deep vein thrombosis which can result in a clot in the lung is potentially a life-threatening condition. Within the published literature, the overall incidence of VTE is thought to be 0.9% in foot and ankle surgery.
• Chronic pain syndrome: this is where the nervous system dealing with pain over reacts in a prolonged manner often to a minor incident. This normally requires management by specialists in this condition and doesn’t always resolve. This is a rare complication with no audit data available.
• Reoccurrence of the deformity or failure of the operation
• Development of secondary problems including overloading of joints adjacent to the ones operated

The risk of having a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre-operative screening and continues through to the rehabilitation exercises.
Pre-operative screening of your health allows us to determine whether you are fit for surgery. It is important that you disclose your full medical history. If there is a query regarding your health, then further investigations or the advice of other surgical and medical specialties will be sought. Professor Tagoe and the theatre team will ensure that the operation is performed effectively and with the minimum of trauma.
 
You can improve the healing process and reduce the risks of complications by:

• Adhering to the post-operative instructions which include resting and elevating the operated leg. Keeping the wound clean and dry until advised otherwise is essential. Please ask the team if you are not sure what to do.
• Having a healthy diet is important. This provides the nutrition required for healing.
• Smoking is associated with a 20% increased risk of delayed or non-healing of bones.
• Alcohol can interact with the drugs that we will prescribe and in excess can impair wound healing.
• Post-operative exercises and in certain cases physiotherapy will be advised. This helps improve the flexibility, strength and stability of your foot.