Retrocalcaneal Exostosis (Heel Spur)
What is a Retrocalcaneal Exostosis?
Extra bone formation (exostosis) on the back (retro) of the heel bone (calcaneus) is called a retrocalcaneal exostosis. Some people will also call this a heel spur, different from a spur found on the bottom of the heel. The extra bone develops on the back of the heel bone and within the Achilles tendon. The formation of this exostosis has a direct connection with the Achilles tendon, its length and its elasticity.
The Achilles tendon is a strong, thick, and important structure that functions to bring the ankle and foot downwards and propel the body forward in gait. Thousands of fibrous bands of tissue bind together to form the dense Achilles. The calf muscle (gastrocnemius) becomes the Achilles tendon about midway in the lower leg. The tendon travels down the back of the leg, crosses the ankle, and attaches to the top and back of the heel bone (calcaneus). The Achilles tendon acts as a “rubber band” that stretches back and forth with each step.
What are the Symptoms of a Retrocalcaneal Exostosis?
Patients will complain of a deep achy and sharp knife like pain on the back of the heel. The pain is more pronounced with each step when walking and any activities. There can even be some pain at rest. There will be a visible mass of extra bone on the back of the heel. Some days the bump will look larger if there is irritation and swelling of the bursa (bursitis). Any direct pressure over the bone will be significantly painful. Most patients will complain of substantial pain when taking their first few steps out of bed or after sitting for some time, and then walking. This pain can ease when there is more walking, and then increase again towards the end of the day.
Most find that being barefoot, using flat shoes and shoes without support lend to more pain because the pull of the Achilles tendon on the bone is at its maximum. Certain shoes may cause more friction of the skin over the bone leading to more pain. The pain usually will worsen gradually over time. In the event of trauma to the heel or a sudden movement and pull on the Achilles, the bone spur can fracture causing even more pain. With continued growth of the bone, the Achilles tendon can also become irritated leading to an Achilles tendonitis.
What Causes a Retrocalcaneal Exostosis?
The bones in the body stay dense and strong due to the pressures placed upon them. Disuse of bone leads to weak bone and osteoporosis. Overstimulation of bone leads to extra bone growth. The constant tugging of a short Achilles tendon on its attachment to the back of the heel bone (calcaneus) stimulates extra bone formation. With the continued bone growth there is more friction against the extra bone from shoes, leading to even more stimulation, leading to even more bone growth.
Patients born with (toe walkers) or develop shortening of the tendon/muscle complex (equinus) over time have a higher chance of developing a retrocalcaneal exostosis. Examples of those that risk shortening their tendon are those that wear high heel shoes for extended periods of time and ballet dancers that go onto point. Those patients with a high arch (pes cavus) have a higher chance of developing the spur formation to due the extra pull of the Achilles tendon.
How is a Retrocalcaneal Exostosis diagnosed?
Diagnosis is achieved by the clinical examination, digital radiographs (x-rays), and a diagnostic ultrasound of the patient. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s foot and ankle and an evaluation of their gait. There will be special examination of the Achilles tendon and its muscle to determine any underlying cause and any shortening of the tendon. Digital radiographs (x-rays) of the ankle to may be obtained in the office and reviewed with the patient. The films evaluate the heel bone for the extent of the heel spur and extra bone. In some cases, an in-office CT scan may be obtained to evaluate the heel bone extra bone in 3D.
Dr. Soomekh may evaluate the tendon using a state-of-the-art diagnostic ultrasound. This examination will show the thickness and swelling and any amount of damage and tearing of the tendon that may be associated with the exostosis.
An MRI may be ordered to evaluate the tendon directly in 3 dimensions. It may also be needed for those patients with suspected partial or full Achilles tendon rupture.
How is a Retrocalcaneal Exostosis Treated?
Dr. Soomekh educates that early diagnosis and treatment of a retrocalcaneal exostosis are the keys to successful treatment, faster recovery and painless lifestyle.
Conservative Treatment for a Retrocalcaneal Exostosis:
Conservative treatment for a retrocalcaneal exostosis is limited. These treatments rely on their ability decrease pain, reduce inflammation, stop the micro tearing of the tendon, and stretch the tendon. Dr. Soomekh will recommend a strict 2 to 4 week initial therapy protocol. Reduction of the inflammation and pain can be achieved by treating the area with a daily regimen of ice therapy and the use of anti-inflammatory medications (NSAID’s). A period of rest will be needed in order to reduce the constant strain on the tendon and pressure on the exostosis while it is trying to heal. Heel lifts can be placed in the shoes to place some slack on the Achilles. In most cases a walking boot to restrict the pull of the tendon on the bone will be recommended. The patient will be educated on a stretching regimen for the calf and the Achilles tendon. Stretching of the muscle/tendon complex is very important in order to elongate the complex allow the tendon to be more elastic and reduce the occurrence of the micro tears. These stretching exercises will be especially important in the mornings before getting out of bed or after a period of rest. Dr. Soomekh may recommend a course of visits to a Physical Therapist.
Custom Molded Orthotics
Custom molded orthotics (insoles) are an integral part of healing and maintaining the integrity of the Achilles and redirecting the pull of the tendon and the position of the extra bone formation. The pull of the tendon on the heel bone plays an important role in the support of the arch of the foot. When the tendon is damaged and irritated, the arch and the heel will need to be supported by a custom orthotic to reduce the forces placed on the tendon while walking and increased activity. The orthotics control the amount of motion through the heel during gait, and take off some of the strain the tendon would normally incur.
These treatments have a high chance of failure because they do not reduce the extra bone itself. Most of the pain is caused by the extra bone formation. At some point, this bone must be removed to alleviate pain.
Cortisone (steroid) Injections:
Dr. Soomekh does NOT recommend cortisone injections for a retrocalcaneal exostosis. Steroid injections have many positive applications for treatment of foot and ankle problems. However, the Achilles tendon can weaken when injected with cortisone.
Surgical treatment for a Retrocalcaneal Exostosis:
Dr. Soomekh will always recommend and attempt conservative treatment when appropriate. However, when a retrocalcaneal exostosis becomes chronically painful and activity is limited, surgical repair may be indicated.
Is Retrocalcaneal Exostosis Surgery Painful?
Considering surgery can be intimidating. Ankle surgery including retrocalcaneal exostosis surgery is not supposed to be painful during recovery. When the skin and the soft tissues are handled with care and focus, most patients experience little to no pain immediately after surgery and throughout the recovery period. Dr. Soomekh takes great care and focus to minimize the chance of postoperative pain. The goal of retrocalcaneal exostosis surgery is to remove the extra bone, remove any scar tissue and damaged tendon, repair tendon tissue, alleviate pain, allow a return to normal shoes, and allow a return to all activities. Dr. Soomekh performs the procedures in an outpatient setting at state of the art facilities.
The objective of this surgery is to remove the extra bone and repair the tendon as needed.
An incision is made into the skin on the back of the Achilles tendon and heel bone. Once the tendon is exposed, an incision is made into the substance of the tendon to remove the portions of damaged tendon, scar tissue, and any extra bulk of the tendon. Any bone fragments or calcifications that may be in the tendon are removed. The exostosis is also removed. If the tendon is too short an extra step may be taken to lengthen the tendon to reduce the chance of recurrence of a new exostosis. Using specialized stiches and anchors, the opened tendon is then repaired and placed back onto the heel bone. The skin is then closed using plastic surgery techniques. The procedure will require some time in a special boot or cast and crutches with no weight bearing.
Dr. Soomekh has perfected and reinvented these surgical procedures and techniques and is recognized by his peers as one of the top heel and Achilles specialists and surgeons in the Los Angeles area.