Examination of a 67-year-old woman with left heel pain finds a tender bump on the back of the heel.
Lateral radiograph of the woman’s heel.
A 67-year-old woman presents with left heel pain that has been present for 1 year. The pain seems to come and go but has been quite bothersome for the previous few weeks. She has tried oral anti-inflammatory drugs, ice, and rest, but nothing seems to help. There is no history of seronegative spondyloarthropathy or recent fluoroquinolone use. On examination, a tender bump is noted on the back of her heel. Lateral radiograph of the heel is taken.
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The patient has insertional Achilles tendinitis. The lateral view radiograph shows a large osteophyte or heel spur and intratendinous calcification. The osteophyte on the posterior calcaneus and intratendinous calcium deposition are causing the patient’s heel bump.
This presentation is often confused with Haglund deformity, which is a prominent posterior superior aspect of the calcaneal tuberosity that causes an overlying bursitis and tendinopathy. This patient’s posterior superior calcaneal tuberosity is normal in shape. Haglund deformity is often referred to as a “pump bump” as it has been associated with certain shoes such as high heels. Unlike insertional tendinitis, which generally occurs in middle-aged to elderly people who have tight heel cords, Haglund deformity occurs in those aged 15 to 30 years for unknown reasons. Sever disease, or calcaneal apophysitis, is a condition caused by an inflamed growth plate in the heel that occurs during adolescence. Intratendinous calcification and heel bump is an unlikely presentation of gout, which is commonly an intra-articular condition.1,2
First-line treatment for insertional Achilles tendinitis includes ice, oral and topical nonsteroidal anti-inflammatory drugs, tapering dose of oral steroids, and physical therapy for heel stretching. Heel sleeves and pads are an effective treatment to reduce contact on the heel, and a small heel lift can help relax the tendon during treatment. A night splint to hold the heel in maximal dorsiflexion helps with persistent heel cord tightness. A weight-bearing cast or walking boot may be recommended if the condition fails to improve with the aforementioned treatments. A steroid injection to the heel is contraindicated because of an increased risk for Achilles rupture. If conservative treatment does not result in improvement within 6 to 9 months, surgery may be considered. Excision of the intratendinous calcification, osteophytes, and diseased tendon would be recommended for this woman should conservative treatment fail. Surgical treatment of Haglund deformity requires larger boney resection at the posterior superior calcaneus.1
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Myerson MS, McGarvey W. Disorders of the insertion of the Achilles tendon and Achilles tendinitis. J Bone Joint Surg Am. 1998;80:1814-1824.
- Hatch D. Achilles tendonitis. http://www.orthobullets.com/foot-and-ankle/7022/achilles-tendonitis. 2016. Accessed December 5, 2016.