Lateral radiograph of a 72-year-old woman with heel pain shows a large bone spur off the calcaneus.
Calcaneal-view radiograph of the patient’s heel.
A 72-year-old woman presents with left heel pain that has been present off and on for months but has become worse over the last few weeks. She recently returned from a walking tour of Europe and admits that the increased activity greatly aggravated her heel pain. The pain seems to be worse at day’s end and is intensified by long walks and stairs. The pain is located at the back of the heel, which is tender to touch at times. Rest and nonsteroidal anti-inflammatory drugs have not helped relieve the pain. On examination, the patient has point tenderness at the Achilles insertion site on the calcaneus, where a small bony bump is noted. Radiographs show a large bone spur off the posterior calcaneus.
This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.
Submit your diagnosis to see full explanation.
The patient has insertional Achilles tendinitis with a large bone spur off the posterior calcaneus. Achilles tendinitis can occur as both insertional and noninsertional type.1,2 Calcaneal bone spurring occurs with the insertional type.
The Achilles tendon, the largest tendon in the body, attaches to the posterior calcaneus and allows plantar flexion of the foot. Achilles tendinitis generally occurs with a sudden increase in exertional activities, such as a sudden increase in walking, jumping, or running. A period of rest permits recovery from the increased demand caused by repetitive stress on the Achilles tendon and calf.2 If patients do not rest and allow the tendon to heal after strenuous activity, tendinitis may develop. This patient went on a walking tour in Europe and she undoubtedly put much more stress on the Achilles tendon than usual. The large bone spur also places the patient at increased risk for tendinitis because it rubs against the tendon during heel motion.2
Initial treatment for insertional Achilles tendinitis includes rest and nonsteroidal anti-inflammatory drugs (NSAIDs).1,2 A steroid taper is commonly used, followed by an oral over-the-counter NSAID for acute relief. Placing the patient in a walking boot allows the Achilles tendon to rest and is generally recommended for a period of 4 to 6 weeks. A small heel lift can be used in the boot to help shorten and rest the Achilles tendon. Physical therapy should be initiated for gastrocnemius-soleus stretching and local modalities. Steroid injections to the Achilles tendon should be avoided because of the increased risk for Achilles tendon rupture. Excision of the calcaneal bone spur is a last-resort treatment option, because the procedure requires a lengthy recovery of up to 1 year for symptomatic relief. A period of at least 6 months of conservative treatment is recommended prior to considering surgery.
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).
- Hatch D. Achilles tendonitis. http://www.orthobullets.com/foot-and-ankle/7022/achilles-tendonitis. Updated March 4, 2016. Accessed August 15, 2016.
- Kadakia AR. Achilles Tendinitis. http://www.orthoinfo.aaos.org/topic.cfm?topic=A00147. June 2010. Accessed August 15, 2016.