Achilles Tendinosis and Heel Spurs

Approximately 6% of the general population reports Achilles tendon pain during their lifetime, and roughly one-third of those cases are insertional. This is a large amount of the population suffering a specific clinical condition. The pathomechanics are complex. The Achilles tendon is under resting tension, ready to pull the calcaneus upward causing forward propulsion the second the brain decides to take a step. Sometimes this resting tension is excessive. This may begin a slow, chronic degenerative pattern at the attachment to the calcaneus. There of course is an age-related phenomenon, with more degenerative changes seen in collagen (the primary structural composition material of tendons) over time. As time goes on, more degeneration, more tension, and more compression leads to more degeneration, responsive bone formation, increasing size of the associated bursa as well as the calcaneus. More one formation leads to more substance being rubbed on by the shoe. This process ultimately leads to an acute inflammatory episode, but is often the last symptom to appear in a slowly forming degenerative process. By the time symptoms have developed and patients present to the office, radiographs show a large bone spur and severely thickened Achilles tendon. These don’t show up instantly. They reflect the years-long degeneration that has been underway without the patient even being aware. Clinical assessment is designed to determine inflammation versus degeneration. MRI is helpful to visualize all of the structures involved in the condition, including accurately distinguishing acute inflammation (what we call tendonitis) from degeneration (tendinosis.) The term 'tendinopathy' is the best descriptor of the condition, since either way a process of collage degradation is occurring, the mechanics of which needs to be addressed in addition to the acute painful condition. When conservative options fail - and they do, often - surgical management has to be tailored to the individual presentation. There is absolutely no one size fits all in calcaneal and Achilles surgery. What would be the point of debriding a degenerative tendon while leaving a large posterosuperior bone prominence and chronically inflamed bursa behind? Thus the decision to operate and what will accomplish the surgical goals must be determined by careful analysis, not by what the patient will recover from the fastest. In my experience most patients respond well to heel lifts, NSAIDs, resting the tendon, icing, and a tailored physical therapy program. When faced with a severely thickened tendon, large amounts of calcification within the tendon or an abnormal posterior calcaneal geometry (so called 'Haglunds deformity') I will discuss realistic expectations of conservative therapy working. Surgical repair is technical, regardless of the methods employed, because there is a higher incidence of wound complications in this area. Therefore this should only be performed by someone extensively trained in foot and ankle surgery.  The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.