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Calcar calcanei - heel spur

Why are you limping? My heel hurts. I must have that heel spurn thing. I have to run a lot to get rid of it.

It's not a joke. This is a conversation led by two marathon runners on the start of a race (discretion is guaranteed). I must state that heel problems are fairly common with our marathoners, at least according to the survey that I myself conducted. However, if heel pain is dealt with by „running to get rid of it“, it's bad news.
Painful heel is one of the most common problems in marathoners. Since our feet experience great stress, it's no wonder that the heel as one of our main strongholds reacts to something not being quite right by sending signals of pain. Pain in the heel is not presented only by heel spur, as most runners believe. First we must see in which part of the heel did the pain occur.
Heel bone (calcaneus) serves as a vertex for two very important anatomic structures for runners. On the back side calcaneus is connected to the Achilles tendon, and on the lower side to plantar aponeurosis. So painful heel syndromes are in marathoners a result of precisely these two structures.  
In this article I will describe the conditions that can cause pain in the back side of the heel.

PAIN IN THE BACK SIDE OF THE HEEL

If you are experiencing pain in this area, it is necessary to consider:

  • Retrocalcaneal bursitis – inflammation of the mucosal sack between the Achilles tendon and calcaneus
  • Achilles tendinosis (tendinitis) – inflammation of the Achilles tendon
  • Haglund syndrome – if retrocalcaneal bursitis and Achilles tendinitis are present at the same time and on the same foot
  • Calcaneal apophysitis – inflammation on the place of insertion of Achilles tendon to calcaneus


Retrocalcaneal bursitis

This is a very common problem with runners, but it is rarely diagnosed because it is often misdiagnosed as Achilles tendonitis. A bursa is a small sack filled with fluid between the heel bone and Achilles tendon. Overtraining leads to its inflammation.

Symptoms:

  • pain in the back side of the heel, especially while running uphill or on soft ground (dirt)
  • swelling in the back part of the heel and feeling painful to touch, which sometimes makes putting on shoes a problem
  • by simultaneously pressing on both sides of the back of the heel we can feel a spongy structure

Treatment:

  • rest
  • apply ice, through bandage or cloth, not directly on the skin, 2x15 minutes with a pause of 10 minutes in-between
  • 3x1 Ibuprofen (400mg)
  • ultrasound physical therapy has proven to be very efficient because it shortens the healing period
  • TENS | Transcutaneous electrical nerve stimulation
  • blockages (steroid local injections) are a possible option in the presence of severe pain, but after the injection one must rest completely for 48 hours. Blockages are used only in special circumstances and are best avoided if possible, especially on lower extremities, because multiple applications can lead to tendon weakening and therefore its rupture
  • operation is needed in some rare cases

Achilles tendinosis (tendinitis)

Achilles tendon is a big tendon on the back side of the ankle. It connects lower leg muscles (gastrocnemius and soleus) with the heel bone. Tendon becomes inflamed after long-term exposure to constant microtraumas. It is thought that this condition makes for 15% of all running injuries.
One of the main causes is also ovetraining, along with exaggerated pronation, which leads to twisting the foot inwards which then causes left-to-right movement of the tendon, irritating and inflaming it.

Symptoms and signs of acute inflammation:

  • pain along the side of the Achilles tendon while exercising (back side of the lower leg, back side of the ankle, and back side of the heel)
  • red skin above the tendon
  • when pressure is applied to the tendon one can feel crepitation (scraping) while moving the foot up and down

If you ignore these signs for a longer period of time (few weeks), you will most likely develop a chronic inflammation of Achilles tendon, which has few chances of successful treatment. 

Symptoms and signs of chronic inflammation:

  • pain in the tendon is present even while being inactive, especially in the morning, and it amplifies with walking uphill or up the stairs
  • symptoms last for weeks

Treatment:

  • rest
  • applying ice locally, not directly on the skin, 2x15minutes with a pause of 10 minutes in-between
  • 3x1 Ibuprofen (400 mg)
  • inserting a heel splint in the shoe to lessen the pressure on the Achilles tendon
  • taping the back of the heel and lower leg in order to provide support for the tendon
  • if the situation is bad, one might consider immobilization using a plaster cast
  • interferential therapy
  • TENS | Transcutaneous electrical nerve stimulation
  • ultrasound physical therapy
  • sports massage prevents the adhesions


Haglund syndrome

When the two previously described injuries (retrocalcaneal bursitis and Achilles tendinosis) occur together at the same time on the same foot, this condition is called Haglund syndrome.
Other than the previously mentioned symptoms, there is usually a bump present on the back of the heel, called exostosis. Sometimes this bum can be so big that runners need to buy bigger shoes.

Treatment:


If standard procedure (as described) doesn't help, the operation is inevitable (removal of the heel bump and repair of the Achilles tendon).  

Heel bone apophysitis

It occurs mostly with children who start training very early (between the ages of 8 and 15). This condition is common with children who grow very fast, because growth of the bone leads to tension in the muscles and tendons. Inflammation happens in the place of insertion of the Achilles tendon in the heel bone, and so called crushing of the heel bone occurs.

Symptoms:

  • pain in the back side of the heel while walking or running
  • a bump on the back side of the heel can (but doesn't have to) be present
  • tensed muscles of the back side of the lower leg (soleus and gastrocnemius)

Treatment:

 

As is seen from the described injuries, pain in the back side of the heel can have multiple causes. Each of the injuries listed demands that you see a doctor who will then based on the gravity of the condition decide whether physical therapy or orthopaedic consultation is necessary.

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