CHAPTER 3

POSTERIOR CALCANEAL OSTEOTOMY: A SurgicalAlternative for Chronic Retrocalcaneal Pain

Dennis E. Manin, DP.M.

The patient who complains of pain and deformityin the posterior aspect of the calcaneus presents achallenge to the treating physician. Although exten-sively discussed in the medical literature, there islittle agreement concerning the methods of treat-ment for this condition. Furthermore, significantovedap exists between several similar clinical con-ditions in this location. Achilles tendoniris,paratenonitis, tenocalcinosis, Haglund's deformity,retrocalcaneal bursitis, and retrocalcaneal spur painall have comparable clinical features. Successfultreatment for these conditions will vary dependingon the exact etiologic factors involved. This paperwill address chronic pain associated with retrocal-caneal spurring and Achilles tendonitis, which willbe referred to as retrocalcaneal spur syndrome.

ETIOLOGY

Both static and dynamic factors may contribute tothe development of retrocalcaneal spur syndrome.Static intrinsic factors, such as a ca\.us or cavo-varus foot type, can predispose the heel toabnormal pressures when combined with impropershoes. As the Achilles tendon and retrocalcanealbursa become pinched between the hard posteriorsuperolateral aspect of the calcaneus and the firmheel counter of the shoe, inflammation and degen-eration may occur. Although this process iscommonly associated with the classic Haglund'sdeformity, it can also be seen as a complicating fac-tor in the retrocalcaneal spur syndrome.

Another static factor that can contribute to thissyndrome is the posterior bursal projection of thecalcaneus or spur formation. An enlarged bursalprojection and/or posterior spur can projectdirectly into the retrocalcaneal bursa and Achillestendon, causing pain with dorsiflexion (Fig. 1). Asthe condition becomes more severe, the tendonwill go through a degenerative process resulting intendon thickening around the insertion site. Whenthis process occurs, any type of closed shoe canselve as a sollrce of pressure irritation (Fig. 21.

Figure 2. Clinical appearance fbllolr.ing chronic tendonitis anddegeneration.

Dynamic factors also contribute to retrocai-caneai spur syndrome. An overwhelming majorityof the patients with this condition present with a

significant equinus deformity of the triceps suraecomplex. In fact, many authorities believe that anequinus deformity is the single most important fac-tor underlying this syndrome. Other dynamiccontributing factors include the daily stressesplaced on the foot. For example, during periods ofintense activity such as fast running, forces up to900 kg can be exerted on the tendon.

Figure 1. The posterior bursal projection ofwithout spur fomation can become a sollrcewith ankle joint dorsiflexion.

the calcaneus with orof mechanical irritation

t4 CFIAPTER 3

The cumulative effect of these static anddynamic forces results in the pathologic changesabout the insertion site of the Achilles tendon.Microscopically, the tendon progresses through a

m),xomatous form of degeneration with eventualfibrosis and calcification within the tendon. As thetissue weakens, varying degrees of tendon rupturecan be seen.

CLINICAL PRESENTATION

Pain, edema, and ery,thema at the insefiion site ofthe Achilles tendon are the most common com-plaints of the patient exhibiting retrocalcaneal spursyndrome. Localized tenderness is usually presentwhen the medial and lateral insefiion fibers of thetendon arc palpated. An obvious enlargement orthickening of tissue in the area of the Achilles ten-don will also be seen. Increased activity and cerlain

ffpes of shoes arc aggrayating factors, and patientswill often experience a reduction in symptoms whenhigh-top tennis shoes or boots are worn.

Retrocalcaneal spur syndrome is common inmiddle-aged or slightly older individuals, although itcan be seen in individuals of any age. Both malesand females are affected, however, females are seenmore frequently for this condition. This tendenry canbe attributed to the types of shoes that females wear.Many of these patients also have varying degrees ofobesity which contribute to the symptoms. When thecondition is seen in youngeq non-obese patients,there is usually some form of aggravating physicalactivity producing the symptoms.

The majority of patients will also demonstratesome degree of equinus deformity when the gas-

trocnemius-soleus muscle complex is tested (Flg. 31.

Figure J. Preoperative assessment reveals a gastro-soleal equinusdeformity,

Gait examination may reveal excessive pronation,an early heel lift, and occasionally, an antalgic iimpon the involved side.

A weighrbearing lateral x-ray will give thebest view of any pathologic changes (nig. 4).

Oblique views can also provide better definition ofthe medial and lateral extensions of the spurring(Fig. 5A, 5B).

Figure 4. Lateral radiographcalcaneal spurring.

confirms the presence of posterior

Figure iA. A medial oblique view reveals significant calcanezrl

spurring.

CHAPTER 3 I5

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Figure 58. The spurring noted in Figure 5A is not evident on tl-rjslateral view.

TREATMENT

Conserwative therapy should be exhausted prior toconsidering any surgical treatment. Physical therapycan occasionally offer gratifying results due to thestron€l dynamic component underlying the etiol-ogy. Physical therapy, combined w'ith nonsteroidalanti-inflammatories (NSAIDs) can frequently keepthe patient comfortable enough to avoicl surgery.

Surgical reconstruction should be consideredif conservative therapy fails. A variety of surgicalapproaches have been described for this condition,but no real consensus exists regarding the mosteffective treatment. Although a few limited casehistories have been reported, no large study hasbeen conducted.

Traditional surgical approaches vary accordingto the primary site of pathology, and the presenceof any medial and iateral extensions of the spurringprocess. The most common incision approachesinclude a medial or lateral paratendinous, a singlelongitudinai mid-linear, or an oblique mid-linearincision (Fig. 6).

\7hen the deep fascia and paratenon tissuesare encountered, a decision needs to be made todetermine the best way to reach the intra-tendinousspur with the least amount of tendon disruption. Inthe past, the spur has been reached through gentlemedial or lateral reflection, or by placing a midlineincision directly through the tendon (Fig.7).Another more recent approach involves completelydetaching the Achilles tendon from the calcaneusancl reflecting it proximally. This method providesexcellent exposure to the underlying osseouspathology. However, this necessitates satisfactory

Figure 6. Common incision approaches A. Fowler and Phillip. BLateral linear. C. Ltzy-L. D. Medial and lateral linear. E. Linear midline

Figure 7. Midline tendon splitting incision

re-attachment of the Achilles tendon, under theproper amount of tension. (Fig. B). Although thesemethods adequately deal with the posterior cal-caneai spurring, none address the underlyingequinus deformity that is often present. Anothernegative factor associated with these traditionalapproaches includes the relatively long and unpre-dictable postoperative rehabilitation process.

Downey (1994) described a modified V-Y flapincision through the tendon that offers advantagesover the previous approaches' (Fig. p). Downey'sapproach allows for easy removal of both retro-calcaneal and intra-tendinous calcification.

r6 CHAPTER 3

Figure 8. Complete detachment of the Achilles tendon providesexcellent exposure to the posterior osseous pathologv.

Although not specifically mentioned by the author,the V-Y tendon flap also permits lengthening of theAchilles tendon during closure. This allows theequinus component of the deformity to be partiallyaddressed.

AUTHOR'S TECHNIQUE

A technique has been designed by the author toaddress both the static and dynamic components ofthe retrocalcaneal spur syndrome. This procedurerequires minimal if any disruption to the Achillestendon, and also has less morbidity and a morepredictable postoperative rehabilitation.

The primary component of the procedureinvolves a shofieninpJ osteotomy of the posterioraspect of the calcaneus (Fig. 10). A wedge of bone isremoved from the calcaneal body, and the most pos-terior aspect of the calcaneus, including the insertionof the Achilles tendon. is advanced anteriorly.

Figure !. The moclifiecl V Y tendon incision es describecl by Dori'ney.

This causes a significant shortening of the lever armof the tendon at the level of the ankle joint (Fig. 11).

The resultant weakening of the gastrosoleal musclecomplex effectively addresses the equinus

Figure 11. Note the ef}'ective strortening of thelever alnt of the Achilles tendon at tl-re anklejoint fbllo*.ing the clescribed osteotomy,

component of the deformity. This will clinicallyperform very similar to the Murphy Achilles tendonadvancement procedure used for spastic eqttinusdeformities. The second intent of this osteotomy is

to decrease the amount of structural irritationresulting from the spur formation and inflamma-tion. Hence, the static component of the deformiryis addressed.

Figure 10, Posterior calcaneal shonening osteotomv

CHAPTER 3 t7

\fith the patient in a TateraT position, the pro-cedure is performed through a 6-8 cm curvilinearincision along the posterolateral calcaneal body(Fig. 12). If an effort is to be made to remove anyexisting posterior calcaneal spur, the incision iskept as close to the Achilles tendon insertion site aspossible.

Figure 12, Typical curv'ilinear incision along the poster.ior lateralcalcaneal body.

As the subcutaneous layer is dissected, caremust taken to identify and retract the sural nerve.When reflecting the superficial fascia froni theunderlying deep fascia, it is essential to obtain asmuch visualization of the posterior calcaneal bodyas possible. This will assure adequate exposure forthe execution of the osteotomy. The periosteum isleft intact, and the osteotomy is cut from lateral tomedial (Fig. 13). The plantar exit of rhe osreotomyshould be just distal to the posteromedial rubercleof the calcaneus. Prior to executing the plantar cut,the soft tissues should be bluntly separated fromthe plantar surface of the calcaneus, to avoicl an

inadvertent laceration. Once the osteotomy hasbeen completed, a wedge of bone can be easilyremoved (Fig. 14).

After the wedge is removed, the posteriorbody is forced forward, closing the osteotomy.Reciprocal planing is used to reduce any residualgapping. A small amount of planing is usually

Figure 1ti. Removal of the superior neclge of bone.

required to achieve a flush fit. Ankle dorsiflexion isevaluated prior to fixating the osteotomy (Fig. 15).If futher dorsiflexion is desired, it can be accom-plished by performing additional planing. Oncesatisfactory correction is obtained, internal fixationcan be applied. This typically consists of either

Figure 15. After closure of the osteotomy andprior to internal tixation. ankle loint clorsiflexionshould be evaluated to assure adequate cofiection.

Figurt l.t. Po.16'p19r r.llr.tneil .horttning osteolum).

l8 CHAPTER 3

screw or staple fixation (Fig. 15A, 168). Screwation requires placement of the screw throughtendon from posterior to anterior. Theoreticallycould weaken the tendon. However, it hasbeen an observed complication.

COMPLICATIONS

To date, this procedure has been performed with-out any significant complications. Although thepotential for a delayed union or non-union exists,

Figure 16R, Internal fixation with staples.

the rich blood supply of the calcaneus and the use

of internal fixation minimizes this risk. There is also

the risk of over-correcting the condition andcreating a calcaneus deformity by advancing theAchilles tendon too far forward. This is an espe-

ciaily important consideration when the procedureis performed on a younger, more active or athleticindividual.

SUMMARY

A new technique has been presented to adclress

chronic, recalcitrant pain associated with retrocal-caneal spur syndrome. Traditionally, this deformiiyis a difficult and frustrating clinical condition totreat. The osteotomy presented in this paper offersa surgical alternative that addresses both the siaticand dynamic components of the deformity, whilemaintaining the integrity of the Achilles tendon.This technique not only allows for a more pre-dictable and successful outcome, but also recluces

morbidity and rehabilitation time.

REFERENCE

1. Downey MS: Retrocalcaneal exostectomy with reattachment oftendo Achilles. In Camasta CA, Vickers NS, Ruch JA (eds):

Reconstrtrctiue Surgery of tbe r-oot attd. Leg, Update 9l Tucker,GA, Pocliatry InstitLrte Publishing, 1994, pp 32-37.

fk-thethisnot

Figure 16A. Rigid internal compression fixation with 6.5-mmcancellous screw.

Postoperatively, the patient is placed in a

below-knee cast and kept non-weight bearing for 6

weeks. It is not necessary to use an above-knee cast

to neutralize the gastrocnemius muscle. Gentle phys-ical therapy is initiated 4-5 weeks following surgery.

RESULTS

Over a two-year period, 11 patients have under-gone this procedure for retrocalcaneal spursyndrome. The group consisted of 8 females and 3

males, with an age range fuom 33-58 years. Allpatients were actively employed, although noneengaged in strenuous exercise.

Ten patients presented with radiographic evi-dence of spurring along the posterior insefiion ofthe Achilles tendon. The eleventh patient showedno evidence of posterior spurring, and primarilyexhibited signs and symptoms of chronic recalci-trant Achilles tendonitis.

Early results of this small patient sample havebeen extremely encouraging from both a sympto-matic as well as a functional standpoint. All patientshave experienced a dramatic improvement, and insome cases a lotal resolution, of the preoperativesymptoms. A11 patients have achieved their desiredlevel of activity without recuffence of pain. Thepatients also relate much more versatility in theirchoice of shoes.