Juan C Goez, DPM examines the causes and presentation of posterior heel pain that results from Achilles tendon inflammation and exostosis. Dr Goez discusses differential diagnoses and the clinical and imaging presentations of retrocalcaneal exostosis and offers recommendations for initial conservative treatments and surgical interventions.
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Juan Goez, DPM
Director, Podiatry Division, Foot & Ankle Service
South Nassau Communities Hospital
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Male Speaker 1: Our next speaker is Dr. Goez [phonetics] from New York. He is Director of Foot and Ankle Service, Orthopedic Department at South Nassau Community Hospital in Oceanside New York, adjunct faculty to Ken State University, the School of Podiatric Medicine and Dr. Goez is going to talk to us about retrocalcaneal exostosis surgical approach. So please welcome Dr. Goez.
Male Speaker 2: Good afternoon, first I would like to thank PRESENT for the kind invitation. It's always a pleasure to come and share some of the new things that I take opportunity to learn every time. So you can see the material that has been presented here is of the highest quality. And so I'm happy to be able to be a part of that. I'm going to talk to you about very common thing that we see in our offices, retrocalcaneal pain, particularly the one that is due to either a Haglund’s deformity or Achilles calcification tendinitis or a retrocalcaneal exostosis. And just to go over some of the things that we do, as you can see it's a common pain. So plantar fascitis being probably the number one pain that I get in my office. I think that we would share that, but the posterior aspect is pretty, pretty common as well. And I always try to, as we train residents, to make sure that we have a differential diagnosis such as exostosis. Some of the differential diagnoses including tendinosis, tendinitis. I have an interesting thing that I do with my patients. I try to tell them how to understand tendinitis, tendinosis, tenosynovitis. So my spiel with them is that I wanted to think of the tendon as a whole bunch of linguine. Think of the tendon as linguine and then you have a sock and you have olive oil in between the linguine and a sock. Then of course, you start getting hungry. And the idea is that the covering of that sock is the covering that’s going to create the liquid, the synovium. And so as we walk and as that tendon gets injured, many of those linguine strands start to break and then of course we get that adipose tissue in between, then we can see tendinosis. The tendinitis is really the inflammation of that liquid, that synovium becomes very liquidy and it's easy for them to understand if you have a car and you don't change the oil, the oil is going to turn like water. So there is high friction coefficient. It goes up, your tendon gets hard, it gets swollen, it gets red. It's usually very helpful for them to visualize and it helps me to help them because they understand exactly what's going on. And then we get the calcification, the intratendinous calcification inside the tendon because of that law of Wolff bone regeneration because we put stress on the bone. You can see there is some evidence. This lecture was put together with one of my residents, Dr. Roger Kilforal [phonetics] and I thought it was very interesting that the majority of the Achilles tendon, the surgical balancing occurs during a sports-related activity, sports related, but as I work with professional teams and as I see the lead athlete is pretty impressive, how much Achilles tendon pathology or Achilles tendon problems the athlete has because they stress it so much. The tendinopathy is either mid substance or at the insertion of the Achilles tendon, but usually not both concomitantly according to my CS in 2015. And then usually typically treated with central tendon debridement, transfer of Haglund’s resection or reattachment of the Achilles tendon. So those are basically your basis for your treatment and the location is 50% of mid substance. I thought that was very interesting to me. With 24% of the insertion, but the concomitant with Haglund's deformity is not widely reported. So we may have the deformity of Haglund’s, but is not reported and I think it's usually because the pain is secondary to the exostosis that is present and the inflammation of the Achilles tendon. The repetitive trauma leads to inflammation followed by the cartilaginous and then bony metaplasia, so that’s how we get our exostosis being there.
Of course, so the patient presents to your office with pain, sometimes limping, hot, swollen, red. Again, we talked about why it happens and then many times we get the enlargement of the Achilles tendon. And that enlargement sometimes becomes quite prominent in some patients. And if you have a rupture, if the tendon ruptured and is very thickened, sometimes it's quite difficult actually to differentiate especially when it's just a partial tear of that tendon. So we move on to our physical exam and here midline tenderness at the insertion site, so you put hands on their foot, you press and you can almost feel sometimes when they have that bony exostosis, very painful. Painful upon dorsiflexion of the angle at the Achilles tendon attachment especially when moderate-to-severe cases, the mild case I don't see that as much. There is of course swelling and may extend proximally along the Achilles tendon. When it starts extending proximally, my problem became a lot bigger because now it's not just the detachment, now I'm getting tendinitis going at the tendon. And your gait exam is going to reveal favoring of course secondary to pain. X-ray will show us a retrocalcaneal exostosis and so the argument sometimes comes academic whether the patient has or does not have a Haglund’s deformity. And sometimes the presence of the bump on the posterior aspect is also related to the presence or the lack of calcaneal inclination. So we need to evaluate because obviously a patient bending no this angulation, the bump in the back may or may not be prominent on the patient. The MRI will show us the tendon degeneration again. You see they are going to light up. If there is a lot of liquid or a lot of that synovitis or tenosynovitis, it's going to show us the tendinosis, the changes of fibers of the Achilles tendon, but the pain is usually at the posterior aspect. So we are all trained to exhaust conservative therapy. It's always a good idea. I think that this is one of those opportunities that is very important to do it. I'm moving less and less in some aspects of our profession as to whether it's really a good idea to do conservative care for everything or at least for such extended periods of time, but in this case I think that is very, very important obviously, because of the risk of the surgical approach. So shoe is very important. AFOs, nonsteroidal anti-inflammatory medication and physical therapy with essential training. I always try to call the physical therapist to make sure that they know what they are doing. For me, it has been important to develop relationship with the physical therapist that I send and I send patients to those places specifically because I know the type of work that they are doing. Abbad spoke in 2013 about extracorporal shockwave, lost a little bit of -- it's not as popular here, but if you go to Europe; Spain, France, England, it's very, very popular, still widely used. Patients still -- as you know, socialized medicine, they don't really have to pay for it, but they have a long, long, long waiting list. The laser therapy, my biggest therapy exposure was with Spain’s Olympic team and they use lasers extensively in their athletes. It’s a part of what they do almost on an everyday basis, particularly the marathon runners, the high jumpers as well as the long jumpers. They feel that it's very, very important for them. Dr. Gian [phonetics] in Madrid Complutense University has extensive research showing that it is very good. I don't think that we have -- it's not as popular here yet and might be part because of expense of buying equipment. PRP, you know, is becoming popular and not so much for the tendo-Achilles tendon, we know that. A study is comparing, saline injections versus PRP. There is no difference, so we still -- I think the queue is out on it. Sclerosant injections, again not as popular. I don't find many of my colleagues doing sclerosant injections. The acetic acid iontophoresis, I thought it was very interesting and this I again learned from Dr. Kilfoil [phonetics] where they did a very interesting case presentation of using acetic acid iontophoresis and they presented a case where they actually took the pain away from the patient.
So it's one of those treatments that we don't -- it's not very widely known, but that may offer something to our patients. And of course, avoid the steroid injections, more than two, it's risky, 63% chance of rupturing of the Achilles tendon. Unfortunately, I see a little too much of that where the tendon ruptures because of the chronic injections. So surgical management, which is the point of this conversation involves making incision on the Achilles tendon, remove the deformity and then we need to reattach the tendon and this is just one of the ways. We know about endoscopic debridement, became very, very popular. Now, we are trying to use also arthroscopy. It's not as widely used, but it seems to work well. The central tendon splitting is something that -- it's a little controversial for some people. They don't like to split it. I know the foot and ankle fellows at the hospital that I work at is what they routinely do. I try not to do it if I don't have to. I prefer maybe a lateral approach, so I don't have to detach the Achilles tendon, but it's something that seems to work well for them. The tendon transfers, retrocalcaneal decompressions and the tendon grafting, again being written about, it's a matter of really training and making sure that you have the experience to do this surgical procedure. My simplest thing is to do the open debridement, resect the deformity, reattach the Achilles tendon using anchors and a lot of the times, we remove the retrocalcaneal bursa. So when you do the open debridement, it's very important for you to think about the incision, midline, lateral, medial, I prefer a midline or a lateral midline that goes a little bit like a J on the bottom. It gives me really, really good exposure. I'm always worried about [Indecipherable] [0:12:11.0]. Unfortunately, we don't have really the greatest technology, although may be the LUNA system is one of the systems that may be able to get a little bit better with the [Indecipherable] [0:12:22.0] I'm always trying to avoid necrosis of the skin on the posterior aspect as you all know it's a nightmare. This actually gives me pretty good exposure to the tendon. And tendon augmentation or tendon transfer is also something that depends on your mechanics of the patient whether the patient has, in addition to the exostoses or the Haglund’s deformity, perhaps a flat foot deformity or a cavus deformity. Depending on that particular condition, you may want to decide to do a tendon transfer. There is a posterior tibial tendon dysfunction, whatever the case may be. Reflect the tendon, debride the tendon, remove the yellowish discolored, non-elastic tissue and then you want to reattach the tendon using either a suture screw or the suture anchors. So here is our Achilles tendon. Of course, we're going to debride it. Here is our calcaneus, exostosis and the picture is going to show us real basically what we wanted to do. Resect the exostosis on the inferior aspect, distal aspect and also if you have a Haglund’s deformity or a bony prominence so that you can get a nice smooth surface to remodel the calcaneus. And then I still use my hammer, my mallets and my chisel, my osteotome to debride. It's one of those things with residents works out pretty well usually because I don't want them to burn the bone, especially when I'm going to attach the tendon. And they usually try to reapproximate the tendon to where I wanted to be so I know exactly where the tendon is going to be. And usually, most of the time, I use suture anchors and the suture anchors -- I've done a pretty decent job of maintaining that Achilles tendon with sutures, pretty effective. But now I have come on to this tendon anchor system, which is really more like a plate that goes basically on the posterior aspect of the Achilles tendon and it's usually fixated with two screws. This particular system has the space here, the legs that you see here is basically designed on purposes to maintain distance between the bone and Achilles tendon.
You don't want to put the plate too tight because then you might create necrosis of the Achilles tendon. So in this case, what this has decided to do is basically to avoid that and it has the ability for you to center it or to place it with an olive wire where you wanted to put it, use your fluoroscope to make sure that you have it in the right place. You can of course remove it, put it in another place that you like or just thoroughly fixate it. So once you realign the tendon where you wanted, we have here a temporary olive wire. Here is the plate of the anchor system with the olive wire, here is Achilles tendon. It has already been debrided. We have removed the exostosis. We remodel the bone. Everything is already done and all I wanted to do is reattach the tendon. So again, it's either this system or the suture system. Once that is in place, you want to fixate it and normally two screws. There are two different sizes, so you can use the one that you like. I prefer the long screws. I think I get purchase power. Here is the plate in its place with the tendon really well-attached. And then I usually try to evaluate it to make sure that the strength -- there supposed to be a really -- I don't know if this is -- can you play the video from the back just to show you? So you just really put the foot into dorsiflexion and it hauls pretty nicely. Fluoroscopy to evaluate it. This is the length of the screw, so you can use usually two screws. Again here are those little legs maintaining the space between the tendon and the bone so that I don't create necrosis of the tendon. I did not find any, I try to actually look for a report of any necrosis of the Achilles tendon after these suturing anchors, but I know that when I do that, I try to do it pretty tight. So this came up -- after this system came up on the market is when I really started worrying about, was I really over jealous of tightening the tendon too much, but again we don't want it to come away, we don't want it to detach. They also have a one hole and one hole that gives a holder and here is the screw and pretty much the same. This is the same kind of idea but with the one hole. I don't feel as comfortable with the one hole. I feel better with the two. I think it's a matter of surgeon preference. It works but for some reason I just feel better with the two systems. This is actually also [Indecipherable] [0:18:05.6] in the sense that you can use it with the maybe for a posterior tibial tendon advancement, a Kidner procedure where you need to just attach the tendon to the navicular and this will allow you to do it as well. So from that I like that. The postop protocol for this particular system is seven days of nonweightbearing and then four weeks in a walking boot. So that’s a big difference. Four-to-five-week mark, gradually wean off walking boot and you return to regular shoe gear. So the biggest advantage of this particular system is that it allows me to go back to weightbearing after seven days. If we use the other suture anchor technique, you are talking about approximately six weeks or at the very least four. So for me, this is a big advantage working in New York. I assume that most of us are from New York. People just want to go back to work. They want to be on their feet right away. So that’s the greatest advantage really of this particular system is that their early return to weightbearing in a boot after one week. Common complications of this surgical procedure basically seem as any other procedure. In addition to plantar flexor and plantigrade neutral position, it's important that we do not create a different problem. That’s why placement of that Achilles tendon in that particular plate is so important. Failure to debride the calcification in the exostosis, you should be able to see that with your fluoroscope. Hardware failure, whichever hardware. We know that a lot of the hardware can fail. Sometimes the surgeon failure, I try to avoid that. And of course infection and rupture of the Achilles tendon.
This is some reference. I just want to -- my special thanks to my resident who helped with this presentation and I thank you guys for your attention.
Male Speaker 3: Do you get any prominence with the hardware in the [Indecipherable] [0:20:18.3] prominent areas or just pretty flush?
Male Speaker 2: It's pretty flush. What I try to do is when I do the bumpectomy or resection of the Haglund’s deformity, I try to place the implant slightly dorsal to make sure that I am in that triangle if you will. So I want to almost replace with the plate what I'm taking away and it's usually pretty flat. So far so good. I'm sorry. Yeah. The screws are actually designed to grab cancellous bone. So it's almost like cancellous screws. They are pretty sharp so they go right through the tendon and they grab pretty well. So far the pullout strength is holding. They were tested pretty nicely before they went to market with this particular system. You know there is a couple of other systems that use basically kind of screw design, but the suture come out and then you suture your tendon and pullout is pretty nice. So I haven't seen that either with the posterior tibial tendon either. With the posterior tibial tendon, the difference would be that you cannot return to weightbearing after a week because it's only one screw so that you got to wait about three weeks. But for the retrocalcaneal exostosis, for the Haglund’s after one week, CAM walker and so far so good. Very high patient satisfaction. Any other questions?
Male Speaker 4: Are you [Indecipherable] [0:22:05] like one screw without a problem, it really needs two screws.
Male Speaker 2: You know like I said we've done it one screw and I just feel better with the two. Even when I was using suture anchors especially because they're going to be weightbearing after one week. That’s really why I feel better to be quite honest with you. With the one screw, I don't feel that secure. So I don't want to go back. Thank you very much.