Achilles Spur/RetroAchilles Bursitis

WHAT IS AN ACHILLES SPUR?

• An Achilles spur is a bony outgrowth that forms at the insertion of the Achilles tendon onto the calcaneus (heel bone). This condition is often associated with insertional Achilles tendinopathy, where chronic stress and degeneration at the tendon insertion lead to the formation of these spurs.
  

• Radiographically, these spurs can be visualized at the posterior aspect of the calcaneus, and they are often associated with pain and swelling in the posterior heel region [Schroeder et al, 2002; van Dijk et al, 2011].
• RetroAchilles bursitis can exacerbate by an Achilles spur. The retroAchilles bursa is located between the Achilles tendon and the skin at the back of the heel. The bursa can inflamed due to repetitive stress or pressure, often from ill-fitting shoes or overuse, leading to pain that is also aggravated by activity and pressure from footwear. RetroAchilles bursitis is also often associated with chronic posterior heel pain, swelling, tenderness, and morning stiffness, which are also symptoms seen in patients with Achilles spurs.
  

WHAT CAUSES AN ACHILLES SPUR?

• Common causes of an Achilles spur include:
  • Chronic Mechanical Stress: Repeated mechanical stress and overuse of the Achilles tendon can lead to microtrauma and subsequent bony changes at the tendon insertion site causing a spur [Thomas et al, 2010].
  • Haglund's Deformity: This is a bony enlargement on the back of the heel that can lead to irritation and inflammation of the Achilles tendon, contributing to spur formation [Thomas et al, 2010; Tu, 2018].
  • Biomechanical Abnormalities: Abnormal foot biomechanics, such as excessive pronation or supination, can increase stress on the Achilles tendon and its insertion, leading to spur formation [Kosmahl & Kosmahl, 1987].

WHAT ARE THE SYMPTOMS OF AN ACHILLES SPUR?

• The typical symptoms of an Achilles spur include:
  • Chronic Posterior Heel Pain: Patients often experience persistent pain at the back of the heel, which can be exacerbated by physical activity and pressure from footwear [Schroeder et al, 2002; Weinfeld, 2014].
  • Swelling: There may be noticeable swelling around the Achilles tendon insertion site, which can be associated with inflammation and irritation of the surrounding tissues [Schroeder et al, 2002; Weinfeld, 2014].
    
  • Tenderness: On physical examination, tenderness is often present at the insertion of the Achilles tendon [Schroeder et al, 2002].
  • Prominence: A bony prominence may be palpable at the site of the spur [Schroeder et al, 2002].
  • Pain with Activity: Pain typically increases with activit that load the Achilles tendon, such as walking, running, or jumping. Patients may also report pain when wearing shoes that put pressure on the heel [Schroeder et al, 2002; Weinfeld, 2014].
    
  • Morning Stiffness: Patients often report stiffness in the heel and Achilles tendon area upon waking, which may improve with initial movement but can worsen withprolonged activity [Janowski et al, 2023].
    

HOW IS AN ACHILLES SPUR DIAGNOSED?

• The diagnosis of an Achilles spur is based on detailed history, physical examination, and imaging.
  
  • Imaging Techniques:
    • Radiographic Findings: Radiographs often reveal the presence of a bony spur at the insertion of the Achilles tendon, which can help confirm the diagnosis [Schroeder et al, 2002].
    • Ultrasound (US) and Magnetic Resonance Imaging (MRI): Ultrasound and MRI are a valuable tools for assessing associated soft tissue abnormalities around the spur, including pathology of the Achilles tendon insertion (learn more about Achilles problems here). [Khan et al, 2003; Wiell et al, 2013; Martin et al, 2018].
    • US/MRI also provides detailed images of the extent of associated soft tissue inflammation, including retroachilles bursitis [Thomas et al, 2010; Weinfeld, 2014].

HOW IS AN ACHILLES SPUR TREATED?

Conservative Management

• Initial treatment of Achilles spurs includes rest and activity modification, ice, NSAIDs, and physical therapy [Thomas et al, 2010; Schroeder et al, 2002].
  

Shockwave Therapy (ESWT)

• Shockwave has shown effectiveness in reducing pain and improving function in patients with Achilles tendinopathy and spurs, with a Grade B recommendation [Thomas et al, 2010; Chen et al, 2022].
  

Surgical Intervention

• Surgical management options for treating an Achilles spur include:

  • Resection of the Posterior Superior Aspect of the Calcaneus: This involves removing the bony spur and any associated pathologic soft tissue, such as inflamed bursa or diseased tendon [Thomas et al, 2010].

    • Spur resection can be performed using a minimally invasive approach using the Tenex bone device.

  • Achilles Tendon Debridement and Reattachment: In cases where the spur is extensive, partial detachment and subsequent reattachment of the Achilles tendon may be necessary to ensure complete resection [Thomas et al, 2010].

  • Gastrocnemius Recession or Achilles Lengthening: These procedures may be considered in patients with equinus deformity to reduce tension on the Achilles tendon [Thomas et al, 2010].

References

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Janowski AJ, Post AA, Heredia-Rizo AM, Mosby H, Dao M, Law LF, Bayman EO, Wilken JM, Sluka KA, Chimenti RL. Patterns of movement-evoked pain during tendon loading and stretching tasks in Achilles tendinopathy: A secondary analysis of a randomized controlled trial. Clin Biomech (Bristol). 2023 Oct;109:106073.

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Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther. 2018 May;48(5):A1-A38.

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Wiell C, Szkudlarek M, Hasselquist M, Møller JM, Nørregaard J, Terslev L, Ostergaard M. Power Doppler ultrasonography of painful Achilles tendons and entheses in patients with and without spondyloarthropathy: a comparison with clinical examination and contrast-enhanced MRI. Clin Rheumatol. 2013 Mar;32(3):301-8.

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Other Foot/Ankle Conditions

• Ankle Sprain
  
• Haglund deformity
• Peroneal Nerve Entrapment
• Plantar fasciitis
• Sever’s Disease
• Tendon pain (PTTD)