Haglund's Deformity 726.73

synonyms: Insertional Achilles Tendonitis, osteochondrosis os tibiale externum, Retrocalcaneal Bursitis / Haglund's Deformity / Insertional Achilles Tendonitis

Retrocalcaneal Bursitis ICD-9

• 726.73 = Enthesopathy of ankle and tarsus; calcaneal spur
• 726.91= exostosis of unspecified site; bone spur NOS

Retrocalcaneal Bursitis Etiology / Epidemiology / Natural History

• Insertional Achilles Tendinopathy: an enthesopathy of the Achilles tendon insertion most likely from cumulative traume/repetitive stress. Primarily caused by tendon degeneration.
• Haglund's Deformity: prominent posterior-superior border of the calcaneous which compresses the Achilles tendon and its surrounding bursa against the posterior shoe counter, causing irritation. Typically young (15-30 y/o).
• Retrocalcaneal bursitis: isolated inflammation in the retrocalcaneal bursa without associated Haglund's deformity. Typically older, low activity patients

Retrocalcaneal Bursitis Anatomy

• (Heneghan HO, CORR 1984;187:228)
• Retrocalcaneal bursa lies between the Achilles tendon and the superior tuberosity of the calcaneous.
• Sural nerve lies 6cm anterior to the lateral border of the Achilles tendon.
• The Achilles tendon inserts inferiofly in the apophyseal portion of the calcaneous, not in the posterior-superior angle.

Retrocalcaneal Bursitis Clinical Evaluation

• Pain at the insertion of the Achilles tendon into the calcaneous usually exacerbated during push-off.
• Pain with shoe wear. Symptoms worse walking up inclines.
• Tenderness / swelling at the Achilles tendon insertion into the calcaneous.
• Dorsiflexion of the foot may cause pain by compressing the inflammed bursa.

Retrocalcaneal Bursitis Xray / Diagnositc Tests

• A/P, lateral and mortise ankle and A/P, lateral and oblique weight-bearing views of the foot are indicated.
• Retrocalcaneal burisitis is indicated if the sharp definition of the retrocalcaneal recess is lost and normal lucency in the region of the pre-Achilless fat pad is replaced by a soft tissue density, or if the there is erosion of the posterior-superior calcaneous.
• Evaluate for calcification at the Achilles tendon insertion and prominent posterior calcaneal tuberosity best seen on lateral view.
• Measure posterior calcaneal angle. Normal is <69°, >75° is abnormal. (Fowler A, Br J Surg 1945;32:494).

Retrocalcaneal Bursitis Classification / Treatment

• Nonsurgical treatment: Activity modification, ice, +/- cam walker with posterior heel relief, heel lift, soft heel counters / backless shoes, NSAIDs.
• Surgical: see Haglund's Technique. Achilles tendon insertion and bursa debridement and calcaneal exostectomy indicated for failure of >6months of non-operative treatment. If substantial Achilles debridement is needed repair to the calcaneous with suture anchors, or FHL augmentation is indicated.
• Isolated Retrocalcaneal bursitis which has failed non-op treatment can be treated with resection of inflammed bursal tissue.
• CPT: 28119 (ostectomy calcaneous for spur, with or withou plantar fascial release)
• Cortisone injections into the Achilles tendon are contraindicated because of the risk of rupture. Angermann P: Chronic retrocalcaneal bursitis treated by resection of the calcaneus.  Foot Ankle 1990;10:285-287.

Retrocalcaneal Bursitis Associated Injuries / Differential Diagnosis

• Seronegative arthritis
• Achilles Tendonitis

Retrocalcaneal Bursitis Complications

• Achilles tendon laceration or avulsion
• Persistent posterior heel pain
• Wound breakdown
• Medial calcaneal sensory nerve injury
• Sural nerve injury
• Ankle stiffness
• Insicional neuroma

Retrocalcaneal Bursitis Follow-up Care

• At 1-2 week follow-up: short-leg walking cast in neutral vs mild equines depending on status of Achilles tendon at surgery.
• At 4 weeks: 1/2 inch heel lift, weight-bearing as tolerated with activity limitations
• At 3 months: resume normal activities.
• Full recovery is typically prolonged and takes 6-12 months.

Retrocalcaneal Bursitis Review References

• Clain MR, Baxter DE: Achilles tendinitis. Foot Ankle 1992;13:482-487

°