The back of your heel is a small area, but there are a few different problems that can cause pain here. This isn’t plantar fasciitis we’re talking about. The area where your Achilles tendon attaches to your heel is what I want to discuss. You can imagine that since this involves your Achilles tendon the more you walk or run the worse it gets. Shoes that push on the back of the heel can cause horrible pain. Achilles heel pain is all in this one small area on the back of your heel so it can be easy to confuse what is causing your pain. If I play tic-tac-toe on the back of your heel I can tell exactly is causing your Achilles pain.
Just this week a resident surgeon diagnosed one of my patients with a “pump” bump. This is a lump of bone on the back outside “shoulder” of the heel that was thought to be caused by high heeled women’s shoes. Unfortunately in this case the patient was a man. How was I going to diagnose the cause of his heel pain without embarrassing my resident or the patient? We played tic-tac-toe. I drew a grid around his Achilles tendon attachment to the heel. Next, I pushed on each square and marked an “X” if he felt pain. When finished I stepped back and looked at the pattern of X’s. All of a sudden the true cause of this patient’s heel pain was staring me in the face.
The center square is where the Achilles tendon attaches to your heel bone. If my X-pattern involves the center row or even sometimes the bottom your problem is with the Achilles tendon insertion. An X-pattern in the upper squares are a sign of Haglund’s deformity. This is a lump of bone extending across the top portion of the heel. The Achilles tendon sits right over this area and is separated from the bone by a fluid filled sack called a bursa. The tendon, bursa, or both can be involved in this pain pattern. If my X’s are more along the outside of the heel (right side of the picture) this would be the “pump” bump my resident had suggested.
You can see from the picture that my patient has a problem in the central square. This is pain at the Achilles tendon attachment to bone. Fortunately anti-inflammatory medicine, ice, stretching, a lift under his heel, night splints, and physical therapy will usually make this better. Some times a heel spur can form in this tendon attachment and needs to be removed, other times an arthritic condition such as Rheumatoid arthritis or systemic lupus can inflame the tendon attachments to bone. This is called enthesopathy and requires medical care with arthritis medications besides the ice, night splints, and physical therapy we just talked about.
The other areas of heel pain in this part of the foot are lumps and bumps. If the pain is across the top squares, a Haglund’s deformity, or along the outside squares, a pump bump, I will recommend starting with the relief of inflammation like I always do and add a change in shoes that won’t push on this painful area of the heel. If your pain does not go away with stretching, night splints, ice, anti-inflammatory medicine, changing shoes, and physical therapy that pretty leaves us with only one option, surgery.
Even though there are 3 causes of heel pain in this area surgery always involves the Achilles tendon because either the tendon is the cause or it lies just over the problem area. For this reason no matter which diagnosis you have the recovery from Achilles heel surgery is the same. Your game plan for recovery will include 2 months completely off that foot using crutches or a knee walker. I will begin your physical therapy at 2 weeks. Your first steps will be in a cast boot with the help of a physical therapist around the 8 week mark. From there I’ll teach you how to gradually return to shoes. Your total time out of shoes will be about 3 months.
I don’t think my resident will ever forget how to diagnose Achilles heel pain after this. Using a simple child’s game to make a complex diagnosis is just one of the things I love about my job.