Introduction

In patients with a chronic retrocalcaneal bursitis, who fail to respond to conservative treatment, we perform 'endoscopic calcaneoplasty'. 
Retrocalcaneal bursitis is caused by repetitive impingement of the retrocalcaneal bursa between the anterior aspect of the Achilles tendon and the posterosuperior aspect of the calcaneus. It occurs most often at the end of the 2nd or the 3rd decade, mainly in females, and is often bilateral. However, it may occur in both sexes and at any age.

Anatomy

The retrocalcaneal bursa is situated in the retrocalcaneal recess between the anterior aspect of the Achilles tendon and the posterosuperior part of the calcaneus. \

History & Physical Examination

Patients with a retrocalcaneal bursitis typically describe the onset of pain when starting to walk after a period of rest.
The distinction between a retrocalcaneal bursitis, Haglund's syndrome, Haglund's deformity, insertional- and mid-portion tendinopathy should be made on history taking and physical examination.

Insertional tendinopathy is defined as a tendinopathy of the tendon at its insertion (calcifications, spur). Co-existence with retrocalcaneal bursitis and mid-portion tendinopathy is known as 'Haglund's syndrome'.
In Haglund's deformity, a bony prominence can be seen at the posterosuperior aspect of the heel, but this prominence does not always cause complaints.
A superficial bursitis, may result from a posterosuperolateral prominence of the calcaneus. The skin overlying the superficial Achilles bursa can be thickened and dyschromic. This is also called a 'pump bump'. The pictures below illustrate these differences.

In retrocalcaneal bursitis, on physical examination swelling can be seen on both sides of the tendon at the level of the posterosuperior calcaneal prominence, and pain can be reproduced by palpation of the lateral and medial side of the Achilles tendon at this level. With dorsiflexion of the ankle, the anterior part of the tendon impinges against the posterosuperior rim of the calcaneus, leading to retrocalcaneal bursitis. A hindfoot varus and pes cavus are both predisposing factors for heel pain. In the cavus foot, the calcaneus is not only in varus malalignment, but it is also more vertical, which results in a more prominent projection posteriorly.

Differentiation can be made with other pathologies: insertional tendinopathy is painful on palpation of the midline of the insertion on the calcaneus. Mid-portion Achilles tendinopathy gives complaints more proximally, and a 'pump bump' is visible as a posterolateral swelling, locally painful on palpation.

Endoscopic calcaneoplasty should only be performed when complaints of the retrocalcaneal bursa are clearly on the foreground, since only this entity can be treated with this procedure. Thorough history and physical examination are therefore mandatory. When diagnosis is unclear, additional investigation should be performed.

Differentiation between mid-portion- and insertional Achilles tendinopathy and retrocalcaneal bursitis should be made. See pictures below.

  1)    2)

   3)  4)

1). Insertional spur

2). Mid-portion tendinopathy, which can again be divided in different pathologies. These will be discussed in a separate chapter.

3). Retrocalcaneal bursitis

4). Superifical Achilles bursitis

Diagnostic Imaging

Conventional radiographs should always be made. When a retrocalcaneal bursitis is present, the posterosuperior aspect of the calcaneus has a white, cloudy appearance. This is exactly where the retrocalcaneal bursa is situated. 

When still not sure about the diagnosis and eventual accompanying problems, depending on the suspected pathology, ultrasound, CT- or MRI- scans can be made.

Conventional Radiography

MRI

MRI; T2 image. The hyperintensitiy (white) is the inflamed bursa.

Post-operative rehabilitation

The patient can be discharged the same day of surgery and weightbearing is allowed as tolerated. The patient is instructed to perform active dorsiflexion of the ankle to the neutral position (knee slightly bent). This exercise should be performed 2 or 3 days times per hour for the first days after surgery. The patient is instructed to elevate the foot when not walking to prevent edema. The dressing is removed 3 days post-operative. Normal walking without crutches at 4 - 5 days post surgery. Patients with limited range of motion are directed to a physiotherapist. Running can be started when range of motion is normal and in absence of swelling. This can on avarage be expected at 3 weeks post surgery. Sport resumption can on average be expected at 6 weeks post surgery. 

Recommended literature

Van Dijk CN, van Dyk GE, Scholten PE, Kort NP. Endoscopic calcaneoplasty. Am J Sports Med. 2001 Mar-Apr;29(2):185-9.

Scholten PE, van Dijk CN. Endoscopic calcaneoplasty. Foot Ankle Clin. 2006 Jun;11(2):439-46, viii.

Van Sterkenburg MN, Muller B, Maas M, Sierevelt IN, van Dijk CN. Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis. Acta Orthop. 2010 Jun;81(3):387-90.

Van Sterkenburg MN, Groot M, Sierevelt IN, Spennacchio PA, Kerkhoffs GM, van Dijk CN.Optimization of portal placement for endoscopic calcaneoplasty. Arthroscopy. 2011 Aug;27(8):1110-7.