Retrocalcaneal Exostosis

Retrocalcaneal exostosis refers to the formation of a bony prominence at the back of the heel bone called the calcaneus. This bony prominence causes difficulty in wearing shoes, tenderness and pain.

This condition is also known as Haglund’s deformity, posterior heel spur or, in laymen’s terms, pump bump.

The bony prominence is formed due to thickening of the bone as a protective response to repeated pressure or friction. The bony bump or heel spur develops at the back of the heel bone at the point of the Achilles tendon attachment. Tendons are thick fibrous bands that connect muscles to bones and move the bones as the muscles contract.

The Achilles tendon is the strongest tendon in the whole body and it unites the calf muscles to the back of the heel. When the calf muscles contract, the tendon elevates the heel and the foot is flexed downwards. To prevent friction between the tendon and the bone surface during movement, a small fluid filled sac called the retrocalcaneal bursa is located between the two structures. Retrocalcaneal exostosis is often accompanied by Achilles tendon inflammation or inflammation of the bursa adjacent to it.

This problem is more commonly seen in females, due to wearing tight, inflexible shoes.

Causes:

The basic reason is a constant pressure or stress on the bone. Shoes with stiff backs such as dress shoes, pumps, skates, etc., press at the back of the heel and are a major cause for the development of these painful bumps.

A tight Achilles tendon leads to repeated excessive pulling at its point of attachment, leading to the formation of heel spurs.

A high arch leads to backward tilting of the heel bone, making the bump of the heel more prominent and susceptible to pressure from shoes.

A tendency to walk on the outside of the heel is also considered a significant contributory factor.

A foot that over-pronates will change the line of pull of the Achilles tendon and strain its attachment.

Symptoms:

Formation of a visible bump at the back of the heel, which is tender to the touch

The bump rubs against the back of the shoe while walking or running, causing pain

The overlying soft tissues and skin may also become inflamed, leading to swelling and pain in the area.

The repeated friction from tight shoes may also lead to thickening of the overlying skin (callus formation).

Diagnosis:

The symptoms and clinical examination aid in determining the cause of the problem. X-rays help to analyze the structure of the heel bone and differentiate the condition from other causes of pain in the retrocalcaneal area.

Treatment:

Conservative treatment is aimed at resolving the painful symptoms; however, it has no effect on the retrocalcaneal exostosis itself.

Avoid shoes with stiff backs or straps that press on the area

Heel lifts help to elevate the heel out of the shoe, preventing contact of the tender area with the back of the shoe

Use padding to reduce friction

Use NSAIDs and apply ice packs, to counter pain and inflammation

In case of high arches, use of insole devices such as arch supports helps to reduce stress on the heel.

Stretching exercises help relax a tight Achilles tendon and reduce pressure at the back of the heel.

Innersoles to correct any foot abnormalities (over-pronation)

Surgical treatment is advised in chronic cases. It may involve removing the bump alone (exostectomy) or removing the bump along with a part of calcaneus (calcaneal osteotomy). The latter procedure is found to give better results. The Achilles tendon may need to be detached and reattached during the procedure

The foot is immobilized for about six weeks after surgery. As the Achilles tendon has a poor blood supply, the area needs more time to heal properly. Post-operative care is imperative to prevent complications.