The primary symptom described by patients with the terrible triad of posterior heel pain is pain in the back part of their heel (Figure 1). The terrible triad includes:
Symptoms may also include swelling that is quite tender to the touch. Standing, walking, and constrictive shoe wear typically aggravate symptoms. Many patients with this problem are middle-aged and some may be slightly overweight. Another group of patients who suffer from this condition are young, active runners.
Haglund’s deformity is the bony prominence associated with the upper part of the heel bone (calcaneus). This is sometimes called a “pump bump.” This prominent bone tends to form gradually over many years, and can eventually cause irritation by disrupting nearby structures (see below). The bony prominence also creates discomfort by rubbing up against the heel counter of the shoe (the heel counter is at the back of the shoe and provides rigid support for the heel).
Whenever tissues rub against one another, a bursa forms to allow for smooth gliding. A bursa is a sac filled with lubricating fluid, which occurs normally throughout the body. Although it is only a few cell layers thick, when irritated, a bursa can become markedly thickened and painful. This is often referred to as bursitis.
The retrocalcaneal bursa is positioned to allow the Achilles tendon to glide over the back part (posterior aspect) of the heel bone. When this bone becomes enlarged, inflammation of the retrocalcaneal bursa occurs. This inflammation results in exquisite tenderness along the posterior aspect of the heel.
The Achilles tendon connects the calf muscle to the heel bone. As the strongest and largest tendon in the body, the Achilles tendon is regularly subjected to forces that are 2-4 times greater than a person’s body weight. The forces are even stronger during athletic participation, which means your Achilles bears an immense amount of stress on a regular basis. Over time, these repetitive loads can lead to degenerative wear and tear, specifically where the tendon inserts into the heel bone (calcaneus). This degeneration incites an inflammatory response and produces pain at the back of the heel. Eventually, the inflamed Achilles tendon may become calcified, forming bone-like fragments in the tendon.
Patients with posterior heel pain due to the terrible triad report tenderness over the back of the heel where the Achilles tendon inserts into the heel bone. The symptoms often come on gradually, although a sudden increase in activity level may start the symptoms. Patients experience swelling, and they may note a bump that is most irritated with tight fitting shoes. Running may aggravate the symptoms.
There is tenderness and swelling on palpation of the heel when compared to the other side. Redness is occasionally present. Patients may walk with a limp or have may have difficulty taking a full stride. In long standing cases, the tendon lengthens and a single leg heel rise becomes difficult.
The standard approach for treating posterior heel pain is through non-operative treatment as operative treatment has a prolonged recovery. Traditional non-operative treatment includes the following:
Due to the lengthy recovery associated with surgery, along with the relatively unpredictable postoperative outcome, non-operative management should be exhausted before surgery is contemplated. However, in high-level athletes that have developed Haglund’s deformity from running, surgery may be indicated. Surgery usually involves:
Recovery from surgery is prolonged. Initially, the leg is immobilized to allow the wound to heal. Then gentle range of motion exercises can be started. Patients are protected from full weight-bearing for the first six weeks while the tendon heals to the bone. Gradually, with physical therapy, full weight bearing and return to activity can be expected. Improvement in strength continues for several months and may take over one year. The recovery is quicker in younger, athletic patients.
Complications that are specific to this surgery include the potential for partial or complete rupture of the Achilles tendon where it attaches (inserts) into the heel bone (calcaneus). . Infection in the area of the Achilles tendon, although relatively uncommon, is a very serious problem due to the limited skin and soft-tissue coverage in this area.