Pain in the back of the heel
Patients present with pain in the back of the heel. They may also have weakness, limping, inability to walk up stairs. When doctors see patients with heel pain they will typically get xrays which is always a good idea. However, until recently MRI was used to evaluate for tears in the achilles tendon. MRI is good at showing if a tear exists, however the tear could be underestimated due to the MRI inability to distinguish between degeneration and blood from a recent tear. Now achilles tendons can be evaluated with MSK ultrasound to improve accuracy.
MSK ultrasound for achilles tendon pain
An MSK ultrasound of the achilles tendon is much faster and more accurate than MRI. The sonographer will place the probe on the heel with some gel and immediately be able to see the tendon. The MRI can take up to 45 minutes to get the images. In addition, the tendon can be visualized while in motion and under pressure to see if the tear is worse that expected and evaluate the quality of the remaining tendon.
the added benefit is that a patient does not have to play with her foot still in a painful position during the exam and can take breaks when needed. Additionally the blood flow within the tendon can be measured. During the exam the bone will also be evaluated as well as for bursitis.
Achilles Tendinosis/Tendinitis
Achilles tendinosis is when the tendon becomes thickened and fibrotic and develops more blood flow. Patient is often have symptoms for a long time and will developed swelling in the back and leg. Again also developed calcifications in the tendon especially if there are micro tears. Achilles tendinosis is usually due to multiple factors that include body weight, gait, foot or hip problems or any problems. This could also be from repetitive stress injury from running or walking. This is commonly seen in mail carriers and long distance running athletes. Achilles tendinitis is different than tendinosis because it is an acute process that comes on suddenly. This is inflammation rather than fibrosis. These often occur hand in hand. Having Achilles tendinosis predisposes the patient to getting a tear but does not guarantee a tear will happen. Early identification of Achilles tendinosis is important because finding out what is causing it can be modified and prevent the risk of tear. Achilles tendon rupture
Achilles Tendon Tear
Achilles tendon tears, also called achilles tendon rupture, usually present suddenly after a patient has pushed off of something with their foot. This is a very common injury for weekend warriors playing sports when running or jumping. It’s common from falling from a stair or ladder onto the ground. An acute tear is very painful and typically results in weakness of the calf muscle and limping. Achilles tendon tears are often associated with bruising that starts at the ankle and ends up in the foot due to gravity. Swelling can be significant and a lot of times patient has an doctors may think the patient has a blood clot. In reality there is a lot of blood in a hematoma caused by the tear. This can be very easily identified on ultrasound. Because doctors are off worry about a blood clot and ultrasound of the veins can be performed to evaluate for a deep vein blood clot although DVT. The problem with MRI for Achilles tendon ruptures is that a complete tear can be missed diagnosis a partial tear because the tendon edges can not come back together and blood between the tendon ages can mimic a normal tendons. Left times patients that have had an MRI that showed a partial tear or just tendinosis in reality will have a high-grade tear or complete tear on ultrasound and at surgery.
Other Causes of Heel Pain
There are other causes of heel pain. Heel pain can be caused by Haglund syndrome which is an abnormal bump on the back of the calcaneous that contributes to pressure on the achilles bursa and tendon. Achilles bursitis can occur from tight poor fitting shoes or from over use or trauma.
A fracture of the calcaneal bone can also case pain and can be commonly caused by overuse or stress fracture or from a trauma or accident. This why it is important that all patients with heel pain that doesn’t go away on its own to get xrays.
When children are still growing they can get overuse injury of the growth plate called Sever’s disease that can be extremely painful when they walk or run.
Plantar fasciitis is a very common cause of heel pain but is typically at the bottom of the heel. Referred pain from plantar fasciitis can not be felt at the back of the heel as well.
Bone spurs are most often a result of a painful process and not because of the pain. There are instances when bone spurs can cause pain including Baxter’s neuropathy in the foot where the bone spur compresses 1 of the nerves. A bone spur could also fracture.
Rarely, bone tumors are a cause pain in the heel which is another great reason why x-rays are always needed because ultrasound may not be able to see a bone tumor. Tumors in the soft tissue or cholesterol deposition in the Achilles tendon can also cause pain.
Ultrasound with xray should be the first line evaluation of the achilles before MRI is considered.
Ultrasound has high sensitivity and specificity in accuracy for evaluation of Achilles tendinitis/tendinosis as well as tears and other conditions that cause heel pain. This is more comfortable for patient’s and less costly for the patient is in the healthcare system. IIT s also a lot easier to get an ultrasound of the achilles tendon than an MRI, especially since hospitals are less available for outpatient imaging because of COVID 19.
Schedule an ultrasound of the ankle today for achilles tendon and heel problems.