What is calcaneal enthesopathy and how is it treated?

Calcaneal Enthesopathy: Diagnosis and Treatment

Calcaneal enthesopathy is inflammation or degeneration at the attachment sites of tendons and ligaments to the heel bone (calcaneus), which should be treated initially with conservative measures including NSAIDs, physical therapy, and appropriate footwear modifications before considering more invasive interventions.

Definition and Causes

Calcaneal enthesopathy refers to a pathological condition affecting the entheses (attachment sites of tendons and ligaments to bone) of the calcaneus. It can manifest in several forms:

• Inflammation or degeneration at tendon/ligament insertion points on the calcaneus, commonly affecting the Achilles tendon insertion or plantar fascia origin 1
• May present as plantar fasciitis, Achilles tendinopathy, or heel bursitis, often with associated heel spurs 2
• Can be inflammatory, degenerative, metabolic, or traumatic in nature, with mechanical factors being the most common cause 1, 2

Clinical Presentation

The presentation varies depending on the specific type of enthesopathy:

• Plantar Fasciitis: Pain at the medial plantar aspect of the heel, typically worst with first steps in the morning 3
• Insertional Achilles Tendinopathy: Chronic posterior heel pain and swelling, with pain aggravated by increased activity and pressure from shoes 3
• Bursitis with Haglund's Deformity: Acute pain and inflammation lateral to the Achilles tendon, often with a visible posterior lateral prominence 3

Diagnosis

Diagnosis is primarily clinical, based on:

• Location of pain and tenderness on physical examination 2
• Radiographs may show spurring, erosion, hyperostosis, or fragmentation at tendon insertion sites 1
• Ultrasonography and MRI can be helpful in unclear cases or for preoperative evaluation 3

Treatment Approach

1. Conservative Management (First-Line)

For plantar fascia-related enthesopathy:

• Regular calf-muscle stretching, cryotherapy (ice for 10-minute periods), and activity modification 3
• Over-the-counter heel cushions, arch supports, and appropriate footwear 3
• Weight loss if indicated, and avoidance of flat shoes and barefoot walking 3
• NSAIDs for pain relief and anti-inflammatory effects 3
• In appropriate patients, corticosteroid injections (except for Achilles tendinopathy) 3

For Achilles tendon-related enthesopathy:

• Open-backed shoes to reduce pressure on the affected area 3
• Heel lifts or orthoses, decreased activity, and stretching exercises 3
• NSAIDs for pain management 3
• Corticosteroid injections are NOT recommended for Achilles tendinopathy due to risk of tendon rupture 3

For bursitis with Haglund's deformity:

• Open-backed shoes, orthoses, accommodative padding 3
• NSAID therapy and physical therapy 3
• Corticosteroid injections (carefully avoiding the Achilles tendon) 3

2. Advanced Conservative Measures (If No Improvement After 6-8 Weeks)

• Customized orthotic devices 3
• Night splinting for plantar fasciitis 3
• Immobilization cast or fixed-ankle walker-type device for more severe cases 3
• Limited number of corticosteroid injections for plantar fasciitis (not for Achilles tendinopathy) 3
• Extracorporeal shock wave therapy (ESWT) has shown efficacy in calcaneal enthesophytosis, improving symptoms and potentially modifying the structure of heel spurs 4

3. Surgical Management (Last Resort)

If no improvement occurs after 2-3 months of comprehensive conservative treatment:

• Plantar fasciotomy for recalcitrant plantar fasciitis 3
• For Haglund's deformity with bursitis: resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa 3
• Some patients may require calcaneal osteotomy to correct alignment 3

Special Considerations and Pitfalls

• Avoid corticosteroid injections near the Achilles tendon due to risk of tendon rupture 3
• Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 3
• Consider referral to a podiatric foot and ankle surgeon if no improvement after 6 weeks of initial treatment 3
• Rule out other causes of heel pain including neurologic conditions, stress fractures, or systemic inflammatory diseases when standard treatments fail 3
• For patients with multiple symptomatic tendons, consider evaluation for underlying rheumatic disease 3

Treatment Algorithm

1. Initial 6 weeks: Conservative measures (appropriate footwear, NSAIDs, stretching, activity modification)
2. If no improvement after 6 weeks: Referral to podiatrist/foot specialist, custom orthotics, night splints, possible immobilization
3. If no improvement after 2-3 months: Consider ESWT or surgical intervention based on specific diagnosis