UKC

Hi

Has anyone any experience with (and/or hopefully success stories about) chronic insertional achilles tendonopathy?

A year or so ago my partner began developing pain and inflammation during and after mountain trips, something she's been doing for 20+ years. Here's a picture:

http://www.flickr.com/photos/flaxbush/4361643931/

After much investigation, conservative treatment (wearing Teva sandals for a year, no mountains/running, rigorous eccentric exercises, cortizone injections) with no improvement, it seems the only way to get back into activities (ie. life!) again is to try surgery. This is expensive (private) and not rated to be highly successful, but there aren't really any other options.

Has anybody had this kind of chronic heel injury before? And any success with surgery or other treatments?

Surprisingly, many sports physicians and allied health people throw up there hands and say "Never seen anything like that". But this forum is basically a bunch of boot-wearing sealevel-fearing hypoxia-craving nuts like us. So surely my girl isn't completely on her own in the world with this?

Cheers
Bruce

In reply to BruceM:
Hi, yes I had the same problem. It is actually called Hagland's deformity, and I understand can be caused by wearing over tight rock boots. Even so, I'd had prominent bones on my for all my life. For instance it always influenced my choice of normal footwear because I'd need to choose shoes with soft or roomy heel cups. Over the years the heel bumps slowly became poor problematic, particularly when wearing snug rock boots or substantial mountain boots. For over 20yrs I couldn't comfortably run long distances in regular trainers without first protecting my heels with lots of sticking plaster. However as I gradually got older I started to have severe heel/tendon pain on my right foot, and could only continue rock climbing by cutting large slits to accommodate the bumps in the back of my rock boots. On one memorable occasion in Colorado my climbing partner was greatly amused by watching me buy a pair of expensive rock boots in Boulder Mountaineer, and then immediately take them back to our camp site and cut the back off both shoes, because the lean fit 'rock god' of a sales assistant in Boulder Mountaineer had kept telling me how good these particular rock boots were for heel hooking!
However after a lot of medical appointments and medical tests I eventually convinced the surgeons that I had a real orthopedic disorder and got the most problematic bump removed. The difficulty with getting the operation performed was because whenever I attended orthopedic out-patients clinics to be seen by doctors they would be full of disabled elderly or blatantly injured people. Then I'd freely walk into the appointment and complain about the pain I was experiencing rock climbing, running, and alpine mountaineering. However they finally ran out of cheaper medical tests and reluctantly agreed to do an MRI scan of my right foot they suddenly became very understanding and helpful. The recovery took about 6 weeks to walk and 6 months to begin running reasonably comfortably. I've been virtually pain free since. I was told that the other foot might need similar surgery in the future. You can find some lovely videos of this type of operation on the internet, but despite the blood and gore and power tools I recommend the op.

In reply to BruceM:

...and I should add by way of explanation that the internal 'bump' of bone gradually presses on the inside of the tendon, but the tendon also slowly stiffens due to age and repeated internal rubbing against the lump. I had exactly the same injections and exercises beforehand to little or no benefit. The NHS will do these operations very quickly once the issue is correctly diagnosed.

In reply to BruceM: I suffer with something called Plantar Fasciaitis, a painful heel disorder probably exasibated by 33 years as a postman,could your problem be a similar condition.

In reply to BruceM:
Thanks very much for your replies, folks.

Jago: interesting story. Particularly that the NHS finally sorted it out for you! Responses so far from several gatekeepers to the system (GPs), have been "Well what do you expect if you go mountaineering!", and "Just wear open backed sandels and you'll be fine, Next..."

In my partner's case, we haven't yet established whether the Hagglund bone prominance is involved. The ultrasound doesn't show bone too well. But I think MRI will be next, for that reason. She hasn't previously ever had that Hagglunds lump on any heel. I do! Mine are probably almost as big as yours are/were and I never go anywhere without taping them up thick. Obviously I'm pretty worried about mine after seeing what's happend to her. Especially as one of my lumps is really tender right now after new shoes! But that's not the point right now.

If hers wan't caused by a Hagglund's bone lump, it could have been long term stress, or some old injury we can't place, combined with age. Lot's of things fall to pieces on your body when you hit 40. The ultrasound does show pretty messed up tendon tissue, unfortunately.

Glad the op helped yours. Did your op just remove the bone lump? Or did you also have the tendon scraped and honed out to try and regenerate healthy tendon tissue? That's the bit that sounds a bit dodgy, and touch and go.

deepstar: no. Plantar Fasciitis affects the underside of the heel. The stuff we're talking about is more on the back of the ankle. With your problem, a lot of people have much success with Trigger Point therapy on muscles in the calf that refer pain to that area. Don't know if you have searched on that.

Cheers
Bruce

In reply to BruceM:
I have a large Hagland's deformity on one heel, on my shorter leg. This is a prominent lump of bone where the achillies attaches to the heel. It means I can't wear mountain boots for more than a day at a time, with a months gap between, and the inside of the heel cup in running shoes wear out in no time. I've been offered an op to have it removed but so far I've declined (I also recovered from a severe prolapsed disc without surgery). So far I've had only one episode of tendonitis which wasn't too severe altho it lasted a year.
What stikes me most about your partners heel is the swelling of the achilles itself, above the heel. This suggests chronic tendonitis and scar tissue to me, which is notoriously hard to treat. You do no specify what op she has been offered, but I would seriously consider the risks vs the chance of success. Remember not all physio's/physicians etc are the same, altho they will all accept your money. Go see another, and see a biomechanics specialist too. If all else fails, time is a great healer.

In reply to BruceM:

I had the bone lump removed, and once that was gone the tendon rapidly recovered. I don't think I'd have let them mess with the tendon unless it had been badly effecting my non climbing mobility. In the op they simply move the tendon to one side to access the bump. As I said previously once the MRI showed the bump so clearly the attitude of the all the Doctors instantly altered - they all love a clear diagnosis!

In reply to BruceM:

I've got smallish ones on both heels, and never had any problems until I took up distance running in late 2008, when I started to develop tendonopathy. It's been on and off pretty much for the last 10 months now, despite a referral for sports physio from my GP and a whole bunch of (very effective in the short term) heavy sports massage sessions from ZygoticGema.

I found the eccentric lifts exercises to be very beneficial, but only when I started doing them with both straight AND bent legs (thus stretching the soleus as well as the gastrocnemus) which I wasn't doing to start with.

However, every time things get better, a bang or a rub on one of the "lumps" sets it off again. I spoke to my GP-referred sports physio about these lumps and she certainly didn't seem to connect them to the pain I was getting.

So I think that, armed with your input, and Jago's, I'll be going back to my GP as my running so far this season has been garbage compared with last year.

Thanks folks.

Yes, I'm incredibly conservative and not one for jumping into surgery. Never had any myself. Hence my query here. The old girl is in a bit of pain when she wears footwear tho. And after a year of no mountains and no running she is getting desperate.

Jago: agree that a straightforward whopping off of a bone that sticks into soft tissue is sensible and worthwhile. I doubt she has that, given her heel profile prior to a few years ago. But it is something we're yet to find out.

Stupot: the op that's been suggested is the standard textbook debridement of the tendon. Go in through the back, chop out any mucky stuff surrounding and within the tendon, as well as any inflammed bursa, and excessive calcaneal prominance. Stitch it up and hope for the best. Not nice. Some research suggests maybe 80% of patients have improvement. Other research is more vague.

So I agree about trying everything else first.

I'm fond of the idea that "experts" will provide a solution to your problem in terms of whatever they are expert in. Podiatrists will sell you orthotics. Surgeons prefer cutting you up. Physios sell you exercises. If you go to a plumber about your heel they will sell you a U-bend. You do have to be your own doc and engineer the solution a bit more objectively. Be it a little subjective

Rob: you could be lucky and find biomechanics is in fact your problem. I've got pretty ugly Haglund's heel lumps and have heel pain that scares the hell out of me when I see what the girl has developed. But given my experimenting around with exercises/trigger points/orthotics/worn-footwear I'm pretty sure mine is biomechanical. So your sports physio might be right. Hopefully.

I'd swear my girl's was due to the same muscular causes, if it weren't for that massive lump on her heel.

Thanks again.