Twenty-two heels in 21 patients treated surgically for a primary diagnosis of insertional Achilles tendinosis were reviewed on the basis of preoperative and postoperative examinations, office records, and a comprehensive questionnaire administered to each subject. Each patient underwent surgical treatment using a midline-posterior skin incision combined with a central tendon splitting approach for debridement, retrocalcaneal bursectomy, and removal of the calcaneal bursal projection as necessary. The findings at surgery revealed involvement of the middle third of the insertion in 21 of 22 cases with only one patient manifesting isolated lateral involvement. Thirteen of 22 had an associated prominent calcaneal bursal projection and four of 22 a superficially inflamed bursa. Three patients required reinsertion of the tendo Achilles via drill holes and one underwent augmentation with a plantaris tendon. Operative findings and complications were reported. Eight male and 13 female patients underwent 22 procedures (one case bilaterally) with an average follow-up of 33 months. Preoperative symptoms include presence of symptoms over a range of three months to two years and pain associated with activities of daily living (17 of 22), limitation of regular activities (six of 22), and pain present at rest in six of 22. Postoperatively, 20 of 22 patients were able to return to work or routine activities by three months; only 13 of 22 were completely pain free. Only 13 of 22 also claimed that they were able to return to unlimited activities. Overall, there was an 82% (18 of 22) satisfaction rate with surgery and 77% (17 of 22) stated they would have the surgery again.

One hundred five patients (70% female and 30% male; average age, 48 years) with 132 symptomatic heels were treated according to a standard nonoperative protocol and then reviewed at an average follow-up of 29 months. The treatment protocol consisted of nonsteroidal anti-inflammatory medications, relative rest, viscoelastic polymer heel cushions, Achilles tendon stretching exercises, and, occasionally, injections. Obesity, lifestyle (athletic versus sedentary), sex, and presence or size of heel spur did not influence the treatment outcome. Ninety-four patients (89.5%) had resolution of heel pain within 10.9 months. Six patients (5.7%) continued to have significant pain, but did not elect to have operative treatment, and five patients (4.8%) elected to have surgical intervention. Despite attention to the outcome of surgical treatment for heel pain in the current literature, initial treatment for heel pain is nonoperative. The treatment protocol used in this study was successful for 89.5% of the patients.

Achilles tendinitis is a problem encountered frequently. There are certain anatomical and biomechanical principles that help explain the etiology of this entity. We prefer to separate our thinking into "insertional" and "noninsertional" Achilles tendinitis. This is helpful because it allows nonoperative and operative treatment to be problem specific and systematic.

In 6 years through 1982, the authors performed 34 operative cases in 26 patients with recalcitrant heel pain. The operative procedure involves an isolated neurolysis of the mixed nerve supplying the abductor digiti quinti muscle as it passes beneath the abductor hallucis muscle and beneath the medial ridge of the calcaneus. The deep fascia of the abductor hallucis muscle is released routinely, and an impinging heel spur or tight plantar fascia is partially removed or released if it is causing entrapment of the nerve. The biomechanical pathogenesis of heel pain in relation to pes planus and pes cavus predisposing to an entrapment neuropathy is described, and the anatomy of the heel in relation to the nerve distribution is clarified and well illustrated. Of the 34 operated heels, 32 had good results and two had poor results. Heel pain can cause total disability in the working population and may jeopardize one's employment or professional athletic career. The authors believe operative treatment has a place in the care of recalcitrant heel pain and that an entrapment neuropathy is an etiological factor in heel pain.

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