What causes Heel Bumps?
Heel bumps can occur at any age. They are caused by an abnormal bony prominence behind the Achilles tendon, or due to wear and tear within the Achilles tendon as it attaches itself to the heel bone.
If there is an abnormal prominence of bone behind the Achilles tendon, this is called a Haglund deformity. This pushes the tendon out, and can rub on it. The body forms a bag of lubricating fluid which can become inflamed and cause pain. The heel counter on a trainer can put pressure on this area, hence they are often called pump bumps, although they are not caused by the footwear. In fact, this deformity is more likely to be inherited.
The Achilles tendon may become inflamed where it joins the heel bone. There may be wear and tear in the tendon at this level, and sometimes calcium is laid down in the tendon itself. This causes a bump that feels very bony, and xrays will show this. The tissue in the tendon on the MRI scan to the left looks like bone, but it is in fact tendon with calcium in it.
If you have a pump bump, it is best to see an orthopaedic surgeon who specialises in foot and ankle surgery. You should have x-rays taken in a standing position. This will help to find the exact cause of the pump bump and what treatment may be available.
How is the Surgery Performed?
There are two different problems that cause heel bumps and each benefits from different operations.
If there is a lump on the back of the calcaneus bone – a Haglund deformity – then this can be removed with keyhole surgery with good results. The incision is made on the outer side of the Achilles Tendon and is only a few millimetres long.
If the lump is caused by the deposition of calcium in the Achilles Tendon, then two operations can be performed depending on the severity. Both are performed by an incision in the line of the Achilles Tendon.
If the Achilles Tendon attachment is completely involved then the damaged tissue is excised and the tendon is reattached to the heel bone. This is done with special bone rawl plugs that secure the tendon. This requires prolonged rehabilitation, with six weeks in plaster and six weeks in an aircast plastic boot.
If the tendon is only partly involved, it may be possible to remove the hard calcified tissue without detaching the tendon. It is possible to weight bear after the operation without the use of a plaster cast.
The type of operation you require can only be determined at the time of surgery. You need to be prepared to have either, depending on what is found.
Surgery is carried out under general anaesthetic, but can be carried out with local anaesthetic injections behind the knee or around the ankle. The injections are normally given while you are asleep for your comfort. They can give good pain relief for the first day after the operation. You can go home the same day in the evening.
Risks of Surgery
Bleeding, infection, poor bone healing, poor skin healing, injury to tendons, injury to nerves, recurrence, and a need for further surgery.
There is a small risk of blood clots in the legs or lungs (DVT and PE), and there are also risks from anaesthesia – the process of being put to sleep for your operation.
Risks of Anaesthesia
The injection behind your knee is given using an ultrasound machine to guide the needle. There is a less than 1% chance of injury to the nerve. General anaesthetic also carries risks. These risks are proportional to your general health. You will need to be assessed for your fitness for surgery and an Anaesthetist will be able to advise you on your individual risk.
What to Expect After Surgery
This depends on what kind of operation you have undergone.
If you only had a Haglund bump removed then you will have a flat postoperative shoe.
If you had the tendon detached and reattached to the heel bone, you will be in plaster for six weeks, and then in a plastic boot for six weeks.
While you are in the plastic boot, you will have a series of wedges in the boot to keep your foot pointing down. This removes tension from the tendon while you are recovering, but allows you to weight bear. The bottom wedge is removed each week and thrown away. Twelve weeks following surgery, there should be no wedge left.
You will have had injections to numb your foot so that you are not in pain after the operation. This injection will wear off after 18-24 hours, so you must take regular painkillers so that you are not in severe pain when the injection wears off.
The pain will settle over a few weeks. You may see blood stains on the dressings. This is normal and not a cause for alarm. If blood is dripping from the dressings however, return to hospital.
The foot will be swollen as well as sore. You should keep the foot elevated as much as possible for the first two weeks. Keep walking down to a minimum – going to the toilet or for meals. Letting the leg hang down will cause the foot to become more swollen. Most of the swelling will settle within the first few months, but swelling can continue for up to one year.
If you are resting on your sofa, keep your foot elevated on the back rest or arm rest. If you are resting in bed, then place a few pillows under the foot to keep it elevated.
You will normally be in a plaster cast with the foot pointing downwards for a total of six weeks. After two weeks, you will have your stitches removed and a new cast applied. You will not be able to weight bear in this cast.
After six weeks, you will have a plastic boot applied. You will be able to put your heel down to bear weight or balance. The plastic boot has a series of wedges inside which keep the foot pointing down. Full weight bearing is allowed in the boot, which is taken off for washing. After another week, the bottom wedge is removed and discarded. Every week, the bottom wedge is discarded until at twelve weeks after the operation, there are no wedges left in the boot.
If you are in plaster for a prolonged period, you will be at risk of developing a blood clot in your leg. You will be given injections to thin the blood to cut this risk down. These can be self-administered, even in the elderly. You can stop taking these as soon as you progress to a plastic boot.
It is important to keep the Achilles tendon moving while it recovers. However, it is important to avoid stretching the tendon as this could decrease the power of the muscle and even cause a further rupture. The foot points down after surgery in it’s natural position. The exercises consist of pointing the foot down from it’s natural position and then relaxing to allow it back to the natural position. In no way should the foot be forced back to the natural position and pointing the foot upwards risks snapping the tendon again. Twelve weeks after surgery, you can wean yourself off the boot and start stretching the tendon by pointing the foot upwards again, under the supervision of your physiotherapist.
You will need a heel raise to wear for three months after the boot is removed.
RETURNING TO WORK
You will be in plaster for six weeks and then in a plastic boot for six weeks. I advise that you do not return to work until you can walk comfortably with crutches and the boot, or if your work environment cannot accomodate you with crutches and a boot, you should have at least four months off work. Full recovery will take at least a year. Remember that not everyone is the same, and some people take a longer time to recover from their surgery. Please request a sick note before you leave hospital, if you need one.