09/19/2014    

Pain S/P Retrocalcaneal Exostectomy

Approximately one year ago, I surgically treated
a 5'7" 300 lb. 40 y/o male with PMH of HTN for a
large 8/10 painful posterior calcaneal exostosis
and gastrocnemius equinus. I performed a retro
calcaneal exostectomy with detach/reattach of
Achilles using S&N Twinfix system along with an
intramuscular gastrocnemius recession. About 4
weeks after the procedure, he fell off his knee
walker and landed on the operative foot,
resulting in a severe increase in pain which
resolved after continuing NWB. He did not tear or
rupture the repair based upon MRI and clinical
findings.

At 6 weeks post-op, he began weight-bearing in
the CAM walker with a heel lift and used that for
6 more weeks (heel lift out after 1-2 weeks). I
put him in PT for 6 weeks at that time also with
good improvement in ROM and strength. When I
advised that he discontinue use of the boot, his
pain subsequently increased, and since that time
he has had chronic pain rated at 6-7/10 after
short periods of activity. The pain is focal and
deep, immediately over the distal attachment site
of the Achilles.

I performed a lazy S incision, so this is not
under the incision site, and there is no thick
scarring in this area. I did bookend the tendon
during this procedure which I typically do not
do.

I have had him do eccentric stretching, home TENS
unit, calf strengthening exercises, use an ankle
brace, do another 6 weeks of PT, return to the
CAM walker for an additional 4 weeks twice, limit
activity, massage the operative site, and nothing
has helped this pain to resolve permanently. The
pain starts after about 1 hour of activity and is
up to 7/10 by mid-afternoon. He can perform a
single limb heel rise, but it is painful to do
so. His equinus has been fixed and he has at
least 10 degrees of dorsiflexion with the knee
extended. He does have some balance deficits.
I ordered a new MRI 6 weeks ago and it came back
“benign.” EMG was normal.

He has complete resolution of pain when wearing a
CAM walker. He also has near complete resolution
of pain when I perform a cortisone injection at
the inferior Achilles reattachment site which
will last approximately 2 months then return. I
have given him 2 injections about 4 months apart
and do not want to do any more. This is obviously
not a good long-term treatment plan but has so
far been my only method of successful pain
relief.

I have considered removing the suture and
anchors. I have also considered another period of
NWB activity, PRP, and possibly laser therapy
(although I don't have one). He is open to
anything, including revision, to decrease pain,
and cost of treatment is not limiting him.

I have performed 25-30 of these procedures over
the past 3 years and this is the only patient who
has not substantially improved. As we know, the
majority of these patients are obese, so while
that may be contributing, it hasn't kept my other
patients from improving. Any thoughts as to what
might be causing the pain and further treatment
options would be appreciated.

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