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HI all,

probably a basic question for a lot, but i would love some input on how to manage posterior calcaneal exostoses. I have seen quite a few in practice, where the posterior heel is quite sore and been seen by other professionals as an achilles tendinopathy, and treated as such. However rasies/stretches etc etc have made no improvement. On presenting to me and with this history, i find pain at the posterior calc (often slightly medial) where an obvious lump is. Not in the achilles. Radiographs generally disclose the same calcific deposits showing an exostosis.

I don't think orthoses are of any relevance here, and often they have already tried conservative management with no success.

From a surgical point of view, what are the options/procedures? How successfull is thi surgery? How long is the rehab (obviously variable....but ballpark)?

Cheers Dawesy.

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My karma ran over my dogma .....

The best form of surgical therapy in my opinion is a modified Murphy type procedure. This is done with the patient in a prone position with an upside down question mark type incision with the "hoop" of the incison placed lateral.

The achilles is disarticulated, and reflected dorsally. The bony protuberances are removed by procedure and technique of choice. The achilles is then reattatched using soft tissue fixation of choice such as Mitek, Arthrex, etc.

Rehab is generally in the 6 - 8 week range with the patient splinted SLIGHTLY plantarflexed. More details if you wish

Summer

I agree that surgery is likely to provide the solution but would not agree that rehab of 6-8 weeks is realistic. 6-8 months can easily pass before patients will feel comfortable after this type of surgery and could take up to 12 months.

Have you heard of any success with less invasive technique, such as scoping?

i believe that although a murphy type incision is very acceptable.the idea of disarticulating the achiles tendon,although still effectively done,is no longer necessary.considering the many arthroscopic techniques available today.it isn't worth sacrificing the stability of the tendon for the sake of visualizing a posterior heel exostosis.
i have even reached these exostosis with small olier type incisions and then guiding the placement of my reducing instrument,via a C-arm.i will do this without ever disturbing the attachment of the tendon.
the patient is then placed in either a cam walker or a bi-valved walking cast for eight weeks,receiving physical therapy for the last four weeks,while immobilized.

I referred one pt for physucal therapy with good results.However,that was catching lightning in a bottle.An exostectomy(Murphy incision is good) is the treatment of choice.