A True Pain In The Heel

HISTORY: 70 yo F with h/o Obesity, DM2, HTN, CKD, presents to the office with a 5 month hx of heel pain. She had CAM Boot for 4 wks, 2 sessions of physical therapy which led to worsening pain and a medrol dose pack. PHYSICAL EXAMINATION: On exam patient had antalgic gait on the left(LT) side. She was neurovascular intact in the LEs. Thompson test was negative. Dorsiflexion was reduced to neutral on the LT. Strength with inversion, dorsiflexion, plantarflexion, and eversion was symmetrical bilaterally. There was enlargement of the posterior heel area at the level of the attachment of the achilles to the calcaneus. There was tenderness to palpation of the area and increased warmth. DIFFERENTIAL DIAGNOSIS: Insertional Achilles Tendinopathy, retrocalcaneal Bursitis, Calcaneal Stress Fracture TESTS AND RESULTS: XR Ankle revealed enthesophyte at the insertion of the achilles tendon and calcific tendinopathy measuring 1.9 cm in length.MSK US confirmed calcific tendinopathy, insertional enthesophyte and additional achilles tendon tendinosis with intrasubstance partial tearing. FINAL WORKING DIAGNOSIS: Calcific Tendinopathy, Achilles Enthesopathy, Achilles Tendinosis with intra-substance partial tearing TREATMENT AND OUTCOMES: Patient did not want to pursue open surgery. She elected to proceed with ultrasound-guided percutaneous tenotomy utilizing the TENEX-Bone needle on 01/19/2022 followed by 4 wks of CAM boot. She noticed 30% improvement and due to the persistence of calcification and symptoms, she had a second procedure on 06/03/2022. She was immobilized for 3 weeks after and noticed improvement up to 70%. She received a platelet-rich plasma (PRP) injection on 07/28/2022. 8 wks after the PRP she felt 90% better and traveled to Europe walking up to 7 miles per day. On 11/11/2022, she received a second PRP injection and reported no pain and being able to walk on the treadmill 1 month after. The patient was satisfied with her walking ability and that she avoided major surgery.