by John M. Schuberth, DPM
Chief, Foot and Ankle Surgery, Kaiser Foundation Hospital
San Francisco

When Dr. Schuberth speaks, a sense of certainty and assurance that can only be conveyed by a seasoned veteran, is palpable in his eloquent words. He has been there, done that, knows what works and what doesn't and can tell us why. For this reason, I felt that a glass of wine was called for today when I reviewed his lecture, rather than the domestic beer that usually accompanies me while reviewing the lectures.

Retrocalcaneal enthesiopathy is a term that encompasses insertional tendonitis, periachilles bursitis, Hagland's deformities and enlarged tubers of the calcaneus. It seems simple enough, but as Dr. Schuberth points out, "There's more back there than meets the eye". He reviews in great detail, the pathoanatomical considerations of this disorder. We clearly see the position of the retroachilles, subcalcaneal, and retrocalcaneal bursae. Their role in this disorder becomes evident as one envisions the heel pistoning up and down in shoe gear. Dr. Schuberth also discusses the enthesis and it's role in enthesiopathy. With this information in tow, we better understand the role of equinus in the development of posterior enthesiopathy.

Dr. Schuberth shares, the "Log in the Sea Concept", with us, and demonstrates how the Achilles tendon becomes more intimate with the back of the heel during dorsiflexion. Treatment alternatives are carefully considered, once we determine whether an inflammatory or mechanical problem exists. On occasion, its best to have your patient put up with the symptoms for a while and continue with conservative care, as this condition has been known to spontaneously resolve. The clinical utility of measurable radiographic parameters are discussed.

Dr. Schuberth shares his philosophy for surgically treating this disorder. He sees a limited role in Tricep's Surae Lengthening. A simple ostectomy is best utilized with a pure posterior lateral prominence. When expansiveness of the entire posterior calcaneus exists, the patient is well served with a posterior osteotomy of the calcaneus. The goal here is to alter the mechanical forces acting on the posterior portion of the heel and reduce the bursal compression. Excellent illustrations and intraoperative photographs are used to demonstrate these concepts. Try a nice Silver Oak Cabernet. It will go quite well with this fine lecture.