A bruised heel from a weekend hike is one thing. A calcaneal fracture that shifts the mechanical axis of your hindfoot is another. The rearfoot carries the load from every step you take, and when alignment, tendons, or joints in this zone fail, the rest of the foot pays for it. This article looks squarely at heel and hindfoot problems that sometimes require surgical care, and what a rearfoot surgery specialist actually does to get people moving again.
What counts as the rearfoot, and why it matters
The rearfoot sits behind the midfoot and forefoot, built around the calcaneus and talus, with the subtalar joint acting as a swivel that lets you adapt to uneven ground. The Achilles tendon inserts on the back of the calcaneus, the plantar fascia anchors under the heel, and key stabilizers like the posterior tibial and peroneal tendons wrap the hindfoot like guy wires. When any of these fail, symptoms rarely stay local. Flatfoot from posterior tibial tendon dysfunction, for example, overloads the forefoot and midfoot. Cavovarus deformity shifts pressure to the lateral column, leading to recurrent ankle sprains and fifth metatarsal stress fractures.
Rearfoot surgery is rarely about a single torn structure. It is about restoring the line of force from tibia to toes so the entire foot functions again. That is why the right foot and ankle surgery specialist studies gait, alignment, and compensations before reaching for a scalpel.
Who is best trained to operate on the hindfoot
Rearfoot work is a subspecialty. Whether you see an orthopedic foot and ankle surgeon or a podiatric foot and ankle surgical specialist, look for advanced fellowship training in foot and ankle reconstruction, case volumes in the procedures you might need, and board certification. Your options include a board certified foot and ankle surgeon through the American Board of Orthopaedic Surgery or the American Board of Foot and Ankle Surgery, among others. In practical terms, an experienced foot and ankle specialist should be comfortable with both soft tissue and bone techniques, from minimally invasive calcaneal osteotomy to complex hindfoot fusion.
Patients often ask how to compare a foot and ankle surgeon vs podiatrist. Titles vary by training path. What matters most is depth of rearfoot experience, outcomes data, the ability to explain trade offs, and a team that can carry you through rehab. If you are an athlete, ask about the surgeon’s role as a foot and ankle sports medicine surgeon. If you have diabetes or Charcot changes, confirm the surgeon routinely performs diabetic foot reconstruction and Charcot reconstruction.
Conditions a rearfoot surgery specialist treats
Not every rearfoot problem needs an operation. Many do well with targeted physical therapy, bracing, injections, or activity changes. The cases that reach my operating room typically fall into a few buckets.
Posterior tibial tendon dysfunction with adult acquired flatfoot. Early stages respond to bracing and therapy. If the arch collapses and the heel drifts valgus, we may correct alignment with a calcaneal osteotomy and reconstruct the tendon, sometimes adding a flexor tendon transfer and soft tissue balancing.
Cavovarus foot from high arches. Often linked to peroneal tendon overload and lateral ankle instability. Treatment ranges from peroneal tendon repair to lateralizing calcaneal osteotomy, first metatarsal osteotomy, and ankle ligament reconstruction.
Achilles tendon problems. These include acute Achilles rupture, chronic insertional tendinosis, and Haglund impingement. Options span primary repair, augmentation with flexor hallucis longus transfer in degenerative cases, and resection of a bony prominence when it catches on shoes or inflames the tendon.
Calcaneal fractures. A bad heel fracture can tilt the subtalar joint, widen the heel, and shorten the Achilles lever arm. Surgery aims to restore height, width, and joint congruity. In elderly or low demand patients, judicious nonoperative care or primary subtalar fusion can be the wiser call.
Subtalar, talonavicular, and calcaneocuboid arthritis. When joints are so worn that each step grinds, fusion removes pain by stopping motion in that joint. If arthritis spans multiple joints, a triple fusion can realign and stabilize the hindfoot.
Chronic plantar fasciitis and heel spurs. More than 90 percent improve without surgery. Recalcitrant cases sometimes benefit from endoscopic plantar fasciotomy or a partial release, with careful protection of the lateral band to avoid arch strain.
Peroneal and posterior tibial tendon tears. A foot and ankle tendon repair surgeon repairs or reconstructs these, often combined with realignment osteotomy if the underlying deformity caused the tear.
Nerve compression at the ankle. A foot and ankle nerve surgery specialist performs tarsal tunnel release for true entrapment. The key is accurate diagnosis with exam and, sometimes, ultrasound. Decompression helps only if pressure on the nerve is the driver of symptoms.
Charcot neuroarthropathy. When the hindfoot collapses from neuropathic bone changes, a diabetic foot surgeon may perform internal or external fixation to stabilize the limb. The bar is high for surgery in these cases, and wound care planning is as important as the operation.
The evaluation that leads to the right plan
A good rearfoot workup starts with alignment in stance. I look behind the patient to see if the heel is in valgus or varus. I check whether the arch reforms on tiptoes, how the forefoot sits relative to the hindfoot, and where calluses collect. Tenderness along tendons tells you about overload patterns. Strength testing and subtle differences in range of motion help sort out partial tendon tears from neuritis or joint disease.
Imaging is specific to the question. Weightbearing X rays show alignment through the calcaneus, talus, and midfoot. If I am planning a calcaneal osteotomy, I measure hindfoot alignment angles and forefoot abduction. MRI is helpful for tendon quality and occult stress reactions. CT outlines joint surfaces after calcaneal fractures or in subtalar arthritis. Ultrasound can be useful for dynamic tendon snapping or to guide injection.
If pain flares with certain shoes, I ask patients to bring them. Insoles, wedges, or lacing changes can be diagnostic in clinic. Sometimes a single heel wedge blocks the pain, which tells me a realignment operation would likely help.
Nonoperative care comes first when it can help
I have rebuilt a lot of hindfeet, but the best surgery is one a patient never needs. High yield nonsurgical options:
- Structured physical therapy focusing on calf flexibility, proximal hip control, and tendon specific loading. Immobilization in a walking boot for a defined period, often 2 to 6 weeks, to cool off a tendon or fascia. Bracing such as a custom ankle foot orthosis for posterior tibial tendon dysfunction, or a lace up brace for lateral ankle instability. Image guided injections in selected cases. Corticosteroid has a role for plantar fasciitis away from the Achilles, while biologic injections are still mixed in tendon disease. Shoe changes, heel lifts, lateral or medial posting to counter varus or valgus.
Time matters. A tendon that has frayed for a year will not reverse in two weeks. If symptoms persist after a full course of targeted care, or alignment is failing, it is time to talk about an operation.
When to see a rearfoot surgery specialist
If any of these are true, book a foot and ankle surgical consultation:
- Your heel sits tilted and you cannot correct it on tiptoes. You have recurrent ankle sprains with a high arch and lateral foot pain. Achilles pain has lasted more than 3 to 6 months despite therapy, or you felt a pop and lost push off strength. A heel fracture changed your foot shape, widened your heel, or made uneven ground painful. Plantar heel pain limits walking after 6 to 9 months of structured nonoperative care.
How procedures are chosen
The right operation depends on the pain generator and the alignment problem. Surgeons do not think in single parts. We map the chain. A foot and ankle reconstruction surgeon may combine a tendon transfer with a calcaneal slide to fix both power and alignment. For rigid deformity or end stage arthritis, the solution can be a fusion that trades motion for stability.
Minimally invasive options exist for many rearfoot problems. A foot and ankle arthroscopy specialist can clean out a subtalar joint, address impingement, or assist calcaneal fracture reduction. A minimally invasive foot surgeon may perform percutaneous calcaneal osteotomies through small incisions. These techniques can reduce wound complications and speed early recovery, but they require accurate imaging and a surgeon who performs them regularly.
Open surgery has its place. Wide exposure is still required for complex fracture fixation, revision tendon work, or when bone grafting and multiple realignments are needed. A top rated foot and ankle surgeon should be comfortable explaining why an approach is selected for your anatomy rather than defaulting to one technique for everyone.
Procedure spotlights from the rearfoot
Flatfoot reconstruction for posterior tibial tendon failure. In a flexible deformity, I often slide the calcaneus medially to bring the heel back under the leg, transfer the flexor digitorum longus to support the arch, and lengthen a tight calf. If the forefoot falls into abduction, a lateral column lengthening may be added. Patients usually spend 6 to 8 weeks protected from full weight, then transition to shoes by 10 to 12 weeks, with strengthening progressing for several months.
Cavovarus correction. For a high arch with a rigid heel varus, a lateralizing calcaneal osteotomy brings the heel under the leg. Peroneal tendon repair or debridement is common. If the first ray is plantarflexed, a dorsiflexion osteotomy of the first metatarsal helps rebalance. Chronic ankle instability often needs a Broström type ligament reconstruction, sometimes augmented with internal brace. Return to running typically starts around 4 to 5 months, cutting later.
Achilles tendon repair and reconstruction. For acute ruptures, a foot and ankle sports injury surgeon can use open or mini open techniques to repair the tendon. Early functional rehab with protected motion shortens downtime and lowers re rupture risk compared with old cast only protocols. For chronic insertional disease, I debride diseased tendon, resect a Haglund bump if present, and reattach with suture anchors. In severe degeneration, I augment with a flexor hallucis longus tendon transfer to restore push off.
Calcaneal fracture fixation. When the heel is widened and the subtalar joint steps off, surgery aims to restore height and joint shape. The decision to operate depends on skin condition, fracture pattern, and patient priorities. In smokers or those with poor soft tissue, I consider less invasive reduction or delayed primary subtalar fusion if the joint is smashed. In healthy patients with good skin wrinkling and a displaced joint fragment, open reduction with plate fixation can restore function. The recovery is long. Expect at least 8 to 10 weeks before weight bearing.
Subtalar fusion. For painful subtalar arthritis or deformity that will not hold correction, fusion removes motion in that joint to relieve pain and stabilize the heel. A foot fusion surgery specialist uses screws and sometimes bone graft. Most patients accept the trade, reporting smoother uneven ground walking because the painful grinding stops. Loss of subtalar motion is noticeable on steep trails or off camber ground, but daily life usually improves.
Chronic plantar fasciitis surgery. Endoscopic or mini open partial release is reserved for the few cases that fail extensive nonoperative care. I protect the lateral band to avoid flatfoot and instruct patients on slow return to load. Most feel meaningful improvement within weeks, with full benefit over months as the fascia settles.
Tendon specific work. A peroneal tendon surgeon addresses splits in the peroneus brevis by tubularizing the tendon or grafting if tissue is poor. A posterior tibial tendon surgeon repairs tears only if alignment is preserved, otherwise repairs Jersey City foot specialist are combined with bony realignment. A foot and ankle ligament repair surgeon managing chronic ankle instability will often scope the joint to treat impinging tissue and evaluate cartilage before reconstructing the ligaments.
Nerve decompression. For a true tarsal tunnel entrapment, a foot and ankle nerve decompression surgeon releases the flexor retinaculum and fascial bands. Predictors of success include a positive Tinel sign and reproduction of symptoms with tapping. Pure neuropathy without compression does poorly with surgery, so diagnosis is critical.
Anesthesia, pain control, and preventing complications
Rearfoot surgery is uncomfortable without a plan. Regional nerve blocks around the sciatic or popliteal region reduce pain for 12 to 24 hours. I prefer multimodal analgesia that layers acetaminophen, an anti inflammatory when safe, and a limited opioid prescription. Elevation matters more than many patients expect. Keeping the heel above the hip for the first few days dramatically reduces throbbing and wound stress.
We mitigate clots by risk stratifying patients and using early calf pumps or chemoprophylaxis when indicated. Smokers and poorly controlled diabetics face higher wound risks, especially for calcaneal fracture surgery. A candid discussion up front lets you decide whether to delay surgery to improve modifiable risks.
Recovery timelines you can actually use
Every case is different, but patterns emerge across thousands of patients. Use these milestones as a directional guide, understanding your foot and ankle doctor surgeon will tailor them to you:
- Weeks 0 to 2: Protect the incision, elevate, begin gentle toe and knee motion. Non weight bearing for most rearfoot procedures. Weeks 3 to 6: Transition to a boot, start partial weight bearing if bone cuts are stable and your surgeon clears it. Begin active ankle motion and isometrics. Weeks 7 to 12: Move into shoes with a brace or orthotic. Progress strengthening, balance work, and low impact cardio like cycling or pool running. Months 3 to 6: Advance to jogging if alignment procedures have healed. Agility and sport drills enter in the 4 to 6 month window for soft tissue reconstructions. Months 6 to 12: Peak strength and confidence return. Fusions continue to remodel. Most patients feel “the new normal” around the 9 to 12 month mark.
A foot and ankle surgery recovery timeline always flexes around biology. Smokers, vitamin D deficiency, and complex reconstructions run slower. Younger athletes without arthritis often recover faster.
Risks, trade offs, and revision scenarios
There is no perfect operation. The honest conversation includes:
Residual stiffness. Fusions stop motion to stop pain. That is the point, but some patients notice it more than they expected. Test drive with a brace that simulates loss of motion can help predict tolerance.
Nerve irritation. The sural nerve along the lateral heel and the tibial nerve branches medially are close quarters. Even with careful handling, some patients feel tingling or numb patches that usually fade over months.
Tendon weakness. Transfers give function, but they rarely match native power. A flexor hallucis longus transfer for Achilles disease restores push off better than leaving scarred tendon, but single leg heel rises may feel different.
Nonunion. Bone cuts and fusions sometimes struggle to heal. I use biology helpers like bone marrow aspirate or local graft when risk is high. Smokers should expect a higher nonunion rate.
Hardware irritation. Screws and plates near the heel can bother thin skinned patients. Removal is sometimes straightforward once the bone is solid.
Revision foot and ankle surgeon work focuses on the cause of failure, not just the symptom. A painful flatfoot repair may need a different osteotomy or a fusion if the joints have deteriorated. A re torn Achilles in poor tendon can demand graft augmentation. Getting a second opinion with fresh imaging helps map the next move.
Athletes, workers, seniors, and kids
Rearfoot problems land differently depending on life stage.
Runners and field sport athletes want return to speed. A foot and ankle sports injury surgeon emphasizes tendon friendly loading, early range of motion, and progressive plyometrics once healing allows. For lateral ankle instability in a cavovarus foot, correcting the heel varus reduces re sprain risk more than ligament work alone.
Workers on their feet need durable alignment and shoe options that match dress codes. We plan around shift patterns and provide clear return to duty milestones, working with occupational health for modified tasks during the mid phase of rehab. For work injury cases, documentation and clear causation statements matter almost as much as surgical skill.
Seniors with hindfoot arthritis often prefer reliable pain relief over athletic performance. A well positioned subtalar or triple fusion can change daily life more than any injection series. Bone health, vitamin D, and fall prevention wrap into the plan.
Children with hindfoot deformity, including severe flatfoot or cavus, benefit from pediatric foot and ankle surgeon input. Growth plates change the calculus. Many cases respond to orthotics and therapy, but persistent deformity that causes pain or shoe wear problems may need guided growth or osteotomy once the child nears skeletal maturity.
Special situations that shape decisions
Diabetes and neuropathy. Wound care sits at the center of every plan. A wound care foot surgeon’s team helps optimize glucose, footwear, and offloading. For Charcot hindfoot collapse, staged reconstruction or circular frame fixation may protect soft tissues better than large incisions.
Smoking. Nicotine is a union killer. I give patients a clear target to stop ahead of surgery, verified when possible. It is not punitive, it is predictive.
Osteoporosis. Fixation strategy changes. Larger screws, locking plates, and longer periods protected from weight bearing are common.
Previous surgery. Scar paths and hardware position drive approach choices. An advanced foot and ankle surgeon who handles revision work is essential if you have already had a procedure.
Choosing the right surgeon and asking the right questions
Labels such as best foot and ankle surgeon or top rated foot and ankle surgeon are marketing phrases. What helps you is specificity. Look for a foot and ankle orthopedic specialist or orthopaedic foot and ankle surgeon who:
- Performs your proposed procedure often. Shows you imaging of similar cases and explains outcomes and complications. Coordinates closely with therapy and orthotics. Offers both minimally invasive and open options when appropriate. Encourages questions and, if needed, supports a second opinion.
Ask about expected function, not just healing time. A foot and ankle replacement surgeon or total ankle replacement surgeon focuses on ankle joint disease, but hindfoot alignment still matters when planning arthroplasty. If your pain lives mainly under the heel, an ankle replacement is not the answer. If stiffness from arthritis is your main issue and imaging shows subtalar disease, an ankle fusion surgeon is not the one you need, but a rearfoot surgery specialist is.
What the day of surgery looks like
You arrive early, meet anesthesia, and review the plan. For many rearfoot cases, a regional block makes the first day surprisingly tolerable. Positioning matters. For calcaneal fracture fixation, you may be on your side to protect the skin edges. For Achilles repair, a small incision or mini open system sits just medial to the tendon to protect nerves. Before you wake up fully, your splint or boot is on, and instructions for elevation, toe wiggling, and medicine timing are in your hand.
In the first week, I call patients or use secure messaging to check pain, swelling, and calf comfort. Small course corrections early, like extra time elevated or a brace tweak, prevent bigger problems later.
What success looks like
Success is specific. The field worker with a calcaneal fracture wants to stand through a ten hour shift without stabbing lateral pain from impingement. The dancer with a repaired Achilles wants a stable single leg relevé at month five. The retiree with subtalar arthritis wants to walk the dog without limping by the second block. When alignment returns and painful abnormal motion stops, the rest of the foot stops shouting.
A rearfoot surgery specialist brings options to the table, from an ankle arthroscopy surgeon treating posterior impingement to a heel spur surgery specialist who knows when the spur is a passenger, not the driver. That range matters. It keeps the plan focused on your pain source, your alignment, and your goals.
Final thoughts
If your heel hurts and your hindfoot tilts, you do not have to guess your way through it. A thorough exam and targeted imaging usually point to a small set of explanations. Most patients improve with thoughtful nonoperative care. If you cross the line to surgery, pick a surgeon who does this work weekly, explains the plan without jargon, and stays engaged through rehab. Rearfoot problems are mechanical problems. Rebuild the mechanics well, commit to the recovery, and the miles feel good again.