Mets outfielder Yoenis Cespedes spoke with reporters at his locker Friday night after appearing in his first major league game in nine weeks. Cespedes had been on the disabled list while recovering from a hip flexor strain, the latest episode in what has become a chronic, recurrent, soft-tissue-injury pattern for him. During the session with the media, Cespedes referenced -- through an interpreter -- an ongoing condition involving calcifications in both heels.
The news naturally left fans curious about what exactly is plaguing Cespedes' heels and what the realistic expectations can be for him moving forward. In the absence of a distinct diagnosis, the interpretation of Cespedes' brief interview warrants some caution. That said, his words, in conjunction with the comments Sunday from Mets assistant general manager John Ricco, offer clues.
The word "calcification" suggests Cespedes is dealing with extra bone growth in his heel; the question then becomes where and how much. Bone will lay down more bone in response to stress (also known as Wolff's Law) which is a good thing when trying to encourage bone growth. For example, for an athlete rehabbing following a fracture, progressive bone loading in controlled amounts is desirable to help stimulate bone healing. But excessive bone growth in a particular area -- or worse, in tissue where bone should not be present, such as a tendon -- can be detrimental because of the subsequent pain, loss of mobility, contribution to further injury ... or all of the above.
Extra bone growth in the form of spurs is not uncommon in the heel area. Bone spurs can exist in isolation and are often present without causing pain. However, if the spurring creates significant friction, or if, as noted above, bone is present within other tissue, the resulting condition can become disabling. When the pain and disability begin to increasingly interfere with the activity necessary to perform, athletes can become frustrated.
Mets manager Mickey Callaway noted that when Cespedes came into the dugout Friday night after his eighth-inning at-bat, he said his heels were "on fire." Shortly thereafter, Cespedes voiced his concern about how much his heels were affecting him. He associated some of his other lower-extremity issues with the aggravation of the heel pain.
"When I feel the pain in my heels, I started to modify my walking way, my running way, even my standing," Cespedes said.
If Cespedes has indeed been altering the way he runs in response to flare-ups of heel pain, it is certainly reasonable to think this could contribute to muscular strains as a result of overcompensation.
Perhaps the most dramatic element of Cespedes' statement to reporters was his comment that surgery would be the only means of truly addressing the problem. When asked if it could be done during the offseason, Cespedes said he was still thinking about it, noting, "The recovery process takes over eight to 10 months."
The combination of his symptom description combined with his perceived recovery time suggests Cespedes is dealing with insertional calcific tendinopathy of the Achilles and a potential Haglund's deformity. According to sources, this is indeed the condition for which Cespedes is being further evaluated.
The term "insertional" refers to the insertion, or attachment point, of the Achilles on the back of the heel. "Tendinopathy" refers to a diseased tendon, and calcific refers to the presence of extra bone, not only at the insertion point, but potentially within the tendon itself. The more calcification within the tendon, the more challenging it is to manage.
Haglund's deformity refers to a specific bone growth on the back of the heel that can also irritate the Achilles tendon. In addition to the presence of extra bone growth, the involvement of the tendon will dictate the clinical picture for the athlete.
The initial course of treatment for this type of condition is typically conservative. Modifications in footwear, physical therapy, episodes of rest and efforts at pain management are all first steps before proceeding to surgery. The medical literature is consistent in recommending surgery as a last resort, in part due to the invasive nature along with the extended recovery time. Depending on the individual case, the recovery window can vary, even exceeding the eight- to 10-month time frame Cespedes referenced.
The recovery is dictated in part by how extensive the surgery is; the more debridement (or cleanup) of the tendon required to remove the calcific deposits or repair the tendon, the more complex the healing process. Then there is the element for an elite athlete such as Cespedes that involves reintegrating to sport and addressing any compensatory mechanics that were present before surgery. These higher-level rehabilitation components are not easy steps, nor are they quick.
When assistant general manager John Ricco spoke with reporters Sunday, he said the heel condition predates Cespedes' time with the Mets, referencing the chronic nature of the condition. Ricco reiterated the notion that surgery is a last resort after conservative treatments have been exhausted.
"The surgery is fairly radical, it's going to put you out for a while, so it's not something that you look to do immediately," he said.
Ricco went on to say the Mets will have Cespedes evaluated by their medical staff, and, given that Cespedes raised the issue of surgery, they will take it seriously.