Insertional Achilles Tendinosis With Associated Retrocalcaneal Bursitis And Evidence Of A Haglund Deformity

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Insertional Achilles Tendinosis With Associated Retrocalcaneal Bursitis And Evidence Of A Haglund Deformity

Authors, Editors, Case Information Author: Swetha Sundaram, MS Affiliation: Rowan-Virtua School of Osteopathic Medicine Co Author(s): Cameron Taylor, DO Altamash Raja, DO, RMSK, CSCS Senior Editor: Michael Krill, MD, ATC Clinical Vignette: 69 year old active male presents with left ankle pain that has persisted for the past month due to excessive walking in dress shoes. Physical examination revealed tenderness at posterior heel/calcaneus. Type of Probe Used: 15-4 MHz Linear Transducer Labeled Long Axis View of the Midportion Achilles Tendonwith Doppler of Achilles Tendon Labeled long axis view of the midportion Achilles tendon with Doppler imaging. The thickness of the tendon is outlined as well as the areas of hyperemia noted in red by Doppler. #2 - Video View Video Unlabelled short axis video of the insertional Achilles Tendon and Calcaneus with the proximal part of the ankle at the top and the distal part at the bottom. The left side is lateral, and the right side is medial. Labeled Short Axis View of the Insertional Achilles Tendon and Calcaneus Labeled short axis view of the insertional Achilles tendon and calcaneus. A yellow circle is around hyperechoic structures which are calcifications creating shadowing (white arrow). Labeled Long Axis View of the Insertional Achilles Tendon and Calcaneus Labeled long axis view of the insertional Achilles tendon and calcaneus. Note the distended fluid collection between Kager’s Fat Pad and the Calcaneus that is the Retrocalcaneal bursa. Hyperechoic space is suggestive of edema. Unlabeled Short Axis Insertional Achilles Tendon Unlabeled short axis view of the insertional Achilles Tendon and calcaneus. Unlabeled Long Axis Midsubstance Achilles Tendon with Doppler Unlabeled long axis view of the midportion Achilles tendon with doppler imaging. Unlabeled Long Axis Insertional Achilles Tendon Unlabeled long axis view of the insertional Achilles tendon and calcaneus. Interpretation Image Interpretation: The Achilles tendon is thickened and hypoechoic, with marked hyperemia, most notable along the mid-tendinous portion. The retrocalcaneal bursa is distended, without hyperemia, but sonopalpatory pain is appreciated here. At the distal Achilles insertion, several small, hyperechoic foci are noted with posterior acoustic shadowing, consistent with calcifications and bony changes. The constellation of these clinical and sonographic findings suggests both midportion and insertional achilles tendinosis with associated retrocalcaneal bursitis and evidence of a Haglund deformity. Teaching Pearl: A Haglund’s deformity, or "pump bump", is a common cause of heel pain. It is commonly found in individuals wearing rigid shoes and high heels. Constant pressure around the calcaneus near the insertion of the Achilles tendon leads to formation and growth of a bony prominence, typically referred to as a Haglund deformity. Furthermore, constant friction at this area leads to irritation of the retrocalcaneal bursa, thickening of the Achilles tendon, and swelling of the surrounding soft tissues.The combination of insertional achilles tendinosis with retrocalcaneal bursitis part of Haglund's deformity is consistent with the clinical diagnosis known as Haglund’s syndrome. Ultrasound is a useful modality which helps visualize Achilles tendinopathy, accompanying retrocalcaneal bursal thickening and/or changes to the underlying fat pad. Since improper shoes are a major cause, one of the first line steps in treatment is to encourage the use of better footwear with open backs or cushioned heels. Heel pads and orthotics can also be used as supplements to further reduce any irritation on the calcaneus and Achilles tendon. Management of the inflammation and pain can be resolved with ice and NSAIDS. Physical therapy is another modality to improve flexibility and strength of this region. In severe cases, surgery is considered to resect any affected soft tissues and possible bony overgrowth.
NOTE: For more information, please contact the AMSSM, 4000 W. 114th Street, Suite 100, Leawood, KS 66211 (913) 327-1415.

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Authors, Editors, Case Information

Labeled Long Axis View of the Midportion Achilles Tendonwith Doppler of Achilles Tendon

#2 - Video

Labeled Short Axis View of the Insertional Achilles Tendon and Calcaneus

Labeled Long Axis View of the Insertional Achilles Tendon and Calcaneus

Unlabeled Short Axis Insertional Achilles Tendon

Unlabeled Long Axis Midsubstance Achilles Tendon with Doppler

Unlabeled Long Axis Insertional Achilles Tendon

Interpretation

UPCOMING EVENTS

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