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: A 69-year-old active male presented with left ankle pain that had persisted for the prior 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 Unlabeled Long Axis View of the Achilles Tendon Insertion Unlabeled Long Axis View of the Achilles Tendon Insertion Labeled Long Axis View of the Achilles Tendon Insertion Labeled Long Axis View of the Achilles Tendon Insertion. The retrocalcaneal bursa is distended. There are several small, hyperechoic foci noted with posterior acoustic shadowing, consistent with calcifications and bony changes at the insertion of the Achilles tendon. Unlabeled Short Axis View of the Achilles Tendon Insertion Unlabeled Short Axis View of the Achilles Tendon Insertion Labeled Short Axis View of the Achilles Tendon Insertion Labeled Short Axis View of the Achilles Tendon Insertion. A yellow circle is around hyperechoic structures which are calcifications creating shadowing (white arrow). Unlabeled Long Axis View of the Achilles Tendon Midportion with Doppler Unlabeled Long Axis View of the Achilles Tendon Midportion with Doppler Labeled Long Axis View of the Achilles Tendon Midportion with Doppler Labeled Long Axis View of the Achilles Tendon Midportion with Doppler. The thickness of the tendon is outlined as well as the areas of hyperemia noted in red by Doppler. #7 - Video View Video Unlabeled short axis cine of the Achilles Tendon from proximal to distal. 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: Initial management of insertional Achilles tendinopathy and Haglund-related symptoms is often conservative, especially when prior treatment has not been attempted. Heel lifts/wedges, footwear modification, and progressive strengthening are commonly used, with care to avoid painful dorsiflexion-compression loads early in rehabilitation. Ultrasound can help identify possible relevant contributors such as insertional tendinosis, partial tearing of deep fibers, calcific enthesopathy, and retrocalcaneal bursitis. These features can help guide whether treatment should emphasize load modification, bursal-specific interventions such as injection, tendon rehabilitation, or surgical consultation. References: 1. Chimenti RL, Cychosz CC, Hall MM, Phisitkul P. Current concepts review update: insertional Achilles tendinopathy. Foot Ankle Int. 2017;38(10):1160-1169. doi:10.1177/1071100717723127 2. Ko VMC, Cao M, Qiu J, et al. Comparative short-term effectiveness of non-surgical treatments for insertional Achilles tendinopathy: a systematic review and network meta-analysis. BMC Musculoskelet Disord. 2023;24(1):102. doi:10.1186/s12891-023-06170-x 3. Zellers JA, Bley BC, Pohlig RT, Alghamdi NH, Silbernagel KG. Frequency of pathology on diagnostic ultrasound and relationship to patient demographics in individuals with insertional Achilles tendinopathy. Int J Sports Phys Ther. 2019;14(5):761-769. doi:10.26603/ijspt20190761
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Authors, Editors, Case Information

Unlabeled Long Axis View of the Achilles Tendon Insertion

Labeled Long Axis View of the Achilles Tendon Insertion

Unlabeled Short Axis View of the Achilles Tendon Insertion

Labeled Short Axis View of the Achilles Tendon Insertion

Unlabeled Long Axis View of the Achilles Tendon Midportion with Doppler

Labeled Long Axis View of the Achilles Tendon Midportion with Doppler

#7 - Video

Interpretation

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