Age / Sex : 59 / M

Chief complaint: Right heel pain with hard protuberance (2YA)

1) What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

(답안은 한 개만 보내주시기 바랍니다)

Courtesy: 양 익 (Ik Yang),  한림대학교 강남성심병원 (Kangnam Sacred Heart Hospital  Hallym University)

Haglund's deformity with Achilles tendinosis & retrocalcaneal bursitis

Discussion

Findings:

<Plain film>

Figure 2-a)

On plain radiograph of the right lateral foot, bony prominence and soft tissue swelling are seen on postero-superior aspect of the right calcaneal tuberosity.

Figure 2-b)

Post operative (ostectomy and Achilles tendon repair) plain radiograph

<MRI>

Figure 3. Right foot MRI

a) T1W sagittal,  b) FS T2W sagittal,  c) PD coronal

About 2.6x1.1x1.6cm bony spur at postero-superior of the calcaneus (Haglund deformity) which  causes an overlying bursitis & tendinosis of the Achilles tendon.

MRI shows diffuse high signal intensity at the calcaneal insertion area of the Achilles tendon & Pre-Achilles, retrocalcaneal bursa.

Differential Diagnosis:

Achilles tendon enthesopathy

Diagnosis:  Haglund's deformity

with Achilles tendinosis & retrocalcaneal bursitis, ankle, right

Discussion:

 Haglund’s disease is frequently associated with “pump”-style shoes. More important than the shoe style is the presence of a stiff-heel counter, which compresses the retro-Achilles bursa against the posterior lateral calcaneal prominence. The calcaneal tuberosity may focally enlarge in response to chronic irritation. This enlargement further irritates the retro-Achilles bursa and the Achilles tendon, which increases the irritation that causes further enlargement of the tuberosity. This results in a cycle of injury, response to injury, and reinjury.

In patients with Haglund’s disease, MR images reveal excessive fluid in the retrocalcaneal bursa, fluid in the retro-Achilles bursa, and an enlarged calcaneal tuberosity.

MRI is helpful in detecting the degenerative changes that occur within the achilles tendon. Also useful to the surgeon to know the extent of the degenerative changes.

The diagnosis of an enlarged calcaneal tuberosity (or of a bursal projection) is made by drawing parallel pitch lines on the upper and lower aspects on the calcaneus on sagittal images. The lower parallel pitch line is tangent to the anterior tubercle and the medial tuberosity of the calcaneus. The upper line is drawn parallel to the lower pitch line at the level of the posterior lip of the subtalar articular facet. In Haglund’s disease, a portion of the tuberosity is seen above the upper pitch line (Figure 4).

References: Schweitzer ME, Karasick D. MR imaging of disorders of the Achilles tendon. AJR. 2000;175 (3): 613-25.