Lecture 6 Flashcards
Heel pain differential (posterior or plantar os calcis)
- Achilles insertional tendinopathy
- Retrocalcaneal bursitis
- Haglund’s Syndrome
- Os trigonum syndrome
- FHL tendinopathy or tenosyvitis
Achilles insertional tendinopathy often accompanied by
- Calcification (spur) at tendon attachment
Haglund’s Syndrome
- Enlarged posterior superior margin of calcaneus
- Can impinge upon retrocalcaneal bursa and Achilles tendon
Os trigonum syndrome
- Presence of os trigonum usually not painful
- Usually triggered by an ankle injury
- Repeated plantarflexion causes ossicle to become impinged
- Posterior ankle impingement
- The connective tissue connection between the ossicle and talus is damaged
FHL tendinopathy or tenosynovitis
- Not common
- Seen in dancers
Other possible heel pain diagnoses
- Plantar fasciitis (inferior heel)
- Calcaneal stress fracture
- Calcaneus fracture
- Tarsal tunnel syndrome
- Other arthropathies
- Infection
Calcaneal apophysitis (Sever’s Disease)
- Overuse/overload injury to the posterior apophysis (posterior growth plate)
- Xrays can rule out other conditions
- Secondary center is usually fragmented (not always)
- Diagnosis is clinical
- Treated conservatively
Calcaneal apophysitis (Sever’s Disease) causes
- Achilles tendon (traction apophysitis)
- Mechanical compression
Calcaneal apophysis ossification
- Secondary center appears mostly btwn ages 6-9 (almost always appears by age 11)
- Fuses btwn 12-18 (most fused by 15)
Calcaneal apophysitis (Sever’s Disease) symptoms
- Pain localized to posterior/plantar heel
- Elicited during weightbearing
Calcaneal apophysitis (Sever’s Disease) most commonly seen in
- Children and adolescents during growth
- Especially ages 9-13 who are active in sports
- Boys > girls
- Both heels commonly affected
Haglund’s deformity (pump bump, Mulholland deformity)
- Bony enlargement of the back of the heel (posterior superior calcaneus)
- Soft tissue surrounding (Achilles, bursa) can become irritated leading to Haglund’s syndrome
Haglund’s Syndrome symptoms
- Retrocalcaneal pain
- Abnormal protuberance of the posterosuperior border
- Retrocalcaneal bursitis and swelling
- Achilles tendinosis
- Pumps or shoes with rigid shoe backs aggravate the enlargement (shoes with a hard back)
Haglund’s Syndrome clinical appearance
- Can be difficult to distinguish Haglund’s syndrome from other causes of hindfoot pain
- Prominent calcaneal posterosuperior protuberance
- Usually on the lateral side
- Swelling and inflammation
Haglund’s Syndrome predisposing factors
- Wearing tight, stiff shoes
- Pes cavus
- Forefoot varus
- Tight Achilles
- Walking on lateral side of foot
Haglund’s Syndrome usually affects
- Middle-aged individuals
- F > M
- Often bilateral
Conservative treatment of Haglund’s Syndrome
- Shoe modification
- Orthotics: heel pads and lifts
- PT: Achilles stretching, anti-inflammatories, ice
- Local injections (bursa)
Surgical treatment of Haglund’s Syndrome
- Removal of bony enlargement (calcaneal osteotomy)
AP view x-ray
- Foot positioned in dorsiflexion
- Toes toward ceiling
Mortise view x-ray
- AP with foot internally rotated ~ 15-20ᵒ
- Brings malleoli parallel to each other
- Allow visualization of mortise (tibial plafond, malleoli, talar dome, clear space)
- Allows assessment of distal tib/fib syndesmosis