Heel pain due to retrocalcaneal bursitis-radiographic diagnosis (with an historical footnote on Sever's disease)

Characteristics of Pressure on the Apophysis in the Course of Paediatric Heel Pain-Preliminary Report

Increased pressure on the heel apophysis is often implicated as a cause of paediatric heel pain. However, there are few reports on the causes of the increased pressure and its origin. Therefore, the aim of this study was to analyse the distribution of pressure on the feet in children with heel pain. The study included 33 paediatric patients with non-traumatic heel pain, i.e., 24 boys (73%) and 9 girls (27%), aged on average 11.2 years (±3 years). Pedobarographic diagnostics proved a decrease in the pressure on the heels in relation to the ground and the transfer of the projection of the centre of gravity to the forefoot. While standing, the average contribution of the pressure on the heel was 0.52, SD = 0.14 in children with normal and reduced weight. In overweight children, the average pressure on the heel was higher (0.60, SD = 0.08), but the small number of children with this characteristic (n = 4) did not allow conclusions to be drawn in this area. Heel underload was also demonstrated during gait. However, the assessment of this aspect requires additional observational analyses in the field of propulsion and gait phases. The reduced pressure on the heel promotes apophysis traction, causing intracanal compression. Studies have shown that the causes of apophysis traction may be postural defects (in particular, forward inclination of body posture) and overpronation of the foot, or defects in the metatarsal area.

Normative size of the osseous part of calcaneal bursa and its comparison with other calcaneal articular areas

The retro-calcaneal bursa presents a synovial and a non-synovial osseous part of variable dimensions. Studies objectively measuring the variability of the size of this osseous bursal surface cannot be found in literature. The objective of this study was to investigate (i) the dimension variability of the bony part of the bursa and (ii) the relationship of this surface to other articulating areas of the calcaneus. A digital planimeter was used to measure the bursae (n=86) and other articular surface areas of the calcaneus and statistically compared with ANOVA and correlation estimations. The osseous area measured 1.12 (±0.55) cm2, with only the superior articulating area demonstrating a weak correlation to this osseous surface. The osseous area presents a weak correlation with the axial articulating area of the calcaneus. Information on the size of the bony bursa may help safe excision of retrocalcaneal exostoses and in Achille's tendon repair around the posterior tuberosity.

Achilles Tendon Disorders

Disorders of the Achilles tendon, the largest tendon in the human body, are common and occur in both active and sedentary persons. A thorough history and physical examination allow primary care physicians to make an accurate diagnosis and to initiate appropriate management. Mismanaged or neglected injuries markedly decrease a patient’s quality of life. A growing body of related literature is the basis for current therapeutic regimens, which use a multimodal conservative approach, including osteopathic manipulative treatment. Although primary care physicians can manage most cases of Achilles tendon disorders, specialty care may be needed in certain instances. Procedural intervention should consider any comorbid conditions in addition to patients’ lifestyle to help guide decision making. When appropriately managed, Achilles tendon disorders generally carry a favorable prognosis.

The appearance of the pre-Achilles fat pad after endoscopic calcaneoplasty

PURPOSE

To evaluate whether the imaging features of the retrocalcaneal recess normalize on a conventional radiograph after surgery for retrocalcaneal bursitis and evaluate whether it can be reused if complaints reoccur.

METHODS

Patients who underwent an endoscopic calcaneoplasty at least 2 years before were eligible for inclusion. A lateral conventional radiograph of the surgically treated hindfoot was made to assess the retrocalcaneal recess and pre-Achilles fat pad; images were analysed, clinical complaints were registered and evaluated. Radiographs were evaluated by two experienced observers (one orthopaedic surgeon one musculoskeletal specialized radiologist), these scored the images either as "normal" (no obliteration of retrocalcaneal recess and pre-Achilles fat) or as "abnormal".

RESULTS

Thirty patients (34 heels: 28 asymptomatic and 6 recurrent complaints) were included in this study. Observer one rated 12 images as "normal" (2 symptomatic heels and 10 asymptomatic), 22 "abnormal". Observer two rated 9 "normal" (1 symptomatic heels and 8 asymptomatic), 25 "abnormal". No correlation between the radiographic appearance and complaints (n.s.) was found. Cohen's kappa for interobserver agreement was low (0.11 n.s.).

CONCLUSION

The appearance of the retrocalcaneal recess on a lateral radiograph cannot be used as a reliable diagnostic criterion for retrocalcaneal bursitis in patients who previously underwent endoscopic calcaneoplasty. This study clinical relevance is based upon the conclusion that a lateral radiograph cannot be used after endoscopic calcaneoplasty, whereas previous work reported the diagnostic value of a lateral radiograph for retrocalcaneal bursitis prior to surgery.

LEVEL OF EVIDENCE

III.

Sever's injury: a clinical diagnosis

BACKGROUND

The diagnosis of Sever's injury (apophysitis calcanei) has previously been partly based on radiographic findings in the calcaneal apophysis. Sclerosis and fragmentation have been supposed to represent signs of inflammation due to tractions from the Achilles tendon. The clinical findings, diagnostic criteria, and studied population are often poorly defined. We sought to define diagnostic criteria by analyzing clinical and radiographic characteristics in a population with Sever's injury and to compare the findings with those of a control group of matched, symptom-free children.

METHODS

We assessed 30 consecutive children with Sever's injury with high levels of pain but high physical activity levels in sports activities and 15 pain-free matched controls.

RESULTS

One-leg heel standing showed 100% sensitivity; the squeeze test, 97%; and the palpation test, 80%. All three tests showed 100% specificity. All of the patients and controls showed increased density of the apophysis. Half of the pain-free controls showed fragmentation versus almost 90% of children with heel pain.

CONCLUSIONS

The diagnosis of Sever's injury is clinical, not radiologic. Radiologic findings of increased density and fragmentation are found also in pain-free controls with high levels of physical activity and may, therefore, represent normal growth and development. We suggest that the diagnosis of Sever's injury should be based on patient history and the results of two specific clinical tests.

Radiologic morphology of the calcaneus: a study of radiologic angles in a pediatric population

BACKGROUND

The Fowler-Philip, calcaneal pitch, and total calcaneal angles define the radiologic morphology of the rearfoot. We studied these angles in healthy adolescents.

METHODS

We studied 141 feet. Patients with inflammatory or traumatic injuries were excluded. The mean participant age was 11.5 years. The Fowler-Philip, calcaneal pitch, and total calcaneal angles were measured on lateral weightbearing radiographs. The statistics included descriptive, sample size (α=0.05 and β=0.20), the Student t test, and analysis of variance; P < .05 was considered significant.

RESULTS

The samples were 141 and 35 radiographs for the Fowler-Philip and calcaneal pitch angles, respectively. Ninety percent, 25.1%, and 97.4% of the adolescents had normal Fowler-Philip, calcaneal pitch, and total calcaneal angles, respectively. In addition, 9.9%, 74.9%, and 2.6% of the values were outside the reference ranges, respectively. The Fowler-Philip angle decreased and the calcaneal pitch angle increased significantly with age (P = .0005). The total calcaneal angle did not change with age (P = .65).

CONCLUSIONS

The mean angle values in a pediatric population did not differ from those in adults. We found a high percentage of calcaneal pitch angles outside the reference range. Age influenced the Fowler-Philip and calcaneal pitch angles but not the total calcaneal angle.

Prevalence of osteochondritis among preparatory and primary school children in an Egyptian governorate

Epiphyseal osteochondritis is a localized disorder in childhood. Vascular insufficiency is thought to be the most significant etiologic factor. This study had been carried on Primary and Preparatory school children in Zagazig City and surrounding villages in Sharkia Governorate, Egypt. Total number of studied children were 16,060, 7,380 males, 8,680 females. The mean age was 11.41 ± 1.99. Our results showed that the prevalence of osteochondritis was 21:10,000. Distribution of Sever's and Osgood-Shlatter diseases were significantly high compared with other osteochondritis. Regarding the sex distribution, osteochondritis was frequent in males. Our results showed that there was history of trauma especially in Sever's and Osgood-Schlatter diseases.

Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis

BACKGROUND AND PURPOSE

A retrocalcaneal bursitis is caused by repetitive impingement of the bursa between the Achilles tendon and the posterosuperior calcaneus. The bursa is situated in the posteroinferior corner of Kager's triangle (retrocalcaneal recess), which is a radiolucency with sharp borders on the lateral radiograph of the ankle. If there is inflammation, the fluid-filled bursa is less radiolucent, making it difficult to delineate the retrocalcaneal recess. We assessed whether the radiographic appearance of the retrocalcaneal recess on plain digital (filmless) radiographs could be used in the diagnosis of a retrocalcaneal bursitis.

METHODS

Whether or not there was obliteration of the retrocalcaneal recess (yes/no) on 74 digital weight-bearing lateral radiographs of the ankle was independently assessed by 2 observers. The radiographs were from 24 patients (25 heels) with retrocalcaneal bursitis (confirmed on endoscopic calcaneoplasty); the control group consisted of 50 patients (59 heels).

RESULTS

The sensitivity of the test was 83% for observer 1 and 79% for observer 2. Specificity was 100% and 98%, respectively. The kappa value of the interobserver reliability test was 0.86. For observer 1, intraobserver reliability was 0.96 and for observer 2 it was 0.92.

INTERPRETATION

On digital weight-bearing lateral radiographs of a retrocalcaneal bursitis, the retrocalcaneal recess has a typical appearance.

Do we really need radiographic assessment for the diagnosis of non-specific heel pain (calcaneal apophysitis) in children?

OBJECTIVE

Non-specific heel pain (calcaneal apophysitis) is a common disorder, particularly in physically active growing children. Foot radiographs are usually obtained as part of the clinical evaluation in routine orthopaedic practice. However, there is still controversy about the specific findings on radiographs, and it is unclear what information is present on radiographs that may alter the diagnosis and management. The purpose of this study was to review a consecutive series of patients with the diagnosis of calcaneal apophysitis to assess the yield of routine radiographs of the foot.

MATERIAL AND METHODS

A prospective study was performed on 61 consecutive patients with a diagnosis of calcaneal apophysitis in a single-surgeon practice. Standard anteroposterior and lateral weight-bearing foot radiographs were obtained for each patient. Seventy-one sets of foot radiographs were reviewed to determine whether radiographs had an impact on diagnosis and management. Patients with antecedent trauma, penetrating injury, foot deformity, achilles tendonitis, bursitis and infections were excluded from the study.

RESULTS

Seventy foot radiographs were considered to be normal. The radiographs changed the diagnosis in only one patient, in whom a simple bone cyst of the calcaneous was seen.

CONCLUSION

Calcaneal apophysitis is a self-limiting disease, and patients can be treated conservatively. Neither the sclerosis nor the fragmentation of the apophysis could be used to establish the diagnosis of calcaneal apophysitis. Therefore, obtaining radiographs as an initial step in their evaluation does not seem to be justified.

Peri-epiphyseal and Overuse Injuries in Adolescent Athletes

CONTEXT

Overuse injuries of the musculoskeletal system in immature athletes are commonly seen in medical practice.

EVIDENCE ACQUISITION

An analysis of published clinical, outcome, and biomechanical studies of adolescent epiphyseal and overuse injuries was performed through 2008 to increase recognition and provide treatment recommendations.

RESULTS

Adolescent athletes can sustain physeal and bony stress injuries. Recovery and return to play occur more swiftly if such injuries are diagnosed early and immobilized until the patient is pain-free, typically about 4 weeks for apophyseal and epiphyseal overuse injuries. Certain epiphyseal injuries have prolonged symptoms with delayed treatment, including those involving the bones in the hand, elbow, and foot. If such injuries are missed, prolonged healing and significant restrictions in athletic pursuits may occur.

CONCLUSION

Some of these injuries are common to all weightbearing sports and are therefore widely recognized. Several are common in gymnastics but are rarely seen in other athletes. Early recognition and treatment of these conditions lead to quicker recovery and so may prevent season-ending, even career-ending, events from occurring.

Sever's injury: a stress fracture of the immature calcaneal metaphysis

Magnetic resonance imaging (MRI) in children with a presumptive diagnosis of Sever's apophysitis and with continuing pain after conservative treatment demonstrated bone bruising within the trabecular bone of the metaphyseal region adjacent to the calcaneal apophysis. Limited portions of the apophyseal secondary ossification center showed similar increased signal changes. MRI studies following treatment with immobilization showed subsidence or disappearance of the metaphyseal but not any apophyseal signal changes commensurate with improvement in symptoms. Accordingly, the disorder commonly referred to as Sever's ''apophysitis'' may be a metaphyseal trabecular stress fracture, similar to the toddler's calcaneal stress fracture that has minimal or no involvement of the apophyseal ossification center, and thus should not be referred to as an apophysitis. Rather, it appears to be an overuse injury causing microinjury within the developing metaphyseal "equivalent" trabecular bone that has not completely adapted to the changing biologic (biomechanical) requirements of the growing, athletically active child.

Foot and ankle problems in the young athlete

In the U.S., greater than half of boys and one quarter of girls in the 8- to 16-yr-old age range are engaged in some type of competitive, scholastic, organized sport during the school year. Children and adolescents are becoming more involved in sports at earlier ages and with higher levels of intensity. Foot and ankle problems, in particular, are the second most common musculoskeletal problem facing primary care physicians in children under 10 yr of age next to acute injury. This report focuses on foot and ankle problems, trauma, and overuse in the young athletic population. Guidelines are given for both conservative and surgical management. Specific problems addressed include pes planus, tarsal coalition, adolescent bunion, os trigonum, accessory navicular, physeal fractures, sprains, peroneal tendon subluxation, metatarsal fractures, sesamoid fractures, turf toe, stress fractures, tendonitis, osteochondritis dissecans, ankle impingement, bursitis, Haglund's deformity, sesamoiditis, plantar fasciitis, apophysitis, osteochondroses, cuboid syndrome, and reflex sympathetic dystrophy. An extensive review of the literature is performed and presented in combination with the extensive experience of a well-established sports medicine clinic at the Boston Children's Hospital.

The retrocalcaneal bursa: anatomy and bursography

The retrocalcaneal bursae, located between the posterior angle of the os calcis and the Achilles tendon, may become inflamed and hypertrophied. There are few objective tests available for the diagnosis of pain syndromes involving the hindfoot and it is often difficult to differentiate Achilles tendinitis and retrocalcaneal bursitis. Retrocalcaneal bursograms can provide further insight into chronic changes in the bursae associated with traumatic and inflammatory conditions. This report describes the anatomy of the retrocalcaneal bursa, the technique of its opacification, and the application of this technique to the diagnosis and treatment of painful hindfoot syndromes. In addition, the anatomy of the retrocalcaneal bursa was investigated further using latex casting techniques. Twelve cadaver limbs were injected with radiopaque latex casting material or renografin into the retrocalcaneal bursae. AP, lateral, and oblique radiographs were then obtained on the specimens. The size, capacity, and configuration of the postmortem bursae were measured and recorded. Subsequently, the cadaver limbs injected with the latex material were cooled and dissection was made of the retrocalcaneal bursae. The latex bursal molds were measured, graphically recorded, and photographed. Fifteen patients with signs and symptoms of retrocalcaneal bursitis and eight asymptomatic patients were selected for this study and injected with radiopaque material into the bursae. Anteroposterior, lateral, and oblique radiographs were then obtained. The size, capacity, and configuration of the retrocalcaneal bursae were measured and recorded. The anatomic characteristics noted from the latex bursal molds correlated well with the findings on bursography. Bursographic findings in patients with retrocalcaneal bursitis can provide insight into the diagnosis and clinical management of this disorder.