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Retrocalcaneal Pain: Diagnostic ultrasound case study

Discussion in 'General Issues and Discussion Forum' started by Mart, Dec 24, 2009.

  1. Mart

    Mart Well-Known Member


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    50 YO female teacher. 5Y + history of chronic episodic posterior heel pain,
    conservative treatment todate foot orthoses plus plethora of physiotherapy with limited benefit.

    Diagnostic ultrasound exam +ve for very active flow with power doppler imaging at retro- tendo-achilles (retrocalc bursitis) and insertional tendosis/neovascularisation.


    DB1.jpg

    high calcaneal inclination angle and Haglunds likely (need to see films to confirm).

    I am thinking of doing US guided dexamethasone into what I interpret as enlarged/inflammed retrocalc bursa

    BUT

    unsure regarding interpretation of adjacent tendon.

    question is

    Does US show tendonsis, retrocalc bursitis or both

    If tendosis is present what is risk for rupture with careful US guided corticosteroid

    image above shows site nicely but difficult to delineate bursa/tendon

    I have put video of dynamic exam at

    http://www.winnipegfootclinic.com/resourses.html

    double click podarena icon to view


    what I think I can see is

    fibrosed remnants of retrocalc bursa attached to posterior aspect of calcaneus (green arrow), and motion of hypertrophic complex dystrophic retrocalc bursa (yellow arrow) interposing between tendo-achilles and fibrous remains with ankle plantarflexion.

    I am unsure if there are 2 lesions (bursa and tendinosis) or one (bursa or tendonosis) - I suspect former.

    Help please from surgeons who might be able to conform/refute this possibility from their surgical experience, expert US opinion.

    Opinions / experience with injection for this?


    cheers

    Martin


    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. Martin:

    You need ultrasound?.....I can diagnosis retrocalcaneal bursitis from across the room from the patient....swelling in the posterior heel and the patient pointing to their posterior heel as the source of their pain.;)

    Retrocalcaneal bursitis, in my clinical experience, occurs most commonly in individuals over 45 years old, who have large and/or tight calf muscles and who are either heavy and/or very active in running sports. Even though the chance of Achilles tendon rupture is slight after careful cortisone into the bursa, I have seen it happen before and, from a legal standpoint, you would not look too good in front of the judge with injecting the bursa with cortisone and the patient developing a spontaneous Achilles rupture within a few months afterward.

    If there is no spurring on radiograph, I treat them with icing, gradual Achilles stretches, NSAIDS, heel lifts and putting them into shoes with no heel counter/back to them (e.g. backless clogs). My current favorite for a specific shoe are the clog style Z-coil shoes for more resistant cases. My theory here is that the bursitis is being caused not only by the tensile force from the Achilles tendon but also by compression force from the shoe heel counter pressing on the bursal area with each step while in the shoe.

    Hope this helps and Merry Christmas!:santa::drinks
     
  4. drsarbes

    drsarbes Well-Known Member

    "I can diagnosis retrocalcaneal bursitis from across the room from the patient.."

    Funny Kevin, and a BIG room at that?

    I've done literally hundreds of retrocalcaneal exostoses (not Haglunds) and what I ALWAYS appreciate (OK, almost always) is a large posterior superior angle with a rather large bursae here. If, surgically, you don't remove this portion of the os calcis then, in my experience, the results are extremely iffy.

    I do have to make one comment contrary to Kevin's observations: I have seen a number of these on patients with rather normal ROM and no enlarged gastroc.

    You KNOW Mart Loves his US!!!!!! Hopefully I will too (as soon as I get one!)
    Mart- Intraoperatively I would guesstimate about half of these patients have pathology in the tendon itself and about a quarter of those I end up grafting.

    Steve
     
  5. Mart

    Mart Well-Known Member

    Thanks for reply Kevin and Happy New Year from the chilly North.

    Even with your hawk like eyesight you wouldn’t have spotted anything unusual from across the room, no swelling really to be noted. At first I thought “there goes Kevin again, winding me up about my US obsession :empathy:”, then I thought “well here’s a good example where in sub acute stage, US is showing bursitis which Kevin would have missed :pigs:”.

    I see this case as an interesting example because with PE I found it is impossible to evaluate the nature of retrocalc pathology. Radiographic exam has limited ability since presence of exostosis doesn’t inform much about soft tissue reaction. As I see it, the US interpretation is vital. It guides me to the next step in recommending a treatment plan and if erroneous may have poor outcome for this lady. Cross correlation with MRI would be helpful and perhaps warrants special consideration regarding ankle positon during imaging. I spent several hours today trying to explore the extent of published knowledge and felt it worthy to share selected parts and invite some comment . . . it is necessarily lengthy but I hope thorough.



    This lady seems in a sub acute phase currently and although uncomfortable doesn’t limp. She recently quit country dancing which mitigates pain and is quite distressed to do this because it has been integral part of prior life style since youth. In addition to the enthesopathy she has bilateral forefoot overload as you might expect with lesion pattern typical for high calcaneal inclination angle. I fabricated foot orthoses several years ago back to deal with forefoot problems which worked OK. With onset of heel pain I added a 5mm heel ramp to same foot orthoses but she reported “not liking the feel in the arch (loss of contact pressure)”. Last week I redigitised her with ankle plantarflexion (7 degrees heel ramp) and the subsequent foot orthoses initially seem to have “better feel”. We have an appointment to review progress in four weeks.


    The million dollar question is; can we tell from the US video sequence I posted what type of tissue is moving into the Retrocalcaneal space and if so what is it?


    My argument is that is if we can be sure


    Then if


    Fat or bursa ; judicious guided soluble corticosteroid injection at anterior margins of inflamed tissue with care not to infiltrate adjacent to tendon reasonable given informed consent for risk of rupture.


    Degenerated tendon; corticosteroid is absolute contraindication, alternative injection therapy discussed later on.


    My MSKUS “bible” is (Martino 2007). For those unfamiliar with US and to make sense of interpretation they state;


    “Acute traumatic bursitis: affects several synovial bursae, the bursal expansion follows direct impact or chronic frictional microtrauma. The most commonly involved bursae includes the retro-calcaneal and superficialis bursa of the Achilles tendon. In acute forms, an increase in anechoic fluid within the bursa is observed (a comparison with the controlateral limb may be useful), while the synovial wall keeps its original thickness. In chronic forms, the fluid often appears hypoechoic and contains hyperechoic spots consistent with microcalcification, and the bursal walls are thickened.Enthesopathy, also known as insertional tendinopathy, is an inflammatory-degenerative pathology involving the osteo-tendinous junction, usually caused by functional overload. It typically affects anchor tendons submitted to continual and intense mechanical stress. In standard conditions the enthesis consists of intertwined tendon fibers and fibrocartilage,with slow flowing vessels that cannot be visualized on Doppler analysis. In enthesopathies, the earliest pathologic finding is local hyperemia and angiogenesis; with Doppler techniques the increase of vascular signals can be identified early, when the matrix of tendons is not yet altered. US is a highly sensitive technique for identifying and quantifying the tendon insertional thickening, the hypoechoic pattern and the inhomogeneous echotexture. Insertional calcification and hypoechoic focal areas, corresponding to myxoid degeneration within the tendon, may be observed. An inflammatory reaction of the adjacent serous bursa and the presence of erosions and of an irregular cortical bone outline at the insertion are often associated. On US, erosions appear as interruptions of the hyperechoic cortical bone outline. In advanced cases, an MR examination should be performed, because it represents the only technique capable of determining the insertional bone involvement appearing as medullary edema within the bone in high contrast sequences.”


    Nothing earth shattering there.


    Here’s the example from Martino, easy to see similarity in appearance to the case study.

    Martino 1.jpg

    I also use;

    Dondelinger, R. F. Peripheral Musculoskeletal Ultrasound Atlas. Stuttgart: G. Thieme Verlag, 1996.

    And

    Adler, Ronald, Carolyn M. Sofka, and Rock G. Positano. Atlas of Foot and Ankle Sonography. Philadelphia: Lippincott Williams & Wilkins, 2004.

    They both have similar images depicting retrocalc bursitis.

    Looking in detail at the anatomy;

    “There is a remarkable discrepancy in the medical literature, oriented on the anatomy and pathology of the heel: on one side a great attention was paid to the diagnostics and therapy of the enthesopathies but on the other side neither the detailed anatomy nor the histological structure of the normal retrocalcaneal bursa (RB) were systematically described” (Kachlik, Baca et al. 2008). Lack of attention to the fat pad itself reflects an insufficient understanding of its functional significance and whether any alteration to its mechanics could bear on injury and pathology posterior to the ankle joint. It has been suggested that Kager’s fat pad acts as a variable space filler and conveys a mechanical advantage on the Achilles tendon insertion, by moving into the retrocalcaneal bursa during plantarflexion (Canoso et al. 1988).


    Kachlik et al describe that “In the ceiling of RB, delicate fascicle of skeletal muscle was discovered, radiating distally into the regularly present synovial fold”.


    I have attached the paper since it seems seminal. It was interesting that the thickness of the cortical bone was largest in its lower part, in front of the tendo-achilles (AT) attachment, where it extended to approximately 200 μm. In its proximal part, the cortical layer was apparently thinner, its minimal thickness was determined on 25–50 μm only.

    I wonder if this might explain location of erosio

    ns seen with the seronegative arthropathies in this region?


    “In the whole extent of the RB the surface of the cortical bone was covered by a layer of fibrous cartilage, which thickness was also largest on the bottom of bursa where it continued dorsally to the cartilaginous segment of the AT attachment and ventrally covered the calcaneal tuberosity” (Kachlik, Baca et al. 2008). Bearing this in mind, if you look at the following images the zone at the red arrow I think might represent fibrocartilage or fibrosed bursa.


    annotated spec.jpg


    left foot.jpg


    I superimposed on the normal specimin a yellow arrow representing exostosis and green arrow zone of pathologic tissue in our patient.

    If you recall the “Sever’s” case we looked at several months ago sonographically there were some similarities in trying to interpret fibrocartilage overlying bone. The contour of the cortex suggests Hagland’s type exostosis. I have not, but intend to see radiographic exam to confirm but feel reasonably confident about this.

    From a mechanical perspective it would seem likely that adaptive thickening of fibrocartilage in response to compression at this site might occur. Evidence for an asymmetric adaptive response of AT to tensile strain is also seen proximally.

    Below are normal values.

    Achilles tendon 20mm proximal of calcaneus in mm; mean, lowest, highest, 2SD


    Sagittal diameter; 4.3 2.6 6.7 1.6
    Axial diameter; 14.3 8.2 20.6 4.1


    (Schmidt, Schmidt et al. 2004)


    left foot prox.jpg


    right foot prox.jpg


    Could we reasonably infer higher right side compressive stress beneath AT at exostoses surface becasue of evidence of tendonosis? I guess it is consistent but overly presumptive.


    Kachlick et al state “We are convinced that the new obtained structural data can be very well used also in the clinical practice, above all in the differential diagnosis of achillar enthesopathies and retrocalcaneal bursitis using the ultrasonography and MRI. The ultrasound image of RB is not as detailed as the MRI one, which was confirmed by many studies. On the contrary, it is evident that every case of the rectrocalcaneal bursitis is easily detectable by ultrasound as a hyperechogenic shade in the shape of a Phrygi helmet, prominent anteroproximally, i.e. in front of the insertional part of AT and above the calcaneal tuberosity [11]. This opinion corresponds to our findings because in case of increasing pathological fluid content of the RB only its soft walls (ceiling and both sides) can yield to the fluid pressure. The protrusion of the ceiling is visible on ultrasound image and the lateral expansions are verifiable both visually and by palpation.”


    Their citation 11 is


    Title: Value of ultrasonography as a diagnostic tool of the Achilles tendon | Wert der sonographie in der diagnostik von bursopathien im bereich der Achillessehne Ultraschall in der Medizin [0172-4614] Mahlfeld



    A slight problem for me is that this study used inferior technology for this type of exam by current standards, they say “We used a 5 and/or a 7.5 MHz linear transducer” which probably accounts for their failure to visualise the RB in normal subjects.

    This also runs contrary to (Bottger, Schweitzer et al. 1998). Like Bottger et al with ankle plantarflexion I have no problem visualising the RB with 12 Mhz probe. If anyone can get their hands on this paper (not available through my library) I would love to read it. Importantly Bottger et al also point out “that after chronic injury in these patients, fibrosis and scarring can occur, potentially obliterating the bursa and resulting in underestimation of its dimensions. These factors likely accentuated the overlap in bursal dimensions of healthy volunteers and patients”.

    This may be a confounding issue in my patient.



    continued in next post I have run out of upload space


    cheers


    Martin



    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  6. drsarbes

    drsarbes Well-Known Member

    Hey Mart:
    on and on.........and on........
    The bursa is relatively easy to find (even without US although not as much fun) and inject, however, as I said, if the posterior superior angle of the os calcis is enlarged then any relief will be short lived.
    I have also found that, upon removal, the bursa extends anteriorly along the superior border of the os calcis quite far, sometimes almost to the posterior process of the talus! THis is no where near the insertional exostosis along the posterior surface.

    I rarely see bursae superficially, more of a chronic mesotendiosis.

    gotta run.

    Wish I could write more....and more!!!!!!!

    Steve
     
  7. Mart

    Mart Well-Known Member

    Here’s another seminal study which is also attached, (Theobald, Bydder et al. 2006).

    Macroscopically it shows similarity to Kachlik et al and what Kachlik calls a synovial fold Theobald calls bursal wedge of fat. Not only has that but stated “The fat extended completely into the bursa, until it reached the enthesis itself. It retracted on returning the foot to the anatomical (neutral) position.. The maximum range of excursion between full active plantarflexion and full dorsiflexion was approximately 4 mm in the non-load-bearing foot and 10–12 mm during load-bearing. By studying US movie files of active plantarflexion under load, it was clear that movements of the calcaneal bursal wedge also resulted from concentric contractions of FHL. As the muscle thickened, it moved (‘pumped’) the FHL-associated fat – which in turn moved the bursal wedge as the final link in a kinetic chain. However, the rapidity of the final phase of bursal-wedge movement suggested that the fat was also sucked into the bursa as the insertional angle between the Achilles tendon and the calcaneus increased on plantarflexion.”


    Ultrasound images of the Achilles tendon enthesis from a subject standing (a) on his toes in a load-bearing, plantarflexed foot and (b) in the anatomical (neutral) position. Note that in a plantarflexed foot, the bursal wedge of Kager’s fat pad (W) extends completely into the bursa as far as the enthesis itself (arrows). Consequently, the superior tuberosity of the calcaneus (S) is in direct contact with the fat and this in turn directly touches the Achilles tendon (T). When the foot is returned to the neutral position, the fat pad is retracted and the tendon and bone now touch each other directly.

    Theobald 2.jpg


    This has important implications in interpreting my images, is it motion of hypertrophic projection of synovial tissue under AT, “bursal wedge” or motion of degenerated anterior AT at exostosis? I favour the later, ie my case this is NOT a retocalcaneal bursits. In which case is entire hypoechoic region degenerated AT? I think now this most likely.

    Theobald 1.jpg

    Macroscopic anatomy of Kager’s fat pad. (a) An MRI of a plantarflexed foot (same subject as in Fig. 1) imaged in the sagittal plane. It shows how the bursal-protruding wedge of fat (W) has moved into the retrocalcaneal bursa, by passing over the superior tuberosity (S) of the calcaneus (C). Note how the tendon and muscle regions of the fat have been moulded into a new shape by foot movements. The FHL-associated fat (F) now makes a sharp inverted L-shaped bend (arrow) before fusing with the Achillesassociated fat (A). The Achilles fat is much wider distally than in a dorsiflexed foot. When the FHL and Achilles fat fuse together, they form the bursal wedge. T, Achilles tendon. (b) A hemisected Achilles tendon from a dissecting room cadaver, showing the bursal wedge of Kager’s fat pad protruding into the retrocalcaneal bursa (B) near the tendon enthesis (E). The fat is anchored anteriorly and posteriorly by fibrous bands (arrows).


    Here’s an interesting series from a study of guided injection for RB associated with psoriatic arthropathy (Brophy, Cunnane et al. 1995). Interestingly the cortical erosion was not seen on radiographic exam. Again there is poor image quality by current standards, no power doppler and no indication from dynamic exam which makes comparison a bit difficult other than AT appearance notably different from my patient.

    psoriatic arth series.jpg

    seminal papers

    View attachment Kachlik.pdf

    View attachment Theobald.pdf

    continued next post

     
  8. Mart

    Mart Well-Known Member


    Hi Steve

    Stick with the extent of my postings if you have time. Can you answer the million dollar question? Once you reach surgery you have gold standard with macroscopic view. How would you interpret this case and what would you do in my postion? I think that it may be possible to mittigate poor outcomes for corticosteroid injections with good US interpretation - perhaps not.

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  9. Mart

    Mart Well-Known Member

    There was an interesting MR study done to look at the normal and pathologic behaviour of the RB (Canoso, Liu et al. 1988). “To clarify the function of the RB the hindfoot was studied by magnetic resonance imaging at various positions of the ankle joint. In normal individuals a tongue-like extension of the retromalleolar fat pad entered the bursa during plantar flexion as the angle between Achilles tendon and calcaneus widened. The reverse occurred in dorsiflexion. In contrast, in a patient with spondyloarthritis and retrocalcaneal bursitis excessive cavitary fluid PREVENTED the intrusion of the fat pad. The sliding motion of the fat pad in and out of the bursa during ankle motion allows a more caudal, advantageous insertion of the Achilles tendon into the calcaneus. “


    This is not consistent with what I think I see in my patient, the lesion (tendon, fat or hypertophic bursa) DOES move under the tendo-achilles with plantarflexion and this seems clear on the video I posted. This leads me to question how to interpret the sonographic evidence. My best guess currently is that perhaps the “lesion” is not a bursa but neovascular degenerated zone of the tendo-achilles. There is hint of the bursa proximally (right side of lesion) represented as thin hypoechoic region looking like a normal bursa. Any thoughts on this?

    So far the investigations look at saggital impressions. Here’s an entirely different perspective.

    “Posterior heel pain frequently is caused by Haglund’s disease. This entity was first described by Patrick Haglund in 1928. It is characterized clinically by localized pain and swelling at the medial and lateral distal Achilles tendon border resulting from retrocalcaneal bursitis. A prominent posterosuperior calcaneal tuberosity is believed to be the initiating mechanical cause leading to a retrocalcaneal bursa impingement against the corresponding anterior Achilles tendon border. A rigid posterior shoe counter is believed another inducing factor. Because of different therapies, some authors recommend differentiating Haglund’s disease from Achilles tendinopathy and from Achilles insertional tendinopathy. Nonoperative treatment often fails to relieve symptoms. Approximately 50% of the patients undergo surgery, however, open surgery has been reported to have disappointing results (fair and poor) in 20% to 50% of patients.

    Operative treatment comprises resection of Haglund’s tuberosity and the associated retrocalcaneal bursa. Likely owing to compression induced by the chronically inflamed and enlarged retrocalcaneal bursa, degeneration and partial tears of the corresponding anterior Achilles tendon fibers have been observed and are called ‘‘Achilles tendon impingement lesions’’. Additional Achilles tendon surgery therefore may be necessary and can be performed only by open surgery .

    Clinical analysis of failures has been focused on the amount of bone resected and orientation of the ostectomy line. However, these variables apparently do not predict outcome, although the size of the remaining posterior bone ridge appears to correlate with poor results”.

    Anatomy texts uniformly represent the posterior end of the calcaneal tuberosity as being convex. However, when the Achilles tendon also is illustrated, confusion is caused by presenting different insertional tendon shapes.

    Some anatomic and operative textbooks and articles have depicted the Achilles tendon insertion only from a lateral or medial view leading to the impression that the tendon’s shape does not change from its oval midportion cross section to the insertional area. Images of the Achilles tendon insertion in a transverse plane occasionally are presented, showing a slightly bent or an unbowed Achilles tendon insertion. Relevant Achilles or plantaris tendon fiber extensions to the medial or lateral calcaneal wall are rarely or are not illustrated

    Operative and some anatomic textbooks show the Achilles tendon and its calcaneal insertion. with respect to the sagittal plane . In this plane, transformation of the Achilles tendon cross section from an oval in its midsubstance to an arcuated or crescent-shaped configuration at its calcaneal insertion is not visible.

    The shape of the Achilles tendon in a transverse plane rarely is shown. Even in a MRI textbook, the image of an unbowed Achilles tendon insertion on an axial section is shown. We found only one report stating the Achilles tendon terminates ‘‘at the medial and lateral bone border of the calcaneus’’. In contrast to our conclusion however, the authors judged these extensions as not being ‘‘significant,’’ and no specific measurements were presented to justify their opinion.

    We believe our observations are clinically important. The Achilles tendon extension around the medial calcaneal surface is more pronounced compared with the lateral side, with maximum values of 9.1 mm and 5.5 mm, respectively. (Lohrer, Arentz et al. 2008).

    Steve how do you feel about the literature reports about surgical outcomes and what this paper concludes? I know you are a busy guy so take your time!

    The only study I could find looking at the direct effect of injectible corticosteroid on TA used an animal model with Steroid doses formulated to be the mass and volume equivalent of a 3mL (30-mg) injection of the same steroid formulation in a 70-kg human subject. (Hugate, Pennypacker et al. 2004). The results echo concerns you made regarding risk but I wonder about dose, any comments on this issue from anyone. One of the benefits of doing US guided injection might be to limit dose according to proximity to healthy segement of tendon. I have been using this approach injecting plantar fascia (to limit volume if spreading along plantar fascia beyond degenerated portion).

    In another small experimental study using polidocanol there were promising and immediate results. The before treatment picture was similar to my patient;

    AA before.png

    Steve given your surgical experience how would you interpret the neovascularised zone above - bursa or tendon?

    Neovascularisation in chronic painful Achilles tendon insertional pain. Longitudinal ultrasound scan. Thickened and irregular distal tendon. Colour Doppler is presented in gray scale and the neovessels are the coloured structures

    AA after.jpg

    The same tendon as above immediately after injection of polidocanol. There is no remaining circulation in the vessels inside the Achilles tendon



    “ultrasonography showed a widening of the distal Achilles tendon in all patients. In the widened area there were structural tendon changes demonstrated as irregular fibre structure and hypo-echoic areas. In all patients, colour Doppler showed small, irregular vessels, inside and outside the ventral part of the structurally changed distal tendon. The vessels were entering the tendon from the fat pad anterior to the Achilles tendon. In seven cases, there were vessels in close relation to the wall of the RB.’ (Öhberg and Alfredson 2003). There doesn’t seem to have been any follow study and I am curious why this might be. My understanding is that polidocanol is banned by the FDA and I am not sure what the status for use is here in Canada. Any comments on this anyone?

    The single study of benefits of hyperosmotic dextrose although promising for mid AT tendonosis showed poor results for insertional cases. “ There were three unsuccessful outcomes in our study. All three patients had insertional tendinosis with evidence of cortical irregularity at the insertion of the tendon and intratendinous calcification. It is our experience that some patients with insertional tendinosis are more difficult to treat and have less favorable outcomes than patients with midportion tendinosis”. In one patient with insertional tendinosis, a large partial-thickness tear became apparent only after the initial injection of dextrose solution. This pre injection sonographically occult tear was so large that the patient was withdrawn from the study and referred for surgical consultation due to fear of tendon rupture. This observation emphasizes the fact that intrasubstance and partial-thickness tears in chronic tendinosis may be sonographically occult (Maxwell, Ryan et al. 2007).

    dextrose bursa.jpg

    Given my interpretation to date I feel that next step if the foot orthoses prove inadequate is to do a diagnostic US guided lidocaine injection into site to evaluate pain relief and check for occult tear. Subsequently if no tear perhaps polidocanol is best option given current level of evidence and potential risk with corticosteroid. Anyone have thoughts on that?

    Cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com




    Bibliography

    Öhberg, L. and H. Alfredson (2003). "Sclerosing therapy in chronic Achilles tendon insertional pain-results of a pilot study." Knee Surgery, Sports Traumatology, Arthroscopy 11(5): 339-343.
    The origin of Achilles tendon insertional pain has not been clarified. Treatment is considered difficult, though tendon, bone, and bursae, alone or in combination, may all be the source of pain. Recently, neovascularisation in the area with tendon changes was shown to correlate with pain in patients with chronic mid-portion Achilles tendinosis. In a pilot study, sclerosing the neovessels outside the tendon cured the pain in the majority of patients. In this pilot-study, ultrasonography and colour Doppler was used for the investigation of eleven patients (nine men and two women, mean age 44 years) with a long duration (mean 29 months) of chronic Achilles tendon insertional pain. All patients had distal tendon changes and a local neovascularisation inside and outside the distal tendon on the injured/painful side, but not on the noninjured/pain-free side. In nine patients there was also a thickened retrocalcaneal bursae, and in four patients also bone pathology (calcification, spur, loose fragment) in the insertion. The sclerosing agent polidocanol was injected against the local neovessels found in all patients. At follow-up (mean eight months), sclerosing of the area with neovessels had cured the pain in eight out of eleven patients, and in seven of the eight patients there was no neovascularisation. Pain during tendon-loading activity, recorded on a VAS-scale, decreased from 82 mm before treatment to 14 mm after treatment in the successfully treated patients. In conclusion, treatment only focusing on sclerosing the area with neovessels showed promising short-term clinical results in this small pilot study. The findings support further studies, preferably in a randomised manner.

    Bottger, B. A., M. E. Schweitzer, et al. (1998). "MR imaging of the normal and abnormal retrocalcaneal bursae." American Journal of Roentgenology 170(5): 1239-1241.
    OBJECTIVE. The aim of this study was to define the MR imaging criteria for normal and abnormal retrocalcaneal bursae. SUBJECTS AND METHODS. Fifty ankles in 25 asymptomatic volunteers and 30 ankles in patients with Achilles tendon disorders underwent MR imaging. Increased signal intensity consistent with fluid or synovium outlining the retrocalcaneal bursa was measured. RESULTS. Of 80 bursae, 77 (96%) had measurable fluid or synovial signal intensity revealed by MR imaging. Asymptomatic volunteers had average bursal dimensions of 1 mm in the anteroposterior dimension, 6 mm in the transverse dimension, and 3 mm in the craniocaudal dimension. Bursal dimensions greater than 1 mm, 11 mm, or 7 mm, respectively, were not seen in asymptomatic subjects but were seen in 16 (53%) of 30 ankles of patients with Achilles tendon disorders. CONCLUSION. On MR imaging, the asymptomatic retrocalcaneal bursa normally contains detectable high-signal-intensity fluid or synovium or both. A bursa larger than 1 mm anteroposteriorly, 11 mm transversely, or 7 mm craniocaudally is abnormal.

    Brophy, D. P., G. Cunnane, et al. (1995). "Technical report : Ultrasound guidance for injection of soft tissue lesions around the heel in chronic inflammatory arthritis." Clinical Radiology 50(2): 120-122.
    We describe the use of ultrasound guidance for local steroid injection of the retrocalcaneal bursa and the tibialis posterior tendon sheath in patients with chronic inflammatory arthropathy. Ultrasound guidance may be the injection technique of choice but is particularly indicated for patients with lesions unresponsive to injections guided by palpation.

    Canoso, J. J., N. Liu, et al. (1988). "Physiology of the retrocalcaneal bursa." Annals of the Rheumatic Diseases 47(11): 910-912.
    To clarify the function of the retrocalcaneal bursa the hindfoot was studied by magnetic resonance imaging at various positions of the ankle joint. In normal individuals a tongue-like extension of the retromalleolar fat pad entered the bursa during plantar flexion as the angle between Achilles tendon and calcaneus widened. The reverse occurred in dorsiflexion. In contrast, in a patient with spondyloarthritis and retrocalcaneal bursitis excessive cavitary fluid prevented the intrusion of the fat pad. The sliding motion of the fat pad in and out of the bursa during ankle motion allows a more caudal, advantageous insertion of the Achilles tendon into the calcaneus.

    Hugate, R., J. Pennypacker, et al. (2004). "The Effects of Intratendinous and Retrocalcaneal Intrabursal Injections of Corticosteroid on the Biomechanical Properties of Rabbit Achilles Tendons." Journal of Bone and Joint Surgery - Series A 86(4): 794-801.
    Background: The use of corticosteroid injections in the treatment of retrocalcaneal bursitis is controversial. We assessed the effects of corticosteroid injections, both within the tendon substance and into the retrocalcaneal bursa, on the biomechanical properties of rabbit Achilles tendons. The systemic effects of bilateral corticosteroid injections were also studied. Methods: The rabbits were divided into three treatment groups. The rabbits in Group I received injections of corticosteroid into the Achilles tendon on the left side and injections of normal saline solution into the Achilles tendon on the right, those in Group II received injections of corticosteroid into the retrocalcaneal bursa on the left side and injections of saline solution into the Achilles tendon on the right, and those in Group III received injections of corticosteroid into the Achilles tendon on the left side and injections of corticosteroid into the retrocalcaneal bursa on the right. These injections were given weekly for three weeks. At four weeks after the final injection, the tendons were harvested and were tested biomechanically to determine failure load, midsubstance strain and total strain, modulus of elasticity, failure stress, and total energy absorbed. The site of failure was also documented. The groups were compared according to the location of the injections, the type of injection (steroid or saline solution), and the total systemic load of steroid. Results: Specimens from limbs that had received intratendinous injections of corticosteroid showed significantly decreased failure stress compared with those from limbs that had received intratendinous injections of saline solution (p = 0.008). Specimens from limbs that had received intrabursal injections of corticosteroid demonstrated significantly decreased failure stress (p = 0.05), significantly decreased total energy absorbed (p = 0.017), and significantly increased total strain (p = 0.049) compared with specimens from limbs that had received intratendinous injections of saline solution. Specimens from limbs that had received intratendinous injections of corticosteroid were biomechanically equivalent to specimens from limbs that had received intrabursal injections of corticosteroid. Specimens from rabbits that had received bilateral injections of corticosteroid demonstrated significantly decreased failure load (p = 0.011), modulus of elasticity (p = 0.015), failure stress (p = 0.03), and total energy absorbed (p = 0.015) compared with those from rabbits that had received unilateral injections of steroid. Conclusions: Local injections of corticosteroid, both within the tendon substance and into the retrocalcaneal bursa, adversely affected the biomechanical properties of rabbit Achilles tendons. Additionally, tendons from rabbits that had received bilateral injections of corticosteroid demonstrated an additive adverse effect, with significantly worse biomechanical properties compared with tendons from rabbits that had received unilateral injections of corticosteroid. Clinical Relevance: Clinicians should use caution when injecting corticosteroids into the Achilles tendon or into the retrocalcaneal bursa as corticosteroid injections in both of these locations weaken the tendon. Bilateral injections of corticosteroids should especially be avoided as they may impart a systemic effect in conjunction with the local effect, further weakening the tendon.

    Kachlik, D., V. Baca, et al. (2008). "Clinical anatomy of the retrocalcaneal bursa." Surgical and Radiologic Anatomy 30(4): 347-353.
    The goal of the study was to perform a detailed anatomical description of the retrocalcaneal bursa (RB). Its morphological arrangement was studied on 10 fresh and 30 embalmed lower extremities by microdissection and light microscopy. The RB was present constantly and in all the cases contained 1-2 cm long synovial fold, beginning on the upper wall of RB and distally interposed between the anterior surface of the Achilles tendon and the posterior surface of the calcaneal tuberosity. The volume of RB was 1-1.5 ml. The histological analysis confirmed that the inner surface of the superior and posterior wall of RB have been covered by unilayered synovial membrane, projecting into synovial villi of different shapes and sizes. In the ceiling of RB, delicate fascicle of skeletal muscle fibers was discovered, radiating distally into the regularly present synovial fold. The whole bottom of RB has been covered by 200-500 μm layer of fibrous cartilage into which the calcaneal tendon attached. The cartilagineous layer continued anteroproximally to cover the whole bursal surface of the calcaneal tuberosity, where the thickness of the cortical bone was reduced on mere 50 μm. The obtained results can be used in the improvement of the differential diagnostics and therapy of diagnostics and therapy of the retrocalcaneal bursitis as well as of other kinds of achillar enthesopathies and heel pain. © Springer-Verlag 2008.

    Lohrer, H., S. Arentz, et al. (2008). "The Achilles tendon insertion is crescent-shaped: An in vitro anatomic investigation." Clinical Orthopaedics and Related Research 466(9): 2230-2237.
    Anatomic and operative textbooks and current literature do not clearly describe the Achilles tendon interface to the calcaneal tuberosity. We dissected 51 specimens to identify the detailed anatomy of the Achilles tendon insertion. Achilles tendon fascicles expanded from the anterior aspect of the distal Achilles tendon over the retrocalcaneal bursa to the anterior part of the Haglund's tuberosity in nearly half of the specimens. The insertion of the transverse section of the Achilles tendon regularly had a crescent-shape corresponding to the posterior calcaneal prominence. In transverse sections, all specimens had a curved appearance with a radius of curvature ranging from 13.8 mm to 43.6 mm (mean, 20.4 mm) and Achilles tendon extensions to the lateral and medial calcaneal surfaces reached 1.0 mm (mean) and 3.5 mm (mean) anterior in relation to the most posterior point of the calcaneal tuberosity. Knowledge of the arcuate configuration and of the medial and lateral extensions of the plantaris and the Achilles tendon insertion with respect to the transverse plane is important to avoid iatrogenic complications during resection of Haglund's tuberosity. © 2008 The Association of Bone and Joint Surgeons.

    Martino, F. (2007). Musculoskeletal sonography : technique, anatomy, semeiotics and pathological findings in rheumatic diseases. Milan; New York, Springer.

    Maxwell, N. J., M. B. Ryan, et al. (2007). "Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study." AJR Am J Roentgenol 189(4): W215-20.
    OBJECTIVE: Chronic tendinosis of the Achilles tendon is a common overuse injury that is difficult to manage. We report on a new injection treatment for this condition. SUBJECTS AND METHODS: Thirty-six consecutive patients (25 men, 11 women; mean age, 52.6 years) with symptoms for more than 3 months (mean, 28.6 months) underwent sonography-guided intratendinous injection of 25% hyperosmolar dextrose every 6 weeks until symptoms resolved or no improvement was shown. At baseline and before each injection, clinical assessment was performed using a visual analogue scale (VAS) for pain at rest (VAS1), pain during normal daily activity (VAS2), and pain during or after sporting or other physical activity (VAS3). Sonographic parameters including tendon thickness, echogenicity, and neovascularity were also recorded. Posttreatment clinical follow-up was performed via telephone interview. RESULTS: Thirty-three tendons in 32 patients were successfully treated. The mean number of treatment sessions was 4.0 (range, 2-11). There was a mean percentage reduction for VAS1 of 88.2% (p < 0.0001), for VAS2 of 84.0% (p < 0.0001), and for VAS3 of 78.1% (p < 0.0001). The mean tendon thickness decreased from 11.7 to 11.1 mm (p < 0.007). The number of tendons with anechoic clefts or foci was reduced by 78%. Echogenicity improved in six tendons (18%) but was unchanged in 27 tendons (82%). Neovascularity was unchanged in 11 tendons (33%) but decreased in 18 tendons (55%); no neovascularity was present before or after treatment in the four remaining tendons. Follow-up telephone interviews of the 30 available patients a mean of 12 months after treatment revealed that 20 patients were still asymptomatic, nine patients had only mild symptoms, and one patient had moderate symptoms. CONCLUSION: Intratendinous injections of hyperosmolar dextrose yielded a good clinical response--that is, a significant reduction in pain at rest and during tendon-loading activities--in patients with chronic tendinosis of the Achilles tendon.

    Schmidt, W. A., H. Schmidt, et al. (2004). "Standard reference values for musculoskeletal ultrasonography." Annals of the Rheumatic Diseases 63(8): 988-994.

    Theobald, P., G. Bydder, et al. (2006). "The functional anatomy of Kager's fat pad in relation to retrocalcaneal problems and other hindfoot disorders." Journal of Anatomy 208(1): 91-97.
    Kager's fat pad is a mass of adipose tissue occupying Kager's triangle. By means of a combined magnetic resonance imaging, ultrasound, gross anatomical and histological study, we show that it has three regions that are closely related to the sides of the triangle. Thus, it has parts related to the Achilles and flexor hallucis longus (FHL) tendons and a wedge of fat adjacent to the calcaneus. The calcaneal wedge moves into the bursa during plantarflexion, as a consequence of both an upward displacement of the calcaneus relative to the wedge and a downward displacement of the wedge relative to the calcaneus. During dorsiflexion, the bursal wedge is retracted. The movements are promoted by the tapering shape of the bursal wedge and by its deep synovial infolds. Fibrous connections linking the fat to the Achilles tendon anchor and stabilize it proximally and thus contribute to the motility of its tip. We conclude that the three regions of Kager's fat pad have specialized functions: An FHL part which contributes to moving the bursal wedge during plantarflexion, an Achilles part which protects blood vessels entering this tendon, and a bursal wedge which we suggest minimizes pressure changes in the bursa. All three regions contribute to reducing the risk of tendon kinking and each may be implicated in heel pain syndromes. © 2006 The Authors Journal compilation © 2006 Anatomical Society of Great Britain and Ireland.
     
  10. Mart

    Mart Well-Known Member

    Hi Steve

    Just wanted to try and suck as many ideas out of you as possible before you get too bored with this (perhaps too late!).

    1 When you do these surgeries do you simply stick a retractor infront of the AT and shave offf whatever exostosis seems to stick out the most, try and correlate with tendonopathy or what do you think about?

    2 Do you have any idea why your surgical failures fail?

    3 Would pre- surgical impression from US regarding location of tendon damage and contour of exostosis in sag and axial plane likely influence your approach?

    4 Do you think it possible that surgical failures might be related to inadequate restoration of the interposing fat tissue motion?

    5 If so, do you have any interest in working up a post surgery US study with me to see if this is true?


    cheers


    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  11. drsarbes

    drsarbes Well-Known Member

    Hi Martin:

    It looks to me fairly straight forward regarding your patient's underlying pathology. Of course you need to relate your US findings with your clinical examination. I would venture to guess that if you palpate the area just anterior to the AT at the level of the posterior superior angle (where the bursa is) that your patient will jump two feet off the exam table. This is where you need to inject. I don't see an exostosis on your US.

    As far as intraoperative findings and procedure:

    WHen I perform a resection of retrocalcaneal exostosis with tendon repair (not a simple haglunds which I place in the exostosis lateral to the AT category - mostly young female patients in my experience) my usual technique is:

    After skin incision and exposure I check with fluoroscopy to verify the position of the exostosis (usually distal - posterior and running from medial to lateral along the posterior aspect of the os calcis) - I then make a medial to lateral incision across the AT (I DO NOT bisect this from prox to distal as is popular) and reflect this proximally. I then can resect the spur with various Hoke osteotomes and rasps. I then Check with Fluoro to make sure it looks anatomic. At times there may be separate intratendinous Ca deposits that need resecting)

    At this point I underscore a bit more to expose the entire posterior superior aspect of the os calcis and - again with fluoro guidance I remove the bursae and resect the post-sup aspect of the os calcis with an osteotome.

    I then examine the tendon. If I see areas of degeneration, fibrosis or obvious inflammatory tissue I resect it. I then reattach the tendon with two bone anchors and, if needed, a Graft Jacket graft is used.

    I have to say that since I've started resecting the posterior superior portion of the Os Calcis that my success has increase dramatically - in fact, I rarely have a patient that is unhappy with their results. Of course these patients are usually very unhappy people pre operatively with a long history of pain, failed conservative treatment and forced change in their life style. The results are so predictable that I look forward to performing these knowing that the patient will likely be very satisfied with their outcome.

    As far as tendon damage - with these it's fairly uncommon. When I get patients with tendon pain (more proximal with fusiform swelling and pain on palpation) these I find - obviously - tendon pathology and I always graft these. It seems most of these are either or - if they have retrocalcaneal spurs and bursitis they rarely have tendon pain proximal to the post surface of the os calcis, and visa versa.

    As far as a post op US study - I'll have to wait until I FINALLY purchase one!!!!! (I'm still negotiating!!)

    If I get a chance I'll scan in some pre and post op fluoroscans.

    Hope all that helps.

    Steve
     
  12. Mart

    Mart Well-Known Member

    Thanks Steve I appreciate your opinion. Glad to hear that your surgery seems to have better outcome that most literature reports.

    This lady has mild pain to palpation currently at lesion site on US; my suspicion is that is because of restriction in weight-bearing activity resulting in sub acute condition which is somewhat ambiguous to physical exam.

    By straightforward do you mean presence or absence of bursitis from US images?

    Perhaps my major query was lost in too much detail. I was trying to flesh out possible pitfalls in interpretation of US image. If you look at hypoechoic zone on patient’s image it could be

    Tendon
    Fat
    Bursa

    Or combination of any of above (I think it is one of these because it behaves a an entity with motion)

    The single frame images with power doppler imaging correlate with appearance of bursitis from several definitive texts.

    The video image shows motion of “defect with ankle plantarflexion into space where bursa should be.

    If you right click on video you can download it and watch carefully behaviour of lesion.

    If the defect is within the tendon then there is no fat motion and that is what I think is shown.

    However

    The defect could be within the fat

    Therefore normal fat motion with inflammation within this tissue (normal tendon)

    Or

    Could be roof of bursa which is pushed under AT with ankle plantarflexion.

    See what I mean?

    So what??

    From an injection therapy perspective I think this is important for choice of agent and post injection care.

    Does anyone feel that patient should be immobilised after corticosteroid into this region to reduce risk for rupture? I have never seen that mentioned but seems a reasonable thought?


    Cheers


    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
     
  13. drsarbes

    drsarbes Well-Known Member

    Hi Mart:
    Nice video, does it come in Blue Ray?
    I assume that was passive motion.
    The hypoechoic area seems to be just proximal to the post-superior angle - where you might expect compression of a bursae during motion. I love the way you microhandle these! I'll spend more time on the video when I can, but, I didn't see anything earth shattering on first viewings. A bit short maybe -!!!!!

    Re_injections - I use 1cc dexamethasone with some marcaine (.5%) - I used to strap the patients and have them walk flat footed for a day, but have since (20 years ago) have them carry out normal non athletic activity with no lifting for 24 hours. I have never (knock on wood) had a rupture.
     
  14. Mart

    Mart Well-Known Member


    Thanks Steve.
    Yes passive motion.
    To give you bit of context here. I practice in a jurisdiction which has been a podiatric interventional backwater. We are currently in process of College surgical regulation committee to approve framework for non-hospital surgical facility procedures for podiatrists. Consequently a couple of us are doing MSc Surgery programs in UK in anticipation of increased scope and a couple of pods with surgical residency accreditation will return to the roost once they can practice surgically. Otherwise we are limited to office based nail and skin lesion removal and injection therapy. Even access to injectible corticosteroids is new for 2009. I am really enjoying doing the MSc process. It demands critical thinking and literature review as its basis. As much as I am able, I try and apply this process to each novel clinical scenario I find myself in, coupled with the US learning curve there is an interesting cross over there. The likes of yourself and Kevin Kirby and many others on podarena are a bit of a lifeline to bounce ideas onto. I feel able to contribute somewhat by taking a thread like this and revisiting things to the nth degree as the literature allows. This helps me learn and hopefully may interest a few others too. So I am gradually picking off different topics, this week was retrocalc issues.
    When you get your US machine it will be very useful if you are able to feed us sonographic and corresponding intraoperative photographic images as time allows. I feel that US cross correlation with macroscopic appearance is the biggest deficit in the literature for US. I suspect that it is because US seems to have low expectations from podiatric surgeons and this is likely because it is hard to appreciate properly unless you do it yourself. In my opinion the status of US needs to be elevated, the podiatry surgeons who I have talked to on the whole seem unimpressed by US, prefering MRI, but they seem to have no idea what they are missing. I think that podiatric surgeons are best positioned to really push forward interpretation with US because they get gold standard check of pathology with those who they treat surgically. I am keen to get into the cadaver lab with my new machine and see if I am right on this.
    I’ll get a longer clip of the video and replace the existing one tomorrow or see if there is a way to make it loop.

    Cheers

    Martin
    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
  15. drsarbes

    drsarbes Well-Known Member

    Hi Martin:

    Good luck to you, hopefully all will continue to evolve. I appreciate your passion.

    Re: correlating US and Surgical findings - that would be a nice text book. I recall when MRI's first came out (back in the day) trying to read those and appreciating texts (like Kang/Resnick's MRI of the extremities) that had Cadaver photos and the corresponding MRI scan. VERY helpful just in appreciating the basic anatomy on MRI.

    I think as the DxUS machines themselves improves there will be less need for clinical experience in reading them and a much faster learning curve for use.

    In the U.S.A. MRI centers are all over the place and ordering is so simple and quick (and paid for) that it's just less time for someone like me to order the MRI, get the CD back and take a look rather than stoking up the US and taking 10 minutes or more to do a proper MSK examination (and perhaps not get paid very much for our time)

    I think a lot comes down to $ and cents.....the reimbursement for US guided injection is about twice what a NON US guided payment is - thus the increase in US machines in private practice.
    When Insurance companies (or our approaching Government run health care system) stops paying for MRIs then you'll see a quick increase in US sales.

    Steve
     
  16. Mart

    Mart Well-Known Member

    Thanks Steve

    Interesting perspective for USA regarding US fee re-embursement.

    Currently that is a bit of an unknown here. My understanding is that in Australia fees for US are only provided to sonographers. That is a real pity because this technology is much better used in the hands of the person needing the info. No disrespect intended to sonographers but it is pretty much impossible to demonstrate a negative finding without providing a compete video in most cases. For the time required to do this it would be more efficient for clinician to do it on the spot, plus added value of guided prodeedures. The key is education and currently adequate opportunity for that seems lacking for MSKUS.

    I have tinkered with the video which is more usable now

    it is saggital view, plantar at top

    red arrow = AT proximally
    yellow arrow = lesion
    green Arrow = superior cortical surface of calcaneus

    http://www.winnipegfootclinic.com/resourses.html

    double click podarena icon

    starts in neutral ankle then 2 cycles of passive ankle plantarflexion.


    question is; considering earlier power doppler images, history and prev descriptive text.

    Is it possible from US to be sure what lesion is?

    If ordering MRI for cross correlation what position for ankle?

    What should next step in treatment plan be if recalcitrant?

    cheers


    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  17. drsarbes

    drsarbes Well-Known Member

    Hi MArt:
    Only have a minute - just saw I have a retrocalcaneal/achilles on the schedule for tomorrow. I'll try to get some nice pictures for you.
    Too bad you can't come over and get a pre-op US!
    Steve
     
  18. Mart

    Mart Well-Known Member

    Great, that would be interesting. The only intra op photos I have seen for this condition are endoscopic and limited picture of anatomy. I'll be In Minneapolis tomorrow with my US . . . a helicopter ride to Wisconsin to do this would be a bit excessive I guess.
    If you get time I wonder if it would be possible to describe the following when you do this surgery.

    Is there palpable swelling around AT margins prior to surgery (medial, lateral and if determinable at roof of bursa)?

    Once the AT is exposed but before you resect and reflect it off the calc;

    Is it possible to view the behaviour of the kager fat with passive ankle plantarflexion, does it have sufficient force to compress the synovial fold under the AT or if a bursa present does it’s pressure prevent this (an important cue on US exam) ?

    Does the bursa visibly extend dorsally along dorsal margins of calc?

    Is there any evidence of increased vascularity in the fat (as opposed to an inflamed bursa roof) deep and just proximal to the AT enthesis, particularly if there is evidence of paratenosynovitis or frank degenerative tendonsis at this site?

    Answers to these questions might hint at interpreting the US images.

    I think it possible that the flow interpreted in text books as evidence of bursitis (and seen in the case study patient) may actually be angiogenesis in the fat pad supplying through to the angiogenesis within the tendon.

    This would explain the disparity in size and position of the zones demarcated on power doppler imaging and greyscale which is I think quite important to be correct about if thinking of injecting steroids.



    Cheers


    Martin


    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
  19. drsarbes

    drsarbes Well-Known Member

    Hi Mart:
    Surgery went very well, picture taking not as good. I was able to get a few shots and a video for you. We tried something new, placing the camera in a sterile bag but this interfered with the focus a bit.

    In any event, I was unable to answer all your questions, especially the dynamics involved simply because my surgical exposure does not allow visualization as well as a cadaver study would.

    The bursae was fairly typical in size. I did not notice any exceptional vascularity nor extent. It, as usual, lies on the superior surface of the Os Calcis from the post superior process anteriorly.

    If you let me know how to upload a video on a post I'll be happy to share it with you. Can't seem to find any instructions here.

    Steve
     
  20. Mart

    Mart Well-Known Member

    Thanks Steve - look forward to seeing whatever you got. I don't think you can upload video onto podarena which is why I linked the US videos through my website. You could do a youtube upload

    http://www.youtube.com/

    If you prefer not to do that I could, depending on file size dump it on my server and create a link if you want to share it with entire group.


    I am doing some US cadaver work later this week and may have an opportunity to inject saline into the RCB of an intact specimin creating a distended pressurised mimic for acute bursitis and see if anything useful can be gleaned regarding how it appears on US and interacts with Kager fat with ankle motion.

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  21. drsarbes

    drsarbes Well-Known Member

    Hi Mart:
    It an AVI format video at 6.4 MB.
    I can't seem to upload the way I do simple jpgs.
    Any suggestions how to get it here?
    Id rather not put it on youtube.

    Steve
     
  22. drsarbes

    drsarbes Well-Known Member

    Hi MArt (again)
    The ADministrator is being kind enough to upload the video for you, I hope this is worth it! It's not the best video - Sorry.
    In the meantime here are three pics (out of a million I took)
    Steve
     

    Attached Files:

  23. admin

    admin Administrator Staff Member

    Download teh video from here:
    http://www.podiatry-arena.com/AT123.mov
    (if it does not open, right click and use 'Save as')
     
  24. Mart

    Mart Well-Known Member

    Hi Steve

    Thanks for trying this, without having a camera op and good zoom/macro control I can see why this was tricky to attempt.

    Really dumb question; on the 3rd jpeg image are you reflecting the AT with tissue forceps or a chunk of thickenned subctaneous tissue?

    cheers

    Martin
     
  25. Martin:

    That's the Achilles tendon......largest tendon in the human body.
     
  26. Mart

    Mart Well-Known Member

    aha . . . . . is the tendon appearance normal or thickenned in this case? Is the RCB pulled apart here or is it sitting on the exposed calc? Is the yellow dangly fat the synovial fold or just a plain old bit of Kager? Texturally looks very different from the cadavers I have looked at which really glissended at that AT / calcaneal interface.

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  27. drsarbes

    drsarbes Well-Known Member

    Hi Mart and Kevin:

    Yes you are correct Mart, living subjects have different looking tissues as compared with cadavers (and I have found that cadavers don't heal as well!!) Must have something to do with blood supply and formalin! hahahaha

    The tendon looked fairly normal. Not thickened nor any degenerative tissue I could see. The patient was rather young - 30s, so this was expected. In older individuals with more chronic symptoms and subsequent long term altered gait I do find more intratendinous pathology. I'm sure Kevin would agree.

    The fat extending laterally was loosely attached to the bursae as well as the mesotendon structures, but on medially. Hmmmm.
    THe posterior surface of the AT where it contacts the posterior aspect of the Os Calcis is always smooth, as this one it.

    Mart: I did try!!
    I do quite a few of these, I'll try again next time to get a decent video for you. The initial photo we took (which was blurred) I had the RN take and it took half a minute - I extrapolated and calculated that I'd be in surgery for hours if I had her continue, so I tried the "camera in a bag" and took them myself- --- Oh well.

    There is one more possibility - I have an Os Trigonum resection coming up, perhaps I can put a scope in and take a video and see how the structures in Kager's Triangle move with passive flexion and extension. I can only do this, of course, if I resect the Os Trig via scope.



    Steve
     
  28. I appreciated Martin's earlier posts and ultrasound images of the Achilles/insertional areas. I've found diagnostic ultrasound very helpful in my podiatry practice; started in office U.S. around 2005 and several months ago switched to the Esaote MyLab 5 machine which has a variable probe 10 - 18 MHz. Typically I use 15-18MHz at a depth of 2-3 Cms. to image the Achilles and the detail is DRAMATICALLY better than the older 8-10 mHz machines. Keep those images coming!! Best wishes from the Ozarks in 2010!!
     
  29. Mart

    Mart Well-Known Member

    Steve, Kevin and Mark,

    Thanks for messages.

    Mark; if you get time I would love to see the fibrilar detail you get at 18 Mhz especially in short axis of the AT for comparison with my 12Mhz. I set my machine to 2cm depth for AT exams initially so would compare usefully.

    Steve your camera efforts were appreciated. I am quite curious regarding the objective of your surgery given that appart from loss of appositional texture to the tendon, both that and the bursa seemed fairly normal.

    I had a chance to look at some preserved cadavers today with US and noticed a couple of things one of which suprised me.

    Although the ankles were all too stiff to plantarflex sufficiently to see any fat motion into the RCB, the anatomy imaged quite well and looked pretty similar to living tissue at the AT enthesis.

    I did a guided injection into the RCB and was able to visualise the AT separate from the calcaneus proximaly with the initial pressure increase. Given the stiffness of the ankle this suprised me. Following this there was uniform slightly bulbous expansion of the bursa roof well into the fat with increased volume and pressure. With about 10cc it kept a constant path along the anterior AT and line of least resistance did not appear to head towards the sub-talar joint. There was sufficient back pressure into the syringe to push the plunger out which made me believe that the bursal walls remained intact. The appearance was somewhat similar to the images posted earlier with the RCBitis associated with psoriatic arthropathy and the eroded calcaneus.

    Perhaps this isolated observation is insufficent to generalise about but it does add a bit more evidence to convince me that the case I initialy posted about was not a bursitis but simply insertional tendon degeneration.

    Also, with a well exposed plantaris tendon, realised that it is futile to see any distinction with AT distally using US , the fibres are not delineated despite the tendons being physically separated.

    enough blathering

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  30. Martin- I'm mailing copies of 2 patient exams to illustrate our US to your office today. Regards from Missouri.
     
  31. drsarbes

    drsarbes Well-Known Member

    Hey Mart:
    Objective of surgery was to allow my patient to get a shoe back on and maybe take his kid for a walk.
    He was in severe pain, more than I usually see with these, for quite some time. By the time he was referred to me for surgery he was pretty much a 9/10 living on Vicodin.

    His spur (which did not photograph well) was painful as well as the bursae, post-superior process area, from medial to lateral.

    He'll do fine.

    Steve
     
  32. betafeet

    betafeet Active Member

  33. Mart

    Mart Well-Known Member


    Thanks Mark, I did not find these, help locating please,

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  34. Mart

    Mart Well-Known Member

  35. drsarbes

    drsarbes Well-Known Member

    Hi Mart:

    Did a resection of a Fractured Posterior process LT Talus yesterday - and thought of you (of course!)
    I was somewhat able to observe the fat pad on passive DF and PL, although I had underscored a bit in order to see this (as I would normally do for this procedure.

    Interesting to see how the fat pad, especially the portion at the Post sup angle slips back and forth during motion. I wasn't able to get any pics for you, but now that I know this is visualized during this particular procedure I'll make sure I plan ahead for the next one.

    Steve
     
  36. Mart

    Mart Well-Known Member

    Hi Steve

    Looking forward to seeing what you can show us with intra-operative photos with pre op US imaging.

    As I mentioned already, I think it may be possible to use the motion of the fat pad as diagnostic sign on US to improve specificity of diagnosis for retrocalc bursitis.

    To illustrate this here is a sequence from a neglected (three months) mid TA rupture I saw recently.

    First image (all are saggital) delineates the proximal retracted portion of tendo-achilles with hyperechoic fibrous healing segment of tendo-achilles void.

    pa0.jpg

    Next view showing retro TA hypoechoicity which has similar appearance sonographically to bursitis (but obviously could not be).

    pa1.jpg

    Next the same view with a “virtual” calcaneus superimposed to mimic appearance of possible insertional scenario.

    pa1a.jpg

    Lastly the same image with power doppler imaging which demonstrates a striking enlarged artery feeding through the Kager fat to the neovascularisation of the healing fibrous void in the tendo-achilles. The hypoechoic retro tendinous zone has very similar Sonographic appearance to retrocalc bursitis and I believe may represent a potential diagnostic pitfall.


    pa2.jpg


    Interesting that there was no response from PA members regarding use of polidocanol. This agent doesn’t seem to be available in Canada.

    Waiting for MRI for cross correlation before going any further with the initial case posted.

    Cheers

    Martin
    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  37. drsarbes

    drsarbes Well-Known Member

    Hi Mart:
    Good images, thanks for sharing them with us.
    Polidocanol is not approved for use in the US

    Yesterday's case, the bursae definitely slid back and forth (ant and post) along the superior surface of the Os Calcis.
    I didn't underscore enough to see if it was sliding posterior and sub achilles or not.
    Now this patient had no problem with the bursae, and it was fairly lipomatous (organized) in appearance although separate from the rest of the fat pad more proximally in the triangle.

    BTW:

    Tell me about this patient in the previous post.

    Steve
     
  38. Mart

    Mart Well-Known Member

    Hi Steve

    I wonder if what you saw was actually fat motion around the synovial fold. If you look at the dissection images I posted earlier in this thread you can see how there is a synovial fold into the bursa which presumably fills with fat with plantarflexion as pressure changes within bursa.

    as far as the tendo-achilles rupture images from my last post - here's a brief history;


    83 yo male, no significant PMHx or PSHx. Sudden onset leg pain 3 months ago. Saw Walk-in MD, was diagnosed partial tendo-achilles rupture, initial treatment plan; immobilized with BKW and heel ramp for two months. Subsequently no pain but walked with limp.

    My initial PE showed plantarflexion weakness ++, unable to perform single limb stance heel raise, palpable mid portion tendo-achilles void, confirmed complete rupture on US. Walks with slow velocity unstable gait with appropulsive limp presumptive loss of plantarflexion power generation.

    Interestingly NO pain despite massive neovascularistion of fibrous defect (what does this imply for similar intact tendonopathy pain?).

    Currently treatment plan; wait and see if fibrous repair is adequate – review in four weeks, may need referral for tendo-achilles repair / ankle foot orthoses if gait not improving.

    Cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  39. drsarbes

    drsarbes Well-Known Member

    83!
    Wow!
    Was she playing basketball?
    I feel for her, having been through that.

    Synovial fold.....I never see anything here that looks like synovial tissue. I'm not sure where these researchers came up with that nomenclature, but it looks like organized fat - bursa to me.

    There is often synovium deeper, of course, as one get closer to the posterior aspect of the STJ and ankle, but I just never see synovial tissue posteriorly on the anterior side of the AT.

    Steve
     
  40. Mart

    Mart Well-Known Member

    Hi Steve


    [​IMG]

    Seems like this is what you saw (arrow to W), which is adipose projection into bursa . . . . AKA synovial fold . . . . whatever will these damm researchers come up with next :empathy: ?


    He (tendo-calcaneus ruptured) reported simply walking along minding his own business when it snapped.

    Steve; time to sell your Porsche, buy a decent US machine and get down to some serious reseaching.

    :drinks


    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
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