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Growth Plate anatomy and dynamic imaging of calcaneus

Discussion in 'General Issues and Discussion Forum' started by Mart, Jul 14, 2009.

  1. Mart

    Mart Well-Known Member

    Members do not see these Ads. Sign Up.
    Would anyone care to help me with interpreting some anatomy?
    I am trying to help a ten year boy with one year + history of bilateral chronic incapacitating heel pain.
    He has Diagnostic ultrasound confirmed tendo-achilles, plantar fascia and retrocalcaneal bursa active inflammation. He has mechanical issues, primarily triceps surae and hamstring tightness.
    Cited in the literature is that juvenile growth plate pain can be associated with elements of the tendo-achilles attaching to the growth plate rather than the calcaneal cortex and creating abnormal stress on the plate. There is a paucity of US studies on calcaneal growth plates, it does however have capacity to look at the dynamic tendo-achilles.
    My question is what is the structure indicated by the Yellow arrow below. Is this likely a normal appearance?

    I have uploaded a short video of the behavior of the site with passive ankle dorsiflexion.
    If you go to my website,
    click on the
    then double click the
    Podarena Icon
    You will be able to see a sequence of the saggital view below
    Any takers?



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

    Attached Files:

    Last edited: Jul 14, 2009
  2. Martin:

    Since I have never seen an ultrasound image from this angle of the posterior calcaneal region in this age group, I would imagine that your yellow arrow is pointing to the calcaneal apophysis. Your patient likely has Sever's disease and the treatment of this disorder has been covered quite extensively on Podiatry Arena over the past few years.
  3. Mart

    Mart Well-Known Member

    thanks Kevn.

    Did you have a look at the video? I don't believe that the yellow tagged structure is the apophysis. It seems to me an attatchement to the apophysis and appears to have the potential to apply traction to it and be separate from the tendo-achilles, you need to look at the dynamic exam to appreciate this.


  4. Martin:

    I looked at the video. Sometimes the apophysis extends fairly far superiorly up the posterior calcaneus. You may want to confirm this with your radiographs. An alternative explanation is that you are simply seeing the posterior-superior surface of the calcaneus at an oblique angle to your ultrasound beam so that the structure you are pointing to is simply the posterior surface of the calcaneus. I would imagine that if you moved the US wand around a little at different angles that you would get a very different picture than what you are seeing here.
  5. Mart

    Mart Well-Known Member

    Thanks again Kevin.

    Of course you are right regarding the probe angle, you will have to take my word that I have enough experience to optimise this.

    This slice is very tangential to the posterior calcaneus and parallel to the tendo-achilles. I have re-annoted the still image above to make the apophyseal secondary segement obvious. The cartilagenous growth plate interposes and appears to attatch to a fibrous structure which is seperate fron the tendo-achilles. Watch the behaviour of the fatty tissue as it interposes between this and the tendo-achilles.

    Another question might be; would you expect the fibres of the tendo-achilles to attatch only to the apophysis or would they bridge the growth plate and the primary centre?


  6. Mart

    Mart Well-Known Member

    Kevin and others interested;

    Here’s a bit more info to explain where my interest in this case (it is not simply a pretext to play with my toy which as you know I like to do :eek:). The images I have posted were made with care, they are truly sagittal, centered and parallel to axis of tendo-achilles and not skewed in transverse plane – regard as essentially equivalent of lateral view splitting the tendo-achilles.

    When Sever reported his condition as osteochondrosis, sclerosis and fragmentation were
    demonstrated as diagnostic X-ray findings.

    However, years later, there is still controversy about the radiographic aspect of the calcaneal apophysitis.

    Some authors showed that sclerotic changes could be observed in normal children Nery, et al. (1996) and Volpon, et al. (2002) stated that fragmentation was the most reliable X-ray finding in calcaneal apophysitis

    There have been studies including sonographic features of the OSD that involves tibial tuberosity. Showing pathologic findings like pretibial swelling, fragmentation of the ossification center, insertional thickening of the patellar tendon and excessive fluid collection in the infrapatellar bursa, they supported the sonographic examination of knee as a simple and reliable method to diagnose OSD.

    In Sever’s disease, ultrasonographic examination provides to examine not only secondary nucleus of calcaneus but also, Achilles tendon and retrocalcaneal bursa. Achilles tendinitis and/or retrocalcaneal bursitis may accompany with Sever’s disease or may be solely a cause of heel pain.

    Hosgoren showed that ultrasonography could demonstrate the fragmentation
    of secondary nucleus of ossification of the calcaneus and surrounding soft tissues. This
    finding might be valuable in the easy diagnosis of Sever’s disease since children are prevented from excess radiation. His study was the first step, and further studies are needed to support the value of the sonographic examination in the diagnosis of Sever’s disease.(Hosgoren et al., 2005)


    Martino sated “A peculiar form of enthesopathy is that affecting
    patients in adolescence. During growth, the
    tendon insertion does not occur on the bone, but
    on the growth plate cartilage, that represents a
    weaker structure of the enthesis compared to bone
    and tendon, and is less resistant to mechanical
    stress. Impact is therefore mostly absorbed by the
    growth plate cartilage, and the corresponding bone
    and tendon are relatively spared. Typical clinical
    conditions that follow this situation are some juvenile
    osteochondroses, such as Osgood-Schlatter’s
    disease (affecting the patellar tendon at its distal
    insertion), Sinding-Larsen-Johansson’s disease
    (affecting the patellar tendon at its proximal insertion)
    and Haglund-Sever’s disease (affecting the
    Achilles). All these patients present with pain at
    the enthesis level and functional loss” (Martino, 2007).

    The lad I am showing you have unequivocal evidence of injuries of tendo-achilles, retrocalc bursa and plantar fascia, which are consistent with overload from his muscular tightness. Interestingly he has 3 cousins with similar and longstanding problems. He has no evidence of fragmentation of epiphysis on US. There are bilaterally some observations which I cannot explain which may or may not be normal, for which I can find no reference to but perhaps may be fathomed by informed reason by someone with MRI or other expertise. The notion described by Martino above I have not seen in any other text and find interesting because other than US or MRI it would remain undetected. It certainly does not seem to be the case in my patient that the tendo-achilles attaches to the growth plate cartilage, but something else does seem to. This “something is not cartilage (on US this is hypoechoic – black), it is incompressible (therefore not fat or normal bursa) and not bone. Could it be thickened fibrous extension of the retocalc bursa (this might be sonographically plausible from its appearance)? What else could it be?
    Hope that helps make this a bit more worthwhile.


    HOSGOREN, B., KOKTENER, A. & DILMEN, G. (2005) Ultrasonography of the calcaneus in Sever's disease. Indian Pediatr, 42, 801-3.

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

    Nery CAS, Prado I, Cho YJ, Oliveria AC, Pereira SEM. Osteocondrite de Sever:
    importância do radiodiagnóstico. Acta Ortop Bras 1996; 4: 104-108.

    Volpon JB, De Carvalho FG. Calcaneal apophysitis: a quantitative radiographic
    evaulation of the secondary ossification center. Arch Orthop Trauma Surg 2002;122: 338-

  7. Mart

    Mart Well-Known Member

    OK Kevin . . . .. I think I finally understand this.

    Unfortunately I do not have a corresponding xray of this US image but did manage to find one from an on line collection (below) which confirms your suggestion. My assumption is that the thin layer (yellow arrow on US) and arrow below is only partialy mineralised and therefore allowing US to penetrate unlike normal cortex.

    This shows my lack of experience reviewing pediatric X rays, I have only seen a few and the epiphysis did not look like this.




    Attached Files:

    • xr .jpg
      xr .jpg
      File size:
      1.9 KB
  8. Martin:

    Yeah, but I thought your ultrasound video was pretty cool....what a neat toy!!:drinks
  9. Jeff Root

    Jeff Root Well-Known Member


    Take a look at page 74 in The Color Atlas of Foot and Ankle Anatomy (McMinn, Hutchings and Logan). The photo is of a sagittal section of the right foot. There is a thickened structure in the same location as your arrow.

    Looking at your video it appears to me that the structure in question is the distal aspect of the posterior wall or lining of the retrocalcaneal bursa, which may serve an articular function with the calcaneus. Notice how the space is compressed and the fluid is displaced in an anterior, superior fashion with dorsiflexion of the foot. The space then re-opens with ankle joint plantarflexion and the fluid returns to fill the space. The strucuture you pointed to is posterior to the fluid filled space as evidenced when viewed during ankle joint plantarflexion. I bet if you were to plantarflex the foot even further, you would see the space open up even more and the structure would extend further from the surface of calcaneus.

    Very nice image! Thanks for sharing it. Do you agree with my observations?

    Jeff Root
    Last edited by a moderator: Jul 17, 2009
  10. Mart

    Mart Well-Known Member

  11. Jeff Root

    Jeff Root Well-Known Member

  12. Mart

    Mart Well-Known Member


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