Would anyone care to help me with interpreting some anatomy?
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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
resources
button
then double click the
Podarena Icon
You will be able to see a sequence of the saggital view below
Any takers?
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
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Attached Files:
Last edited: Jul 14, 2009 -
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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. -
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.
cheers
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. -
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?
cheers
Martin -
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)
ALSO
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.
cheers
Martin
HOSGOREN, B., KOKTENER, A. & DILMEN, G. (2005) Ultrasonography of the calcaneus in Sever's disease. Indian Pediatr, 42, 801-3.Bibliography
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-
341.
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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.
:drinks
Cheers
MartinAttached Files:
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Yeah, but I thought your ultrasound video was pretty cool....what a neat toy!!:drinks -
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?
Respectfully,
Jeff Root
www.root-lab.comLast edited by a moderator: Jul 17, 2009 -
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Mart said: ↑Jeff Root said: ↑Hi Jeff
I thought about this issue of the bursa and until reconsidering Kevin's suggestion wondered if this might represent some kind of bursal fibrosis pathology and pain generator. I believe that what you notice is the normal motion of the fat pad in and out of the retrocalc space with the epiphysis beneath it. Normal cortical bone will reflect US waves at the low power used in Diagnostic ultrasound machines. The best explaination seems to be that the epiphysis has not mineralised enough to be highly reflective but also not having transparency of normal cartiliage which has low impedance to US.
cheers
MartinClick to expand...
Martin, thought you might be interested in this if you haven't already read it:
The Achilles tendon inserts on the posterior surface of the calcaneus, and immediately above its attachment, the space between the tendon and the bone is occupied by the retrocalcaneal bursa. The anterior wall of this bursa is formed by the calcaneus and the posterior by the tendon (Rufai et al. 1995). As the foot is dorsiflexed, the tendon bends near its attachment, the bursa flattens and its walls become opposed, i.e. the distal part of the tendon is pressed against the bone.
The term ‘enthesis organ’ has recently been coined to describe the tendon insertion site itself, together with the bursa and its walls (Benjamin & McGonagle, 2001). The word ‘enthesis’ collectively embraces the concept of a tendon, ligament or joint capsule attachment to bone – be it the origin or insertion of a tendon, or the equivalent attachments at the two ends of a ligament. An ‘enthesis organ’ is thus a collection of related tissues that act together to protect both the tendon and bone from wear and tear. The enthesis organ of the Achilles tendon includes three fibrocartilages (FC) – an enthesis FC at the tendon–bone junction, together with two fibrocartilages that form the bursal walls and protect them from compression (Rufai et al. 1995). These are a sesamoid FC in the deep surface of the tendon and a periosteal FC covering the superior tuberosity of the calcaneus (Rufai et al. 1995).
A detailed three-dimensional (3D) picture of the orientation of the fibrocartilages associated with the human Achilles tendon insertion is of clinical relevance, as modern MRI techniques have now developed to the point at which subtle signal abnormalities can be demonstrated in patients with chronic Achilles tendon pain, for example that associated with Haglund's deformity, ectopic tendon calcification, calcaneal spurs or retrocalcaneal bursitis. Movin et al. (1998), for example, have correlated histopathological signs of increased glycosaminoglycan production and altered fibre structure in patients with achillodynia, with changing signal intensity. As MRI is essentially a 3D technique (albeit commonly presented in 2D), the imaging capability requires an anatomical knowledge of the 3D arrangement of the fibrocartilages in the Achilles tendon, if we are to improve our understanding of what is ‘normal’ or ‘abnormal’ in MRI. Furthermore, a knowledge of the nature and orientation of the fibrocartilages is relevant to surgeons who must choose between different tendon resection methods when treating posterior heel pain (Kolodziej et al. 1999).
You can find the full article at http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1570650#b4
Respectfully,
Jeff
www.root-lab.comClick to expand... -
Jeff Root said: ↑Mart said: ↑Martin, thought you might be interested in this if you haven't already read it:
The Achilles tendon inserts on the posterior surface of the calcaneus, and immediately above its attachment, the space between the tendon and the bone is occupied by the retrocalcaneal bursa. The anterior wall of this bursa is formed by the calcaneus and the posterior by the tendon (Rufai et al. 1995). As the foot is dorsiflexed, the tendon bends near its attachment, the bursa flattens and its walls become opposed, i.e. the distal part of the tendon is pressed against the bone.
The term ‘enthesis organ’ has recently been coined to describe the tendon insertion site itself, together with the bursa and its walls (Benjamin & McGonagle, 2001). The word ‘enthesis’ collectively embraces the concept of a tendon, ligament or joint capsule attachment to bone – be it the origin or insertion of a tendon, or the equivalent attachments at the two ends of a ligament. An ‘enthesis organ’ is thus a collection of related tissues that act together to protect both the tendon and bone from wear and tear. The enthesis organ of the Achilles tendon includes three fibrocartilages (FC) – an enthesis FC at the tendon–bone junction, together with two fibrocartilages that form the bursal walls and protect them from compression (Rufai et al. 1995). These are a sesamoid FC in the deep surface of the tendon and a periosteal FC covering the superior tuberosity of the calcaneus (Rufai et al. 1995).
A detailed three-dimensional (3D) picture of the orientation of the fibrocartilages associated with the human Achilles tendon insertion is of clinical relevance, as modern MRI techniques have now developed to the point at which subtle signal abnormalities can be demonstrated in patients with chronic Achilles tendon pain, for example that associated with Haglund's deformity, ectopic tendon calcification, calcaneal spurs or retrocalcaneal bursitis. Movin et al. (1998), for example, have correlated histopathological signs of increased glycosaminoglycan production and altered fibre structure in patients with achillodynia, with changing signal intensity. As MRI is essentially a 3D technique (albeit commonly presented in 2D), the imaging capability requires an anatomical knowledge of the 3D arrangement of the fibrocartilages in the Achilles tendon, if we are to improve our understanding of what is ‘normal’ or ‘abnormal’ in MRI. Furthermore, a knowledge of the nature and orientation of the fibrocartilages is relevant to surgeons who must choose between different tendon resection methods when treating posterior heel pain (Kolodziej et al. 1999).
You can find the full article at http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1570650#b4
Respectfully,
Jeff
www.root-lab.comClick to expand...
Yep I have read those papers too.
I have for a while regarded the diagnosis of Sever's a bit of a throwaway term which like plantar fasciitis means different things according to how you interpret what you see.
Most clinicians I think in both these instances are actually treating pain, we consider a good outcome if the pain goes away, this is mostly all we can really say and we don't normaly look at any oher end point and dont even know for sure where the pain comes from. What I see with US is that mostly, with chronic tendo-achilles and plantar fascia pain, although the sonographic signs correlate well with the presence of pain and morphologic change is proprtional to degree of pain, little if any sonographic change is seen in the short term with pain resolution. I find this an interesting and possibly important anomally. US quantitatvely does provide an objective non invasive end point other than pain and if it is true that there is a disconect between them as an end point I feel an explanation might be rewarding.
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.comClick to expand...
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