MRI in patients with Haglund's deformity and its influence on therapy.

INTRODUCTION: Heel pain is one of the common reasons why patients consult orthopaedic surgeons in an outpatient setting. The dorsal heel pain is often caused by a Haglund's deformity which is an exostosis of the posterior superior calcaneus. It often leads to Haglund's syndrome with calcaneal bursitis and Achilles tendinosis. This study aims to investigate the roll of MRI in diagnosis of Haglund's syndrome and its influence on therapy. MATERIALS AND METHODS: We retrospectively analysed data of 45 patients which clinically and radiologically confirmed Haglund's deformity. Patients were divided into two groups that either did not receive MRI (MRI_0) or received MRI (MRI_1). To evaluate the significance, Fisher´s test was used. A statistical significance was assumed at p < 0.05. RESULTS: The average age was 57.0 years. There was no significant difference in therapy comparing the groups MRI_0 and MRI_1. Haglund's syndrome was detected in 86.7% of all patients with Haglund's deformity. CONCLUSION: MRI does not influence the therapy of patients with Haglund's deformity. Therefore, the resources of this cost-intensive and limited type of investigation should be used elsewhere. In cases of atypical heel pain, the MRI might be useful.

Novel Radiographic Measurements for Operatively Treated Haglund's Deformity.

BACKGROUND: Haglund's deformity, which is characterized by a bony prominence of the posterosuperior aspect of the calcaneus, causes posterior heel pain. To date, there is no standard radiographic parameter to diagnose symptomatic Haglund's deformity. Herein, we proposed novel radiographic measurements to distinguish between patients with and without symptomatic Haglund's deformity. METHODS: We retrospectively evaluated ankle radiographs of 43 patients who underwent surgery for symptomatic Haglund's deformity (Haglund group) and 41 healthy individuals (control group) free of heel complaints. Fowler-Phillip angle (FPA), Heneghan-Pavlov parallel pitch lines (PPL), Haglund's deformity height, bump height, and bump-calcaneus ratio were measured and compared between the groups. Furthermore, the reliability and cut-off value of each parameter were validated via ICC and ROC curve analysis, respectively. RESULTS: The bump height (p < 0.001) and the bump-calcaneus ratio (p < 0.001) showed significant differences between the control and Haglund groups, unlike FPA, PPL, and Haglund's deformity height. ROC curve analysis revealed that the AUC of bump-calcaneus ratio was larger than that of bump height. The optimal threshold was 4 mm or higher for bump height and 7.5% or higher for bump-calcaneus ratio. The intra- and inter- observer ICCs were, respectively, 0.965 and 0.898 for bump height and 0.930 and 0.889 for bump-calcaneus ratio. CONCLUSIONS: This study proposes two novel radiographic parameters to identify operatively treated Haglund's deformity, namely bump height and bump-calcaneus ratio. They are easy to measure and intuitive. Both of them are effective diagnostic parameters for Haglund's deformity. Furthermore, bump-calcaneus ratio is more reliable diagnostic parameter than bump height.

The effectiveness of conventional radiofrequency ablation for chronic plantar heel pain due to heel spur.

OBJECTIVES: The purpose of this study was to investigate the effectiveness of conventional radiofrequency (CRF) ablation treatment on chronic plantar heel pain due to heel spur. METHODS: A total of 20 patients with heel spur who did not respond to conservative treatments were recruited for the study. Under fluoroscopy guidance, CRF was performed to three points at the top, above, and below the heel spur in the longitudinal plane of the foot. Pain intensity, the pressure pain threshold (PPT), and functional status were assessed using a visual analog scale (VAS), pressure algometers, and the Foot Function Index (FFI). All measurements were taken before the procedure, as well as 1, 3, and 6 months following the procedure. RESULTS: CRF was applied to 20 patients - 16 (80%) females and 4 (20%) males. Their mean age was 51.40+-8.10 years, the mean body mass index was 33.80+-5.47 kg/m2, the mean duration of symptoms was 18.30+-9.02 months, and pes planus was present in 5 patients (25%). A statistically significant decrease was observed in VAS score and PPT and FFI measurements at the 1st, 3rd, and 6th month following CRF compared to before CRF (p<0.001). CONCLUSION: CRF is an effective, safe, minimally invasive method to reduce pain severity in patients with chronic heel pain due to heel spur in the short (0-3 months) and intermediate term (3-6 months).

Low-dose radiation treatment for painful plantar enthesophyte: a highly effective therapy with little side effects.

AIM: Plantar enthesophyte is a common degenerative disorder. Surgical and medical treatment options are associated with either poor outcome or high percentage of relapse. Observations have indicated a beneficial effect of radiation therapy. We therefore wanted to evaluate pain reduction using orthovolt or cobalt-based radiation treatment for painful plantar enthesophyte and determine long-term response as well as prognostic parameters in this condition. METHODS: We identified a total of 102 consecutive patients treated for a total of 117 symptomatic heel spurs. 59 patients were treated with cobalt radiation, 31 patients with orthovolt therapy and 12 patients with both radiation systems. Primary outcome measure was pain reduction being scored using the modified Rowe Score prior therapy, at the end of each treatment series as well as after 6 weeks. Secondary outcome measure was long-term outcome, evaluated in patients with a follow-up period of longer than 3 years. RESULTS: Before radiation therapy, 61 patients (60.4%) had a score of 0, significant strong pain. At the time of completion of radiation treatment, 3 patients (2.7%) were pain-free (score of 30), whereas 8 patients (7.9%) had still severe pain (score 0). 6 weeks after radiation therapy, 33 patients (32.7%) were pain-free and 8 patients (7.9%) had severe pain (score 0), while at the time data of collection, 74 patients (73%) were free of pain and 1 patient (1%) had strong pain (score 0). Duration of pain before the start of radiation treatment was a significant prognostic factor (p = 0.012) for response to treatment. CONCLUSION: Radiotherapy of painful plantar enthesophyte is a highly effective therapy with little side effects providing long-term therapeutic response. The only significant prognostic parameter for response to treatment is the duration of pre-radiation therapy pain. Early integration of radiation therapy in the treatment seems to result in superior pain reduction.

Diagnosis of heel pain.

Heel pain is a common presenting symptom in ambulatory clinics. There are many causes, but a mechanical etiology is most common. Location of pain can be a guide to the proper diagnosis. The most common diagnosis is plantar fasciitis, a condition that leads to medial plantar heel pain, especially with the first weight-bearing steps in the morning and after long periods of rest. Other causes of plantar heel pain include calcaneal stress fracture (progressively worsening pain following an increase in activity level or change to a harder walking surface), nerve entrapment (pain accompanied by burning, tingling, or numbness), heel pad syndrome (deep, bruise-like pain in the middle of the heel), neuromas, and plantar warts. Achilles tendinopathy is a common condition that causes posterior heel pain. Other tendinopathies demonstrate pain localized to the insertion site of the affected tendon. Posterior heel pain can also be attributed to a Haglund deformity, a prominence of the calcaneus that may cause bursa inflammation between the calcaneus and Achilles tendon, or to Sever disease, a calcaneal apophysitis in children. Medial midfoot heel pain, particularly with continued weight bearing, may be due to tarsal tunnel syndrome, which is caused by compression of the posterior tibial nerve as it courses through the flexor retinaculum, medial calcaneus, posterior talus, and medial malleolus. Sinus tarsi syndrome occurs in the space between the calcaneus, talus, and talocalcaneonavicular and subtalar joints. The syndrome manifests as lateral midfoot heel pain. Differentiating among causes of heel pain can be accomplished through a patient history and physical examination, with appropriate imaging studies, if indicated.

Ground reaction force analysis for assessing the efficacy of focused and radial shockwaves in the treatment of symptomatic plantar heel spur.

BACKGROUND: Extracorporeal shock wave therapy is among the conservative treatments for symptomatic heel spur. OBJECTIVE: The purpose of this trial is to evaluate and compare the therapeutic effects of radial shock wave (RSWT) and focused shock wave (FSWT) applied in the treatment of symptomatic heel spur. METHODS: Fifty-five participants were randomly divided into two comparative groups that were administered FSWT and RSWT, respectively. The severity of dysfunction (Foot Function Index, FFI), ground reaction forces (GRF) and walking temporal parameters were measured in all patients at baseline and at weeks 1, 3, 6, 12 and 24 after treatment. RESULTS: In both groups, a gradual decrease in the FFI values occurred after treatment. The percentage reduction in the FFI was comparable for both groups. Statistically significant changes were only noted between some measurements of GRF and walking temporal parameters. The percentage changes in the values of the force and temporal parameters were similar between the groups. CONCLUSIONS: Both FSWT and RSWT are efficacious in the treatment of symptomatic heel spur and their therapeutic effects are comparable. Objective data registered by force platforms during walking are not useful for tracing the progress of treatment applied to patients with symptomatic heel spur between consecutive procedures.

Brodie's abscess of the calcaneus in an adult patient.

Brodie's abscess of the calcaneus is an uncommon benign lesion that has rarely been reported in the literature. This study presents a rare case of a Brodie's abscess of the calcaneus caused by Staphylococcus aureus in an adult patient. A 46-year-old immunocompetent man had undergone nonsurgical treatment since childhood owing to the diagnosis of a heel spur. Radiological evaluation revealed a benign radiolucent cystic lesion of the calcaneus surrounded by a sclerotic rim. This condition was accompanied by perilesional bone marrow edema. Thereafter, surgical treatment was planned. During surgery, the content of the lesion was observed to be purulent. Meticulous intralesional debridement was performed, and antibiotic-loaded bone cement beads were placed. Subsequent to microbiological and pathological examinations, the cystic lesion was confirmed to be a Brodie abscess; however, direct clinical evidence of an intraosseous infection was lacking. The patient was followed up for 14 months with no complications until recovery. A Brodie abscess may mimic bone tumors. The onset of a Brodie abscess is insidious, and the clinical findings of such lesions may be obscure. A Brodie abscess of the calcaneus should be considered in the differential diagnosis of patients with chronic heel pain when suspicious radiological findings are evident.

Getting to the heel of the problem: plantar fascia lesions.

Heel pain is a frequent disabling symptom. Clinical diagnosis is often difficult with a large range of possible diagnoses. Lesions of the plantar fascia form an important group. We present a review describing the common lesions of the plantar fascia, including plantar fasciitis, plantar fascia rupture, plantar fibromatosis, and plantar xanthoma, and illustrate them with appropriate magnetic resonance imaging (MRI) and ultrasound imaging. We also address foreign-body reactions, enthesopathy, and diabetic fascial disease.

[Arthroscopic treatment for calcaneal spur syndrome]. / Artroskopická lécba syndromu plantární ostruhy.

PURPOSE OF THE STUDY Arthroscopic treatment of calcaneal spur syndrome is a tissue-sparing and effective approach when conservative therapy has failed. This method, its results and our experience with the treatment of this syndrome are presented here. MATERIAL Between January 2003 and November 2007, 26 patients underwent an arthroscopic procedure for calcaneal spur syndrome; of these, 20 were women with an average age of 49 years, and six were men with an average age of 45 years. Four, three women and one man, were lost to follow-up, therefore 22 patients with 24 heels were eventually evaluated. All had conservative therapy for 3 to 6 monts. METHODS The arthroscopic method used was developed by the arthroscopic group of the Orthopaedic Service of Hospital Hermanos Ameijeiras in Havana, Cuba. The surgical technique insolves treatment of the spur and plantar fasciitis commonly found in calcaneal spur syndrome, but it also addresses adjacent calcaneal periostitis. RESULTS The results were evaluated on the scale that is part of the foot function index developed by Budiman-Mak for measuring rheumatoid arthritis pain. The patients were asked mine questions on pain intensity during various activities before and after surgery. Pain was evaluated on a scale with grades from 0 to 9. The average value was 5.9 before surgery and 1.4 after surgery. A 0-1 pain range was reported by 25 %, 1-2 by 26 % and 2-4 by 22 % of the patients. All patients reported improvement. DISCUSSION The orthopaedic group in Havana led by Carlos achieved 85 % excellent outcomes (pain range, 0-2) at one-year followup; this was 79 % in our study, in which no problems with foot arches or wound infection were recorded. CONCLUSIONS The heel spur syndrome is a result of an inflamed ligament (plantar fascia) due to repeated microtrauma. It is not a traction osteophyte,but a reaction of the tissue where it attaches to the calcaneus. Adjacent calcaneal periostitis is usually present as well. Therefore, this method treting all three causes of the syndrome appears to be more effective than mere fasciotomy.

The age dependent change in the incidence of calcaneal spur.

OBJECTIVE: The aim of the present study was to evaluate the association between the calcaneal spur incidence and age, gender and side. METHODS: Lateral ankle X-rays of 1335 patients (550 (41.2%) females and 758 (58.8) males; mean age: 46.5 ± 13.5 years) who referred to our hospital because of trauma were reviewed. Incidence of plantar calcaneal spur, posterior calcaneal spur and association of such incidences with age, gender and side were all evaluated. RESULTS: Incidences of plantar calcaneal spur and posterior calcaneal spur were detected as 32.2% (male: 31%, female: 34%) and 13.1% (male: 11%, female: 16%), respectively. Incidence of plantar calcaneal spur increased by age whereas there was not any association with gender and location. The highest incidence was detected as 41.8% over 70 years of age. Incidence of posterior calcaneal spur increased by age and female gender whereas no significant association was observed with location. The highest incidence was detected as 22.3% between 61 and 70 years of age. CONCLUSION: Incidences of plantar and posterior calcaneal spur were detected as 32.2% and 13.1%, respectively. Both plantar and posterior calcaneal spur incidence increases by age. Posterior calcaneal spur occurs significantly more frequently in females while, no difference is found between the males and females in incidence of the plantar calcaneal spur. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Radiation therapy for painful heel spurs: results of a prospective randomized study.

PURPOSE: To evaluate the efficacy of two different dose-fractionation schedules for radiation therapy (RT) in patients with painful heel spurs. PATIENTS AND METHODS: 130 patients were randomized into two groups: the low-dose (LD) group (n = 65 heels) received a total dose of 3.0 Gy given in two weekly fractions of 0.5 Gy; in the high-dose (HD) group (n = 65 heels), two weekly fractions of 1.0 Gy were applied over 3 weeks (total dose 6.0 Gy). In 24 sites of the HD group and 17 sites of the LD group, a second RT course was given. The results were assessed using a five-level function score which was documented before RT, at the end of each RT course, and at 6 weeks and 6 months thereafter. RESULTS: At 6-month follow-up, RT led to a highly significant reduction of symptoms in both groups. In the HD group, 31 sites were classified as excellent (score: 90-100), 13 as good (score: 70-85), twelve as moderate (score: 45-65), and nine as poor (score: 0-40). In the LD group, 35 sites were classified as excellent, eight as good, ten as moderate, and twelve as poor. The comparison of the difference of the sum score and the single criteria before RT and at 6 months after RT using the Wilcoxon-Mann-Whitney U-test revealed no statistically significant difference of response to RT between both groups. CONCLUSION: RT is an effective treatment option for the management of inflammatory heel spurs. The dose for an RT course should not exceed 3.0 Gy.

[Heel pain]. / Von der Achillessehnen-Tendinitis bis zur Knochenzyste. Fersenschmerz--was steckt dahinter?

Upper and plantar heel pains are differentiated from one another. Plantar heel pain is usually caused by plantar fasciitis. A heel spur is a side effect and is not related to the cause of the symptoms. Upper heel pain is mostly caused by tendonitis of the Achilles tendon or Haglund exostosis. Only through an exact diagnosis is an adequate and usually conservative therapy possible. If the conservative therapy should fail, it is nevertheless important to clarify the indication for surgery to prevent the problems from becoming chronic.

Haglund's syndrome. Two case reports. / Síndrome de Haglund. A propósito de 2 casos.

Haglund's syndrome produces posterior impingement of the heel, which is caused by a posterosuperior calcaneal exostosis, known as Haglund's deformity, associated with Achilles tendinitis and retrocalcaneal bursitis. Its pathogenesis is unknown. We report two cases that were diagnosed clinically and confirmed radiographically. One patient was treated conservatively and the other underwent surgery. The diagnosis is based on clinical signs and radiological images, using the measurement of the parallel pitch lines, in a lateral radiograph of the ankle. Initial treatment is usually conservative and includes anti-inflammatory or analgesic agents, physiotherapy and low-heeled, open-heeled shoes. If conservative treatment does not relieve the pain, surgery may be necessary.

Chronic pain after ankle fracture: an arthroscopic assessment case series.

BACKGROUND: The purpose of this study was to document findings of ankle arthroscopy in patients with residual complaints after an appropriately treated ankle fracture. METHODS: Patients who had ankle arthroscopy at the Alpine Orthosports Clinic between 1998 and 2000 were identified by a retrospective review of the ankle arthroscopy database. Fifty patients were identified who had arthroscopy for complaints after ankle fracture. The mean duration from injury to arthroscopy was 20.5 +/- 33.5 months, with a range of 2 to 184.6 months. RESULTS: There were 37 isolated fractures and 13 combination fractures. The Danis-Weber classification was used for lateral malleolar fractures. There were five type A, 14 type B, and 11 type C lateral malleolar fractures. RESULTS: Synovitis was present in 46 ankles and was located anterolaterally in 36. Synovitis was noted in 26 of the 30 ankles that had a lateral malleolar fracture. Arthrofibrosis was found in 20 ankles, with anterolateral joint involvement in 16. There was chondral damage noted in 45 ankles, 30 located on the talus and 15 on the tibia. Spurs were found in 15 ankles, and nine had loose bodies or debris. There were two postoperative complications: one patient had bleeding from a portal and the other had an area of paresthesia at the anterolateral portal site. CONCLUSION: Synovitis and chondral damage were more frequent than arthrofibrosis and spurs. Synovitis and arthrofibrosis were found most frequently in the anterolateral aspect of the joint. Also, the higher the lateral malleolar fracture was in relation to the syndesmosis, the higher was the occurrence of talar chondral damage.

The association of calcaneal spur length and clinical and functional parameters in plantar fasciitis.

INTRODUCTION: Plantar fasciitis (PF)is the most common cause of plantar heel pain. Despite many treatment alternatives for heel spur, the association of calcaneal spur size with clinical and functional parameters is inconclusive. The objective of this study to investigate the correlation of calcaneal spur length with clinical findings and functional status documented with Foot Function Index in patients with plantar fasciitis. METHODS: We performed power analysis for the sample size estimation. 87 patients with PF were scrutinized to reach the estimated patient number 75. Computer-aided linear measurements were done for spur length from tip to base in milimeters. Perceived pain intensity was evaluated by visual analog scale (VAS). Patients were asked to rate the pain experienced on a 10-cm VAS. Foot function index was applied to the patients to evaluate pain, disability and activity limitation of the patients. RESULTS: Of the 75 participants, 24 were males (32%) and 51 were females (68%). The mean age was 47 ± 10 years (range 30-65 years). The mean calcaneal spur length was 3.86 ± 3.36 mm (range between 0 and 12.2). Calcaneal spur length was significantly correlated with age (p = 0.003), BMI (p = 0.029), symptom duration, (p = 0.001) VAS (p = 0.003), and FFI total score (p < 0.001). DISCUSSION: Our study demonstrated that length of the calcaneal spur is significantly correlated with age, BMI, symptom duration, perceived pain, FFI pain and disability subscores, and FFI total scores. CONCLUSION: The size of the calcaneal spur is an important parameter correlated with pain and functional scores in PF.

Degenerative lesions of the plantar fascia: surgical treatment by fasciectomy and excision of the heel spur. A report on 38 cases.

The authors studied 38 cases of degenerative lesions of the plantar fascia which were treated surgically between 1989 and 1999. MRI showed chronic fasciitis in eight cases and an old rupture of the plantar fascia in 30 cases. Surgical treatment, which was performed in all cases after failure of conservative treatment of several months duration, combined excision of the fascia with resection of the heel spur. Histological examination found inflammation in all cases (fasciitis or rupture), calcification of the aponeurosis in four cases, cartilaginous metaplasia in four and fibromatosis in four. Patients were assessed a minimum of one year and a maximum of seven years after operation. The postoperative results were assessed using three criteria: resolution of pain, results on the static foot and patients' functional activity. Overall there were 24 very good and good results, nine fair and five poor. MRI performed at the time of follow-up revealed good healing of the plantar fascia in 16 cases, defects in two cases, inflammation in seven cases and defects associated with inflammation in 13 cases. Surgical treatment may be considered in cases where conservative treatment of talalgia has failed. Symptoms originating from degenerative damage to the plantar fascia, such as rupture or fasciitis, may benefit from fasciectomy. Short-term results show resolution of pain in 75% of cases, and a slight sagging of the plantar arch. Pre-operative MRI study is useful to determine the exact location of the lesions.

Cryoultrasound therapy in the treatment of chronic plantar fasciitis with heel spurs. A randomized controlled clinical study.

BACKGROUND: Plantar fasciitis is one of the most common causes of pain in the inferior heel and is very frequent in some running sports. It affects up to 10% of general population and accounts for 11% to 15% of all foot pain symptomatology. Several treatments have been suggested, but there is no evidence supporting a specific conservative management strategy. AIM: Evaluation of the efficacy of combined cryoultrasound therapy on chronic plantar fasciitis with heel spurs resistant to pharmacological and instrumental therapies. DESIGN: Single-blind randomized clinical trial. POPULATION: 102 consecutive patients affected by chronic plantar fasciitis with painful symptomatology for at least 6 months, intensity of pain higher than 5 on the VAS score, presence of heel spurs, use of plantar orthoses and ineffectiveness of previous therapies. METHODS: The patients were randomized into two groups: Group A treated with cryoultrasound therapy and Group B with cryotherapy. Our protocol was based on 10 daily treatments, lasting 20 minutes. Each participant was evaluated using VAS score before (T0) the treatment and 3 months (T1), 12 months (T2) and 18 months (T3) after. Effectiveness index was calculated from T1 to T3. RESULTS: Both treatments have been found effective. The difference in pain intensity on the VAS scale between the two groups at T2 was 4.35 points in favor of Group A (IC 95% 3.75; 4.95; P<0.001), reaching the primary end point. The difference in pain intensity on the VAS scale between the two groups at T1, T2 and T3 was 3.00, 4.35 and 4.81 respectively, showing a statistically significant difference between VAS average scores at all follow-ups in favor of Group A. Scores of at least 66% at the effectiveness index were only achieved in Group A (P values <0.001). CONCLUSION: Cryoultrasound therapy could be an efficient treatment option for chronic plantar fasciitis. CLINICAL REHABILITATION IMPACT: Cryoultrasound therapy promises an effective and long-lasting clinical improvement in patients with chronic plantar fasciitis, granted its high therapeutic efficiency, patients' satisfaction, its limited cost and its short and repeatable protocol of use.

Plantar heel pain.

Plantar heel pain is a common complaint encountered by orthopedic surgeons, internists, and family practitioners. Although it is most often caused by plantar fasciitis, this is a diagnosis of exclusion. Other mechanical, rheumatologic, and neurologic causes must be considered first. The history and physical examination are typically all that is needed to make the proper diagnosis, but diagnostic adjuncts are available to assist the clinician. When plantar fasciitis is diagnosed, conservative modalities must be tried first. Corticosteroid injections and extracorporeal shock-wave therapy may also be used. After 6 months of failed conservative treatments, surgical intervention should be considered.

Diagnosis of hyperostosis of the medial calcaneal tubercle similar to a heel spur.

Calcaneal osteochondromas are rare conditions. To our knowledge, we present the first report of a calcaneal osteochondroma in an adolescent patient that was surprisingly similar to a heel spur, and, in addition, symptoms due to compression of the medial plantar nerve were present.