Clinical History
The patient presented pain in the Achilles tendon insertion area. The symptoms worsened while walking. The pain had started three years before, becoming worse during the past six months.
Clinically there was redness, a focal bump and swelling. There was also pain when pressing the Achilles tendon insertion.
Imaging Findings
The axial T1-w and fat suppressed PD-w as well as the sagittal fat suppressed PD-w MR images, showed a small effusion into the tibiotalar joint, a hypertrophic posterior process of the talus in keeping with a Stieda process, Achilles tendon tendinopathy with abnormal signal intensity in its anterior aspect of insertion and reactive bone marrow oedema subcortically at the tendon insertion. There was also bony overgrowth in the superoposterior calcaneus with minor retrocalcaneal bursitis and oedematous soft tissue changes anterior and posterior to the Achilles tendon. Irrelevant associated findings included varicose veins in the medial and anterior aspects of the ankle and bony overgrowth in the calcaneal attachment of the plantar aponeurosis, without indications of plantar aponeurositis.
Discussion
Haglund’s deformity refers to a bony enlargement on the back of the heel. The soft tissues near the Achilles tendon may become irritated when the bony enlargement rubs against shoes. This often leads to painful local bursitis.
Haglund's deformity is often called “pump bump” because the rigid backs of pump-style shoes can create pressure that aggravates the enlargement when walking. In fact, any shoes with a rigid back, such as ice skates, men’s dress shoes, or women’s pumps, can cause this irritation. To some extent, heredity plays a role in Haglund’s deformity. Inherited foot structures that can make one prone to developing this condition include a high-arched foot, a tight Achilles tendon and tendency to walk on the outside of the heel. Haglund’s deformity can occur in one or both feet.
Haglund's syndrome is a constellation of soft tissue and bony abnormalities and represents one cause of retrocalcaneal pain resulting from inflammation of the regional soft tissues, Achilles tendinopathy and bone marrow oedema. In young athletes, posterior impingement may also be a cause of pain. MR imaging is crucial since treatment of the above painful entities are different.
The diagnosis of Haglund's syndrome is often made clinically. Plain radiographs may show increased density in the deep and superficial Achilles bursae on a standing lateral radiograph. Ultrasound may show the bursitis and tendinopathy but is unable to demonstrate the osseous structures. However, ultrasonography is useful to guide treatment of the bursitis and the tendinopathy.
In the case presented here, Achilles tendinopathy presumably resulted from the Haglund's deformity.
Differential Diagnosis List
Haglund's deformity and chronic Achilles tendinopathy.
Achilles tendon partial tear
Achilles tendon xanthoma
Final Diagnosis
Haglund's deformity and chronic Achilles tendinopathy.
