0:00

MRI images on this 72-year-old patient

0:05

with chronic pain referred to the heel

0:08

area for about nine months revealed

0:10

the presence of Achilles tendinopathy.

0:14

The Achilles tendon in the axial plane

0:17

should have a concave configuration.

0:21

With the anterior portion of the Achilles

0:24

tendon curve, uh, posteriorly, as we lose that

0:30

concavity going into the insertional portion,

0:34

this makes the diagnosis of chronic tendinosis.

0:39

The signal intensity characteristics that also.

0:43

The range, we see that there are areas

0:47

of intrasubstance T2 bright signal,

0:50

particularly at the level of the enthesis

0:53

where the tendon is meeting the bone.

0:56

And this is causing enthesopathy or

0:59

enthesitis with marrow edema of the posteroinferior

1:03

superior calcaneus to visualize on MRI.

1:06

You tell images.

1:08

We come to realize what is the underlying problem.

1:12

So we have a rather prominent posterior

1:15

superior calcaneal tuberosity.

1:18

I drew the lines.

1:19

This is Pavlov's method for parallel pitch

1:24

line assessment for Haglund's deformity.

1:28

And we see that the posterior

1:29

superior calcaneal tuberosity

1:32

is touching and slightly protruding above the

1:36

superior parallel line, making the diagnosis

1:39

of Haglund's deformity in this patient.

1:43

Haglund's deformity is a syndrome with several

1:46

signs, including the presence of Haglund's

1:49

deformity, the presence of retrocalcaneal

1:52

bursitis, which we see in this patient,

1:55

insertional Achilles tendinosis, or tears.

2:00

And then we often see also edema in the

2:03

retro-Achilles subcutaneous fat pad.

2:07

So, in this patient, we come down to the

2:10

diagnosis of Haglund's syndrome with chronic

2:14

insertional Achilles tendinosis and superimposed

2:18

longitudinal splintering at the level of the enthesis.

Wk 1, Case 1 - Review

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0:00

MRI images on this 72-year-old patient

0:05

with chronic pain referred to the heel

0:08

area for about nine months revealed

0:10

the presence of Achilles tendinopathy.

0:14

The Achilles tendon in the axial plane

0:17

should have a concave configuration.

0:21

With the anterior portion of the Achilles

0:24

tendon curve, uh, posteriorly, as we lose that

0:30

concavity going into the insertional portion,

0:34

this makes the diagnosis of chronic tendinosis.

0:39

The signal intensity characteristics that also.

0:43

The range, we see that there are areas

0:47

of intrasubstance T2 bright signal,

0:50

particularly at the level of the enthesis

0:53

where the tendon is meeting the bone.

0:56

And this is causing enthesopathy or

0:59

enthesitis with marrow edema of the posteroinferior

1:03

superior calcaneus to visualize on MRI.

1:06

You tell images.

1:08

We come to realize what is the underlying problem.

1:12

So we have a rather prominent posterior

1:15

superior calcaneal tuberosity.

1:18

I drew the lines.

1:19

This is Pavlov's method for parallel pitch

1:24

line assessment for Haglund's deformity.

1:28

And we see that the posterior

1:29

superior calcaneal tuberosity

1:32

is touching and slightly protruding above the

1:36

superior parallel line, making the diagnosis

1:39

of Haglund's deformity in this patient.

1:43

Haglund's deformity is a syndrome with several

1:46

signs, including the presence of Haglund's

1:49

deformity, the presence of retrocalcaneal

1:52

bursitis, which we see in this patient,

1:55

insertional Achilles tendinosis, or tears.

2:00

And then we often see also edema in the

2:03

retro-Achilles subcutaneous fat pad.

2:07

So, in this patient, we come down to the

2:10

diagnosis of Haglund's syndrome with chronic

2:14

insertional Achilles tendinosis and superimposed

2:18

longitudinal splintering at the level of the enthesis.

Report

Patient History
72-year-old man patient complaining of pain and swelling in the Achilles area for 9 months.

Findings
SKELETAL/BONES:
Moderate to severe enthesopathy of the distal Achilles tendon, with stress edema of the enthesophyte and dorsal calcaneus and calcaneal tuberosity. Prominent dorsal calcaneal enthesophyte is possibly fractured at its base. Prominent enthesophyte-related osseous erosion at the dorsal calcaneus.

Haglund’s deformity with reactive osteoedema noted.

Low-grade (likely stress related) osteoedema involving the medial malleolus and medial talus. No fracture or focal aggressive osseous abnormality.

ARTICULATIONS:
Unremarkable.

LIGAMENTS:
High ankle ligaments: Intact.

Low ankle ligaments: Intact.

Subtalar/Chopart: Intact.

TENDONS:
Moderate to severe insertional tendinopathy and enthesopathy of the distal Achilles tendon with a developing thin undersurface high footprint delamination insertional partial thickness tear measuring 1.3 centimeters length, 1.0 centimeter width and less than 10 percent depth.

A second, mostly concealed tear at the inferior-most segment or footprint is best seen on series 9 image 8 below the delamination.

Tibialis posterior, flexor digitorum longus, flexor hallucis longus, peroneus longus/brevis and extensor tendons are intact and unremarkable in appearance.

GENERAL:
Sinus tarsi: Unremarkable.
Muscles: No traumatic muscle injury. No volumetric muscle atrophy.

Soft tissue: Retrocalcaneal bursa mildly thickened and edematous. No effusion.

Plantar fascia: Intact.

Neurovascular complex/tarsal tunnel: Unremarkable. No evidence of entrapment neuropathy.

Intra-articular/loose bodies: None.

Impressions
1. Moderate to severe insertional tendinopathy and enthesopathy of the Achilles tendon.
2. Developing undersurface delamination high insertional partial thickness tear of the Achilles tendon.
3. Concealed interstitial delamination tear of the lower-most segment of the achilles.
4. Small Haglund deformity.

Case Discussion

Faculty

Stephen J Pomeranz, MD

Chief Medical Officer, ProScan Imaging. Founder, MRI Online

ProScan Imaging

Jenny T Bencardino, MD

Vice-Chair, Academic Affairs Department of Radiology

Montefiore Radiology

Edward Smitaman, MD

Clinical Associate Professor

University of California San Diego

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Wk 1, Case 1 - Review