MRI reveals cause of heel pain

CLINICAL HISTORY

A 51-year-old woman presented to the clinic complaining of left heel pain. On physical exam there was tenderness and soft tissue swelling of the posterior aspect of the left heel. Conventional radiographs of the left ankle were obtained in anteroposterior, lateral, and oblique views. They were essentially unremarkable, although the lateral view showed equivocal prominence of the posterior superior calcaneal tuberosity, along with subtle findings of increased density in the pre-Achilles fat (arrows, Figure 1). MR imaging was subsequently performed.

FINDINGS

Sagittal T1-weighted image (Figure 2) demonstrates focal decreased T1 signal within the pre-Achilles fat, as well as a prominent posterior superior calcaneal tuberosity (arrow). Sagittal proton density image (Figure 3) shows increased signal intensity in the pre-Achilles fat/retrocalcaneal bursa (arrow). Sagittal T2-weighted image (Figure 4) reveals mildly increased signal intensity within the distal Achilles tendon without evidence of a full-thickness tear. Axial T2-weighted image (Figure 5) better demonstrates increased signal intensity within the Achilles tendon (arrow) with associated retrocalcaneal inflammatory disease.

Diagnosis

Haglund’s complex.

Discussion

Haglund’s deformity, commonly referred to as “pump bump,” is an enlargement of the posterior superior calcaneal tuberosity. Friction between the bony enlargement and Achilles tendon causes soft tissue inflammation, resulting in retrocalcaneal bursitis. This constellation of Achilles tendinosis, the bony enlargement, and retrocalcaneal bursitis constitute Haglund’s complex.¹ This condition is most commonly seen in young women who wear pump-style shoes. These shoes irritate the soft tissue by placing increased pressure on the bony enlargement. Other individuals who are prone to this condition include those with naturally high arches or a tight Achilles tendon.

Symptoms include pain at the Achilles tendon insertion site, erythema and swelling of the heel, and pain that is aggravated by dorsiflexion.

Initial treatment consists of conservative methods such as oral anti-inflammatory medications, heel lifts, ice, shoe modification, and calf-stretching exercises. Steroid injections are usually avoided in cases of Achilles tendinitis to avoid subsequent tendon rupture. If these methods are unsuccessful, surgery is considered.

MRI is the modality of choice in differentiating common causes of heel pain such as, but not limited to, plantar fasciitis, fracture, tarsal tunnel syndrome, bursal abnormalities, or tendon rupture.

Heel pain is a common complaint and many times can be managed conservatively. However, in cases where etiology is questionable and medical management is unsuccessful, MR imaging is useful in determining not only the diagnosis, but also the extent and severity of disease.


Ms. Crawford is a medical student and Dr. Desruisseau is a physician in the Radiology department at Meharry Medical College in Nashville, TN.

References

1. Stephens MM. Haglund’s deformity and retrocalcaneal bursitis. Orthop Clin North Am 1994;25(1):41-46.
2. Narváez JA, Narváez J, Ortega R, et al. Painful heel: MR imaging findings. Radiographics 2000;20(2):333-352.