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Background/aim: In this study, it was aimed to determine the morphometric properties of the Kager’s triangle, which is located in the posterior region of the ankle where interventional procedures are frequently performed and contains fat pad. Materials and methods: For our study, bilateral lower extremity of 4 female and 4 male cadavers were dissected. Tibia length, fibula length, foot length, intermaleolar length, intercondylar length, gastrocnemius muscle’s medial head and lateral head and tendon length, floor, anterior margin, posterior margin lengths and area of Kager’s triangle were measured in the cadavers. Descriptive and statistical analysis of the morphometric measurements we made was performed. Results: All 3 parts of the Kager’s triangle, which are defined anatomically in the literature, have been observed. The base of the Kager’s triangle is an average of 24.33±2.05 mm in women and 31.44±3.84 mm in men. The anterior border of Kager's triangle is 60.10±6.56 mm in females and 67.19±19.05 mm in males. The posterior border of Kager's triangle was found to be 55.61±6.38 mm in women and 72.52±17.56 mm in men. The area of Kager's triangle was found to be 6.74±1.15 cm² on average in females and 9.06±1.85 cm² in males. Conclusion: The data obtained will be a guide for the injections to be applied to the region or surgical interventions to be performed in the region, especially for the treatment of pathologies such as Achilles tendinopathy in this region. It is aimed that this study will contribute to the literature on the anatomy of the relevant region

Purpose The aim of the study was to map connections within the Kager’s fat pad between the structures which limit it. Methods A retrospective re-review of 200 ankle magnetic resonance imaging (MRI) examination was conducted. Connections within the Kager’s fat pad between the superior peroneal retinaculum, the fibulotalocalcaneal ligament, the posterior talocalcaneal ligament, the flexor hallucis longus, the paratenon of the Achilles tendon, the flexor retinaculum and bones were studied and a model of the connections was constructed. Results The superior peroneal retinaculum was directly connected with the fibulotalocalcaneal ligament in 85.5% of cases, the lateral part of the paratenon in 82.5%, the processus posterior tali in 78.5%, the posterior talofibular ligament in 32%, the flexor retinaculum in 29.5% and the anterior talofibular ligament in 9%. The fibulotalocalcaneal ligament was connected with the paratenon (on the medial side 88.5%, on the lateral side 68.5%), the flexor retinaculum in 70%, the posterior process of the talus in 79%, the osteofibrosus tunnel for the flexor hallucis longus in 53%, the posterior talofibular ligament in 43.5% and the calcaneofibular ligament in 10.5%. The posterior talocalcaneal ligament was connected with the fibulotalocalcaneal ligament in 71%, with the osteofibrosus tunnel for the flexor hallucis longus in 76.5%, with the flexor retinaculum in 70%. The plantaris tendon showed projection to the crural fascia in 34 of % cases. Conclusion In the Kager’s fat pad there are present more connections than previously reported. All the connections unit at the level of the posterior process of the talus.

The aim of this study is to present a more extensile osteotomy performed for the treatment of Haglunds disease and the results of 2-year follow-up of these patients.Fifteen feet of 15 patients who underwent open surgery by the same surgeon between 2011 and 2015 were included in the study. In this technique, the Achilles tendon is split into two in the middle and tenotomized at its insertion. Retrocalcaneal bursa and exocytosis is completely excised and tenodesis of the Achilles tendon to its old insertion is performed with the help of two 5 mm suture anchors. All patients were discharged on the postoperative first day. Postoperatively, a short leg plaster cast was applied for six weeks with the ankle in slightly plantar flexed position. For the next six weeks, patients were followed up with an ankle foot orthosis with the ankle in neutral position. At the end of the third month, orthosis treatment was discontinued in all patients. The patients were evaluated with the visual analog scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores (FAOS) preoperatively and at 3 months postoperatively. The mean follow-up period was 27.4 months. A statistically significant difference was found between preoperative and postoperative for both VAS and FAOS scores (p [Med-Science 2019; 8(4.000): 923-6]

Purpose: The aim of the study was to establish the relationship between the shape of the calcaneal tuberosity (flat, stepped, rounded, normal) and the probability that retrocalcaneal bursitis among people who train running regularly. Methods: The study included a group of 30 runners who suffered from retrocalcaneal bursitis in the past, and 30 people who never had symptoms of this disease. The study was based on a diagnostic survey, as well as on clinical examination. The surface of the calcaneal tuberosity and the slope of the calcaneus were assessed using X-rays. The mobility of the bursa, its surface size, the thickness of the Achilles tendon and its attachment rate were established during an ultrasound examination. Results: Flat surface of the calcaneal tuberosity increases fourfold the risk of suffering from retrocalcaneal bursitis (OR = 4.3). The people whose calcaneus slope is above 25° are at increased risk of suffering from such an inflammation compared with the people whose calcaneus bone is more horizontal (OR = 2.8). The analysis shows that the thickness of the Achilles tendon (p = 0.001), the surface size of the bursa (p = 0.009), as well as the flat surface of the calcaneal tuberosity (p = 0.008) are strongly associated with the occurrence of retrocalcaneal bursitis. Conclusions: The flat shape of the calcaneal tuberosity increases the risk of bursitis. The risk of inflammation is higher when the Achilles tendon is thicker and the surface of the bursa is smaller than normal.

Haglund’s deformity is characterized as an enlarged prominence of the superior aspect of the posterior calcaneus, which can cause painful inflammation within the retrocalcaneal bursa and anterior surface of the Achilles tendon as a result of mechanical irritation. This may ultimately lead to the development of insertional Achilles tendinopathy. Operative treatment is indicated if conservative therapy, including shoe wear modification, physical therapy, and newer modalities including shockwave therapy, fails to relieve the pain. Endoscopic surgery has the advantages of fewer complications and shorter recovery times in comparison with the open technique. Endoscopic calcaneoplasty is performed using 2 portals, through which the Haglund’s prominence and the degenerative portion of the anterior Achilles tendon are debrided, providing better visualization compared to the open procedure. Endoscopic surgery has demonstrated good to excellent outcomes in the short to medium term. This article describes technique of endoscopic calcaneoplasty and Achilles tendoscopy.

Objectives Inflammation of the retrocalcaneal bursa (RB) is a common clinical problem, particularly in professional athletes. RB inflammation is often treated with corticosteroid injections however a number of reports suggest an increased risk of Achilles tendon (AT) rupture. The aim of this cadaveric study was to describe the anatomical connections of the RB and to investigate whether it is possible for fluid to move from the RB into AT tissue. Methods A total of 20 fresh-frozen AT specimens were used. In ten specimens, ink was injected into the RB. The remaining ten specimens were split into two groups to be injected with radiological contrast medium into the RB either with or without ultrasonography guidance (USG). Results In specimens injected with ink, diffusion outside the RB was observed with staining of the anterior portion of the AT. In eight contrast-injected specimens (five USG, three non-USG), a similar localised diffusion pattern was observed, with the contrast identified superiorly and anteriorly. In two contrast-injected specimens (non-USG), the diffusion pattern was more extensive. Conclusion This study confirmed the existence of connections between the RB and the AT, especially rich in the anteroinferior portion of the tendon, which should be considered a weak zone for substances injected into the RB. We hypothesise that this part of the AT might be most vulnerable to rupture after corticosteroid injections. Cite this article: P. A. Pękala, B. M. Henry, J. R. Pękala, K. Piska, K. A. Tomaszewski. The Achilles tendon and the retrocalcaneal bursa: An anatomical and radiological study. Bone Joint Res 2017;6:446–451. DOI:10.1302/2046-3758.67.BJR-2016-0340.R1.

The purpose of this study was to assess changes in the thickness of the retrocalcaneal bursa (RB) with respect to the ankle position with or without flexor hallucis longus (FHL) contraction. Forty feet of 20 female volunteers were examined. RB was sonographically scanned as the horizontal short-axis image of the posteromedial talar process and the calcaneal tuberosity. RB thickness was measured at three different ankle positions (20° dorsiflexion, neutral, and 40° plantar flexion) with or without FHL contraction. Without FHL contraction, the mean thickness of the RB was 2.6 mm in dorsiflexion, 2.4 mm in neutral, and 2.3 mm in plantar flexion. With FHL contraction, the mean thickness of the RB was 2.5 mm in dorsiflexion, 2.5 mm in neutral, and 2.3 mm in plantar flexion. No significant differences were detected with respect to the ankle position or FHL contraction. This study showed that in healthy subjects, the thickness of the RB in the horizontal plane did not change with respect to the ankle position with or without FHL contraction.

ObjectiveTo analyse the imaging changes in bone marrow oedema of the calcaneal prominence, retrocalcaneal bursa and degenerative Achilles tendon after the surgical treatment of insertional Achilles tendinopathy (IAT).MethodsThis retrospective study analysed patients with IAT and retrocalcaneal bursitis that were diagnosed based on their symptoms and radiographic and magnetic resonance imaging (MRI) examinations. For patients that had received 3 months of conservative treatment but still presented with symptoms, arthroscopic debridement of the retrocalcaneal bursa and resection of calcaneal prominence were undertaken. Patients with degeneration of the Achilles tendon underwent debridement of Achilles tendon calcification with an open incision. The last follow-up included radiographic and MRI imaging, Visual Analogue Scale (VAS) pain scores and American Orthopedic Foot and Ankle Society (AOFAS)-Ankle and Hindfoot scores.ResultsThirty patients were included (mean ± SD follow-up, 3.1 ± 0.5 years). The VAS pain and AOFAS-Ankle and Hindfoot scores were significantly improved after surgery. MRI showed that bone marrow oedema of the calcaneal prominence and the retrocalcaneal bursa was significantly reduced compared with preoperative values. There was no significant change in the high signal area of the IAT.ConclusionSurgical treatment of IAT and retrocalcaneal bursitis effectively alleviated local pain and restored function.

Modern humans have the longest Achilles tendon (AT) of all the living primates. It has been proposed that this anatomy increases locomotor efficiency and that its elongation may have played a crucial role in the origin and early evolution of the genus Homo. Unfortunately, determining the length of the AT in extinct hominins has been difficult as tendons do not fossilize. Several methods have been proposed for estimating the length of the AT from calcaneal morphology, but the results have been inconclusive. This study tested the relationship between the area of the superior calcaneal facet and AT length in extant primates. The superior facet is instructive because it anchors the retrocalcaneal bursa, a soft tissue structure which helps to reduce friction between the AT and the calcaneus. Calcanei from 145 extant anthropoid primates from 12 genera were photographed in posterior view and the relative superior facet size quantified. AT lengths were obtained from published sources. The relative area of the superior facet is predictive of AT length in primates (R2 = 0.83; p

Endoscopic calcaneoplasty is a minimally invasive technique for resection of inflamed retrocalcaneal bursa and resection of abnormal prominence over the postero superior part of calcaneum.In this article we would like to compare the results of open versus endoscopic calcaneoplasty after a minimun followup of one year. AIMS: To evaluate the functional outcome of patients with Haglunds deformity and compare open technique versus endoscopic method using AOFAS {American orthopaedic foot and ankle society hind foot} Scoring system after one year

article i nfo Article history: Received 19 July 2013 Accepted 3 December 2013 Achilles tendon insertion Haglund's disease Retrocalcaneal bursitis Achilles tendinopathy Heel pain Background: We questioned whether different forms of Achilles tendon overuse injuries can be differentiated by retrocalcaneal bursa pressure measurement. Methods: Retrocalcaneal bursa pressure was determined by using invasive pressure measurement in patients suffering from retrocalcaneal bursitis (n = 13) or Achilles tendinopathy (n = 15), respectively. Standardized measurementsweretakenwiththesubjectlyingprone.Initially,thefootandanklewasinaspontaneous,unsup- ported position. Then passive dorsiflexion was induced by an increasing pressure which was applied in five defined steps against the plantar forefoot. Findings: Mean pressures found in unloaded position were 30.5 (SD 28.9) mmHg in retrocalcaneal bursitis and �9.9 (SD 17.2) mmHg in Achilles tendinopathy (p b 0.001). A stepwise increase in passive ankle dorsiflexion was associated with increasing pressure values in both groups. The differences were p = 0.009 to 0.035 when dorsiflexion was initiated with 10, 20, 30, and 40 N, respectively. Dorsiflexion induced by 50 N load resulted in a mean pressure of 113.7 (SD 124.9) mmHg for retrocalcaneal bursitis and 32.5 (SD 48.9) mmHg for Achilles tendinopathy (p = 0,051). Interpretation: Higher retrocalcaneal bursa pressure values were found in patients suffering from chronic retrocalcaneal bursitis. This result supports the hypothesis that retrocalcaneal bursa hypertension leads to an impingement lesion of the corresponding anterior Achilles tendon.

Retrocalcaneal bursitis is an inflammation of the bursa located in the retrocalcaneal recess between the anterior aspect of the Achilles tendon and the posterosuperior part of the calcaneus. The inflammation is caused by repetitive impingement between the ventral side of the Achilles tendon and the posterosuperior calcaneal prominence. Patients present themselves with a typical pain when starting to walk after a period of rest. It can occur bilaterally, mainly in women and often at the end of the second or third decade. A distinction must be made between retrocalcaneal bursitis, superficial calcaneal bursitis, and insertional and midportion Achilles tendinopathy. This distinction can be made by acquiring a detailed medical history and physical examination (Figs. 10.1 and 10.2).

Background/Aim. In a condition of pain in the Achilles tendon insertion there are multiple structures involved, such as the Achilles tendon itself, the retrocalcaneal bursa and a bony protrusion at the calcaneal tuberosity called Haglund’s deformity. The innervation patterns of these structures are scarcely described, and the subcutaneous calcaneal bursa is traditionally not considered to be involved in the pathology. This study aimed at describing the innervation patterns of the four structures described above to provide a better understanding of possible origins of pain at the Achilles tendon insertion. Methods. Biopsies were taken from 10 patients with insertional Achilles tendinopathy, which had pathological changes in the subcutaneous and retrocalcaneal bursae, a Haglund deformity and Achilles tendon tendinopathy as verified by ultrasound. The biopsies were stained using immunohistochemistry in order to delineate the innervation patterns in the structures involved in insertional Achilles tendinopathy. Results. Immunohistochemical examinations found that the subcutaneous bursa scored the highest using a semi-quantitative evaluation of the degree of innervation when compared to the retrocalcaneal bursa, the Achilles tendon, and the calcaneal bone. Conclusions. These findings suggest that the subcutaneous bursa, which is traditionally not included in surgical treatment, may be a clinically important factor in insertional Achilles tendinopathy.

Insertional Achilles tendinopathy is a chronic condition in which patients describe functional impairment, pain, and swelling at the tendon insertion. Treatment is primarily nonsurgical with physical therapy, nonsteroidal anti-inflammatory drugs, rest, heel lifts, or heel sleeves; but for patients who fail nonsurgical management, surgical debridement of the Achilles tendon at its insertion can provide relief. The goal of surgery is to remove the diseased tendon and intratendinous calcifications, as well as to address associated pathology, including inflamed retrocalcaneal bursa, prominence of the posterior-superior calcaneal tuberosity, and gastrocnemius contracture. This article presents the author's preferred technique for surgical treatment of insertional Achilles tendinopathy and discusses the rationale behind this technique.

Posterior ankle arthroscopy can be used in the treatment of various conditions of the posterior ankle and subtalar joints as well as the retrocalcaneal bursa. This article describes the indications, operative technique, postoperative care, complications, and results of posterior ankle arthroscopy, with a particular emphasis on sporting individuals who present with posterior impingement.

Endoscopic calcaneoplasty is a minimally invasive technique for resection of inflamed retrocalcaneal bursa as well as the posterosuperior part of the calcaneus. A relative contra-indication for this technique is a tear of the Achilles tendon. In this report, we describe the treatment of a patient with Haglund's deformity associated with a tear of the Achilles tendon. Both the lesions are treated endoscopically. The technique is described and the pitfalls are discussed.

Anatomic and operative textbooks and current literature do not clearly describe the Achilles tendon interface to the calcaneal tuberosity. We dissected 51 specimens to identify the detailed anatomy of the Achilles tendon insertion. Achilles tendon fascicles expanded from the anterior aspect of the distal Achilles tendon over the retrocalcaneal bursa to the anterior part of the Haglund’s tuberosity in nearly half of the specimens. The insertion of the transverse section of the Achilles tendon regularly had a crescent-shape corresponding to the posterior calcaneal prominence. In transverse sections, all specimens had a curved appearance with a radius of curvature ranging from 13.8 mm to 43.6 mm (mean, 20.4 mm) and Achilles tendon extensions to the lateral and medial calcaneal surfaces reached 1.0 mm (mean) and 3.5 mm (mean) anterior in relation to the most posterior point of the calcaneal tuberosity. Knowledge of the arcuate configuration and of the medial and lateral extensions of the plantaris and the Achilles tendon insertion with respect to the transverse plane is important to avoid iatrogenic complications during resection of Haglund’s tuberosity.

Background: Lower extremity bursae are very vulnerable to injury during strenuous physical exercises. Understanding the imaging characteristics of normal bursae is essential for early diagnosis of morphological abnormalities. Therefore, we evaluated the normal range of lower extremity bursae in healthy young men using high-resolution ultrasound (HR-US) imaging. Methods: Bursae in the lower extremities were examined by HR-US in 290 Chinese healthy young men with a median age of 18 years (range, 18–23 years). The bilateral suprapatellar bursa (SPB), deep infrapatellar bursa (DIPB), popliteal bursa (PB), and retrocalcaneal bursa (RCB) were imaged and measured for analysis. Results: The HR-US identification rates of the SPB, DIPB, PB, and RCB were 89.0% (517/580), 55.0% (319/580), 29.4% (171/580), and 49.5% (287/580), respectively. With the assumption that the bursae were normal in 95% of the study participants, the length and width values at the maximal cross-section of the SPB, DIPB, PB, and RCB were ≤18.00 and 6.09 mm, 8.10 and 2.11 mm, 7.67 and 3.93 mm, and 7.82 and 2.04 mm, respectively. Conclusions: Using HR-US imaging, we were able to analyze lower extremity bursae with high detection rates in healthy young men. The normal ranges of lower extremity bursa dimensions in healthy young men measured by HR-US in this study could be used as reference values for evaluation of bursa abnormalities in the lower extremity.

The proper rehabilitation of posterior lower leg injuries is critical in achieving optimal clinical outcomes. Successful rehabilitation requires collaboration between all parties involved in the care of the patient and an injury-specific program that is tailored to patient goals. Although each case is unique, following fundamental principles of rehabilitation and evidence-based approaches should be the basis for development of the rehabilitation program. This chapter reviews the literature and provides recommendations for the rehabilitation of the following structures and injuries: distal hamstring tendon, proximal gastrocnemius and soleus, musculotendinous junction of gastrocnemius and soleus, popliteus, neurovascular entrapment, tibialis posterior, flexor hallucis longus, chronic exertional compartment syndrome (CECS), Achilles tendon, retrocalcaneal bursa, posterior impingement, and Sever’s apophysitis.

Haglund’s disease, an inflammation of the retrocalcaneal bursa and a bone enlargement on the back of the heel, is a painful syndrome mainly caused by the exostotic prominence of the posterior calcaneus. Conventional treatment consists of rest, shoewear modification, medical therapy and, in selected cases, surgery. We report the case of a 59-year-old male with a history of severe atraumatic monolateral heel pain treated with foot orthotics, rest and surgery with partial regression of symptoms. Owing to the persistent heel pain and physical impairment after surgery, the patient underwent radiotherapy, which was successful in relieving his symptoms.

To describe a lateral fluoroscopically guided retrocalcaneal bursa injection technique, report patient outcomes at 1-4 weeks after steroid/anesthetic retrocalcaneal bursal therapeutic injection, and correlate pre-injection diagnostic heel ultrasound variables with improvement in patient pain scores.After IRB approval, fluoroscopically guided therapeutic retrocalcaneal bursa injections performed using a lateral approach were retrospectively reviewed. Pre-injection heel ultrasound results and pre- and post-injection patient VAS pain scores (scale 0-10) were recorded. The Wilcox matched-pair test compared pain scores, and Spearman's rho assessed for correlation between pain score changes and heel ultrasound results.Thirty-two injections were performed in 30 patients (25 females, 5 males; mean 56.5 ± 9.3 years, range 39-75 years; 21 left heel, 11 right heel) with technical success in 32 of 32 cases (100 %). Insertional Achilles tendon pathology and retrocalcaneal bursitis were present in 31 of 32 cases (97 %) and 16 of 32 cases (50 %), respectively. Median pre- and post-procedure pain scores were 8 (IQR 7, 10) and 1.75 (IQR 0, 6). A statistically significant decrease in pain score was observed following injection, with a median change of 4.75 (IQR 3, 8; p 0.001). Clinically significant response (50 % reduction in pain score) was present in 69 % (95 % CI, 0.52-0.86; p 0.001). No significant correlation was identified between a decrease in pain score and a sonographically abnormal Achilles tendon or retrocalcaneal bursa.Fluoroscopically guided retrocalcaneal bursal steroid/anesthetic using a lateral approach is an effective technique. This technique yielded 100 % technical success and a clinically significant decrease in patient pain scores (p 0.001).

We report a case of focal tuberculous involvement of the posterior margin of the calcaneus with preservation of the articular margin. The route of infection was direct extension through tuberculous retrocalcaneal bursitis, a rare and atypical pathogenesis. Magnetic resonance imaging was helpful in ruling out neoplasm and in limiting the diagnosis to an inflammatory infectious process. (J Am Podiatr Med Assoc 95(3): 285–290, 2005)

Is it merely a curiosity that fat pads are found adjacent to the area of tendon affected by tendinopathy? We propose that fat pads share an anatomical and functional relationship with their adjacent tendons and may therefore contribute to the pathogenesis of tendinopathy. Fat pads and tendons have a shared blood supply,1 and cytokines produced in the fat pad have only a short distance to travel in order to affect the tendon.2 Fat pads lubricate, insulate, protect and provide structural support for tendons. However, the functional significance of the fat pad is often overlooked. In an early study of fat pad function, the distal tip of Kager's fat pad migrated into the retrocalcaneal bursa during ankle movement in healthy individuals, but not in an individual with a hindfoot disorder.3 This ‘variable plunger’ mechanism minimises pressure changes within the bursa during ankle movement. …

Deep retrocalcaneal bursa is a synovial bursa located deep to the Achilles tendon acting as friction attenuator between the Achilles tendon and the posterior superior aspect of the calcaneus. This structure allows for a smooth gliding between these structures during ankle movements, and in normal conditions, it cannot be demonstrated as it contains only a small amount of fluid.

AIM The goal of this study was to check the usefulness of ultrasonography as a diagnostic tool for a bursitis in the area of the Achilles tendon. Furthermore, we assessed the shape and size of the retrocalcaneal bursa of normal subjects. METHOD The ultrasonograms of 28 patients with a bursitis at the Achilles tendon were analysed. In addition, we sonographically examined the region of interest in 10 normal subjects (20 Achilles tendons). We used a 5 and/or a 7.5 MHz linear transducer. The examination was done in both standard planes. RESULTS The examination of 10 normal subjects could not reliably demonstrate a bursa in the expected location of the subachillic bursa or the subcutaneous calcaneal bursa in a single case. We could, however, depict a subachillic bursitis (echofree to hypoechoic) in 22 patients. A subcutaneous calcaneal bursitis was found in 7 cases. CONCLUSIONS The retrocalcaneal and subcutaneous calcaneal bursa is not demonstrable by ultrasonography in healthy people. Exsudation and proliferation of the bursa, however, facilitate the detection by ultrasound. Taking that into consideration, the sign of the bursitis is not the enlargement but the fact that the bursa is demonstrable at all by ultrasonography. In the case of the peritendinitis of the achilles tendon a concurrent bursitis should be looked for. During operative explorations an existing bursitis has to be removed. Ultrasonography is the method of choice for the diagnostic evaluation of a bursitis in the area of the achilles tendon.

A 42-year-old man presented with synovial osteochondromatosis (SO) of the retrocalcaneal bursa with intraosseous lesions in the calcaneum, leading to significant pain and consequent disability. Simple x-rays, computed tomography, and magnetic resonance imaging were performed preoperatively. The patient has remained asymptomatic, clinically and radiographically, without recurrent lesions for 18 months postoperatively.

To determine the amount and distribution of synovial fluid detectable with ultrasonography (US) of the hindfoot and ankle in asymptomatic volunteers.US was performed with a 7.5- or 10-MHz linear transducer of 60 hindfeet and ankles in 30 volunteers. Presence and amount of fluid were assessed in the ankle joint recesses, adjacent bursae, and tendon sheaths. Symmetry of bilateral fluid was evaluated.Fluid was detected in the anterior recess in 20 ankles (bilaterally in eight volunteers), retrocalcaneal bursa in 30 ankles (bilaterally in 12 volunteers), posterior tibial tendon sheath in 46 ankles (bilaterally in 19 volunteers), and common peroneal tendon sheath in seven ankles (bilaterally in three volunteers). No fluid was seen in the posterior recess. On average, symmetry was present for only the retrocalcaneal bursal and peroneal tendon sheath fluid.US of the hindfoot and ankle commonly depicts articular, bursal, and tendon sheath fluid in asymptomatic volunteers. The presence of fluid in these locations, even when unilateral or asymmetric, does not necessarily imply underlying abnormality.

The retrocalcaneal bursae, located between the posterior angle of the os calcis and the Achilles tendon, may become inflamed and hypertrophied. There are few objective tests available for the diagnosis of pain syndromes involving the hindfoot and it is often difficult to differentiate Achilles tendinitis and retrocalcaneal bursitis. Retrocalcaneal bursograms can provide further insight into chronic changes in the bursae associated with traumatic and inflammatory conditions. This report describes the anatomy of the retrocalcaneal bursa, the technique of its opacification, and the application of this technique to the diagnosis and treatment of painful hindfoot syndromes. In addition, the anatomy of the retrocalcaneal bursa was investigated further using latex casting techniques.Twelve cadaver limbs were injected with radiopaque latex casting material or renografin into the retrocalcaneal bursae. AP, lateral, and oblique radiographs were then obtained on the specimens. The size, capacity, and configuration of the postmortem bursae were measured and recorded. Subsequently, the cadaver limbs injected with the latex material were cooled and dissection was made of the retrocalcaneal bursae. The latex bursal molds were measured, graphically recorded, and photographed.Fifteen patients with signs and symptoms of retrocalcaneal bursitis and eight asymptomatic patients were selected for this study and injected with radiopaque material into the bursae. Anteroposterior, lateral, and oblique radiographs were then obtained. The size, capacity, and configuration of the retrocalcaneal bursae were measured and recorded.The anatomic characteristics noted from the latex bursal molds correlated well with the findings on bursography. Bursographic findings in patients with retrocalcaneal bursitis can provide insight into the diagnosis and clinical management of this disorder.

The purpose of this study was to evaluate the long-term results of surgery for chronic Achilles tendinitis. Twenty-seven competitive athletes (average age 32, range 17–56 years) and 21 noncompetitive athletes (average age 40, range 20–65 years) were studied. The average duration of preoperative symptoms was 2.7 years (range 0.25–14 years) for the competitive athletes and 4.0 years (range 0.5–27 years) for the noncompetitive athletes. In all cases, conservative treatment failed as assessed by severity of pain and extent of disability. Surgical procedures included: tenolysis (A), n = 20; tenolysis, excision of the posterior aspect of the os calcis, and the retrocalcaneal bursa (B), n = 25; and tenolysis and excision of the retrocalcaneal bursa only (C), n = 3. The average length of follow-up for all groups was 52 months (range 15–96 months). The criteria for assessment of recovery were based on the degree to which the patients were able to return to their preinjury activity level. Where there was a complete absence of pain, the result was considered excellent. Where occasional but minor symptoms persisted, the result was termed good. Using these criteria, procedure A was associated with a 95% success rate while procedures B and C (pooled because of small n) were associated with a 93% success rate. The average time for all patients to return to their preinjury level of activity was 22 ± 12 weeks following procedure A, 29 ± 16 weeks following procedure B, and 32 ± 19 weeks following procedure C. The time to “full activity” for all patients was significantly, (p < 0.05), longer following procedure B compared with procedure A. The recovery times following procedure A were significantly, (p < 0.05), longer for noncompetitive compared with competitive athletes. Ten patients did not return to their previous level of activity, four because of persistent heel pain and six due to other reasons. We conclude that surgery for chronic Achilles tendinitis is efficacious in recalcitrant cases but the choice of surgical procedure affects the time to recovery.

The Achilles tendon has a spiral configuration, internally rotating prior to inserting inferiorly onto the posterior calcaneus. The retrocalcaneal bursa lies anterior to the Achilles tendon, is located between the tendon and the calcaneus immediately proximal to its insertion, and provides lubrication for the tendon passing over the bone. The retro-Achilles bursa is posterior to the Achilles tendon at its insertion and functions to lubricate motion between the Achilles tendon and the overlying skin. In insertional Achilles tendinopathy, both the retrocalcaneal bursa and calcaneal tuberosity, and also the retroAchilles bursa, are potentially involved in the pathologic process. 2

BackgroundInitial nonoperative treatment of pain at the Achilles tendon, often referred to as “tendinitis,” is not always successful.HypothesisSurgical treatment is effective for patients with insertional tendinitis unrelieved by nonoperative measures.Study DesignRetrospective cohort study.MethodsThirty-five patients (41 feet) who had painful Achilles tendon syndrome unrelieved by 6 months of nonoperative measures were treated surgically. The technique consisted of a single incision along the lateral border of the Achilles tendon. The dissection exposed the retrocalcaneal bursa and fat pad, which were completely excised along with any scarred and thickened paratenon. A partial calcaneal exostectomy of the tubercle was performed.ResultsAt a minimum follow-up of 20 months (average, 39), the patients’ pain scores (rated from 0 to 6) improved from 4.7 (SD, 1.1) preoperatively to 1.5 (SD, 1.3); 90% had complete or significant relief of symptoms, 10% felt improved, and none felt unchanged or worse.ConclusionsSurgical treatment of chronic Achilles tendon pain with resection of the prominent tuberosity, complete debridement of the bursa, excision of thickened, scarred paratenon, and removal of accessible calcific deposits within the tendon is an effective treatment.

The anatomy, physiology, and pathophysiology of the retrocalcaneal bursa (RB) have been described well1,2. Ultrasound has been shown to be a valuable tool by enhancing the accuracy of challenging procedures that in the past have been performed blindly, such as aspiration or injection of the RB3,4. We describe ultrasound-assisted corticosteroid injection of this structure. A 55-year-old woman …

Background 12 weeks of eccentric exercise has been shown to be a useful therapy for Achilles tendinopathy, but little is known of the time-course of recovery, or the nature of any structural changes during therapy. Objectives To assess the time-course and pattern of Achilles tendon symptoms, thickness, stiffness, and ultrasound (US) signs during 12 weeks of eccentric exercise (EE). Methods Five subjects of age range (mean) 38–52 (46) years with main-body AT were included. For each subject, serial measurements of VISA-A score, the presence of neovascularisation and grey-scale US signs within the tendon, and the thickness of the Achilles tendon at 3 points were recorded for the first three weeks of a twelve week EE programme. Results Median VISA-A score increased from 48.5 to 54.5 (p=0.116). Median mid-tendon thickness decreased from 0.834 cm to 0.790 cm (p=0.107). A trend towards a decrease in tendon thickness was noted directly superior to the retrocalcaneal bursa and at the soleus myotendinous junction. Neovascularisation, paratenon blurring and hypoechoic areas improved in 1/3, 1/3 and 2/5 tendons respectively. No significant change occurred in median tendon stiffness. Conclusion 3 weeks of EE do not produce significant changes in AT symptoms and tendon thickness or stiffness, but improve US signs and neovascularisation in some subjects. The non-significance of findings may be a type II error and further work with larger sample sizes is planned.

We aspirated the retrocalcaneal bursa in cadavers to determine the characteristics of bursal fluid. A small amount of clear, viscous fluid was constantly present in the bursa. Leucocyte count was low, and the mucin clot test was good. With the same technique we aspirated the retrocalcaneal bursae of 4 patients. Three had Reiter's syndrome; the bursal fluid was inflammatory, and symptoms promptly resolved after local corticosteroid injection. The fourth patient presented with heel pain; intracellular, positively birefringent crystals were present in the aspirate, consistent with the diagnosis of pseudogout.

To clarify the function of the retrocalcaneal bursa the hindfoot was studied by magnetic resonance imaging at various positions of the ankle joint. In normal individuals a tongue-like extension of the retromalleolar fat pad entered the bursa during plantar flexion as the angle between Achilles tendon and calcaneus widened. The reverse occurred in dorsiflexion. In contrast, in a patient with spondyloarthritis and retrocalcaneal bursitis excessive cavitary fluid prevented the intrusion of the fat pad. The sliding motion of the fat pad in and out of the bursa during ankle motion allows a more caudal, advantageous insertion of the Achilles tendon into the calcaneus.

Abnormalities of the Achilles tendon and adjacent bursae are common problems that may be difficult to diagnose clinically. Twenty patients with symptoms involving the Achilles tendon and 10 control subjects were evaluated with real-time sonography in order to explore the role of sonography in defining abnormalities of the tendon and adjacent bursae and in differentiating between conditions requiring surgery and those needing conservative therapy. Normal anatomic structures seen consistently included the Achilles tendon, the musculotendinous junction, the retrocalcaneal bursa, and the calcaneal tendon insertion site. The normal range of tendon thickness was 4-9 mm (mean, 6.2 mm). All patients had repeat sonograms after either clinical resolution (14 cases) or surgical intervention (six cases). Twelve of the symptomatic patients had abnormal findings. Partial ruptures of the Achilles tendon were reliably differentiated from other lesions. No evidence of tendon thickening was found in tendinitis. Tendon thickening was found only in cases of previous tendon rupture. The superficial tendo Achillis bursa was imaged only when inflamed. Sonography was found to differentiate reliably between conditions that require surgical intervention and those that will respond to conservative therapy.

Diseases and injuries of several specific structures in the heel region have been an enduring focus of medicine: The anatomical terminology of many of these structures has not been established until recently. The aim of the study was a historical analysis of the advances of anatomical terminology of three selected morphological units in the heel region--the Achilles tendon, calcaneus and retrocalcaneal bursa. It starts with a critical evaluation of the mythological eposes, the Illiad and Odyssey, describing the exploits of heroes in the Trojan war, followed by a review of relevant terms used for the designation of selected heel structures in the Middle Ages as well as in the 18" and 19" centuries. Principal versions of Latin anatomical terms used for the denotation of the mentioned structures are discussed. Recently applicable Latin terms and their recommended English synonyms, according to the latest version of Terminologia Anatomica (1998) are summed up. It surveys examples of "not very appropriate" terms, which are frequently used in clinical literature. The authors consider the use of official anatomical terms (both Latin and English) as an important step for the improvement of the clinical expressions and formulations.