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Case 336

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Male patient, 45 years old, clerk, is overweight and has chronic pain in the posterior region of the left heel, without irradiation. Denies changes in the standard of pain nor history of rheumatic diseases. On physical examination: pain on palpation of the posterior region of the left heel. Simple radiography of ankle was obtained as an initial approach.

Given the clinical history and the image presented, what is the most appropriate step to be taken next for diagnosis elucidation?

a) Computed tomography (CT) with contrast

25%

b) Bone scintigraphy

25%

c) Magnetic resonance imaging (MRI)

25%

d) Ultrasonography (US) of calcaneus

25%
   

Image analysis

 

Image 1. Simple X-ray of theleft ankle, mediolateral profile incidence.Bone protuberance - Haglund's deformity (red arrow) - on the upper posterior border of the calcaneus (red dashed line). Plantar fascia insertion point in the calcaneus (dashed yellow line). Enthesopathy inproximal portion of the plantar fascia - calcaneus enthesopathy (yellow arrow). Soft tissue involvement can not be excluded. Heterogeneity of bone trabeculation highlighted, with areas of higher and lower density, which may be relatedto stress fracture.

Highlights

- The pain location (posterior heel) is essential for the differential diagnosis in Haglund's syndrome;

- Bone protuberance in the calcaneus posterosuperior region may be associated with bursitis and Achilles’ tendinitis, characterizing Haglund's disease or syndrome;

- The simple radiography in the mediolateral projection is the 1st choice examination ;

-  MRI findings compatible with Haglund's syndrome include: spinal cord edema radiating out of the prominence, pre or retroachillian bursitis  and insertional tendinopathy.

References

- Tu P and Bytomski J. Diagnosis of Heel Pain. American Family Physician. 2011.

- Fields KB. Evaluation and diagnosis of common causes of foot pain in adults. In: UpToDate. Available at: https://www.uptodate.com/contents/evaluation-and-diagnosis-of-common-causes-of-foot-pain-in-adults?search=haglund%20Syndrome&source=search_result&selectedTitle=1~5&usage_type=default&display_rank = 1: H13378346. Accessed on: 01/20/19.

- Vaishya R, Agarwal A, Azizi A, Vijay V. Haglund's Syndrome: A Commonly Seen Mysterious Condition. Cureus. 2016.

-Appropriateness Criteria [Internet]. Acsearch.acr.org. 2019. Available at: https://acsearch.acr.org/list. Accessed on 2/4/2019.

Authors

William Alves, 6th year medical student at Universidade Federal de Minas Gerais

Email: willp.alves [at] gmail.com

Supervisors

Ana Rita da Gloria Soares, Radiologist at the Department of Radiology and Diagnostic Imaging at the Madre Teresa Hospital, Belo Horizonte, MG.

Email: soares.ar[at]globo.com

 

Júlio Guerra Domingues, Professor of the Department of Anatomy and Image at UFMG

Email: juliogdomingues [at] gmail.com

Reviewers

 Lucas Cantaruti, Mateus Nardelli, Prof. José Nelson Mendes Vieira, Profa. Viviane Santuari Parisotto Marino

Translated by

Luana Fonseca de Almeida, 4th year medical student at Universidade Federal de Minas Gerais.

Email: luana.fonseca.almeida[at]gmail.com

 

Test question

UFU (2017) - On the Haglund deformity, what is the correct alternative?

a) It is more common in women

25%

b) Usually requires surgical treatment

25%

c) It is caused by acute inflammation of the calcaneal bursa

25%

d) It has the same time of evolution of the contractional tendinitis of the calcaneus tendon

25%

e) It is better evaluated with calcaneus axial radiography

25%
   

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