The lateral plain film view of the ankle demonstrates soft tissue thickening of the distal Achilles tendon, at its insertion on the posterior calcaneus, as well as soft tissue denstiy within the retrocalcaneal bursa.Sagittal and axial fat-suppressed T2-weighted images demonstrate fusiform enlargement of the distal Achilles tendon at its insertion on the posterior tuberosity of the os calcis, with heterogeneous intrasubstance signal intensity. There is an associated fluid collection in the retrocalcaneal bursa and marrow edema in the adjacent posterior calcaneus. History and imaging findings are most consistent with Haglund's syndrome.
Imaging findings demonstrate the typical appearance of insertional Achilles tendinitis and retrocalcaneal bursitis, a constellation of findings referred to as Haglund's syndrome, or "pump-bump." Differential considerations for these findings would include systemic inflammatory processes, such as rheumatoid arthritis, seronegative arthropathy, and gout.
The Achilles tendon inserts onto the posterior calcaneus, with two associated bursa.
The bursa that lies deep to the Achilles tendon, between the Achilles tendon and the calcaneus, is termed the retrocalcaneal bursa.
The bursa that lies superficial to the distal Achilles tendon is termed the Achilles bursa. Haglund syndrome occurs as a result of repetitive mechanical effects that cause insertional Achilles tendinitis and retrocalcaneal bursitis. Achilles bursitis may coexist.
This condition can be seen in the patients of either sex at any age, but is most often seen in athletes and people who wear tight-fitting shoes, classically high heels.
Finally, Haglund's syndrome may be caused by Haglund's deformity, which is a prominent superior posterior calcaneal process, which impinges the retrocalcaneal bursa against the Achilles tendons during dorsiflexion.
Plain films are often sufficient in demonstrating the abnormality, as well as excluding other osseous causes of heel pain, such as calcaneal stress fracture.
The lateral image is usually the most helpful, demonstrating thickening at the insertion of the Achilles tendon and soft tissue density in the region of the retrocalcaneal bursa.
MR demonstrates heterogeneous thickening of the distal Achilles tendon and fluid in the retrocalcaneal and/or Achilles bursa.
Haglund's deformity may also be identified. Erosive changes within the calcaneus should raise suspicion for a systemic inflammatory process, such as rheumatoid arthritis.
The mainstay treatment of Haglund's syndrome is conservative therapy, consisting of rest, anti-inflammatory medication, and footwear modification. Immobilization with a cast may be necessary, if activity restriction alone is insufficient. Surgery is reserved for complicated cases, including persistent or progressive symptoms despite conservative therapy or Achilles tendon rupture.