Laboratory Studies
- If the retrocalcaneal bursitis cannot be explained by local factors (eg, poorly fitting shoes, increased running, high heels), or if systemic symptoms or signs of rheumatologic involvement exist, consider laboratory studies to evaluate the possibility of gout (hyperuricemia), rheumatoid arthritis (rheumatoid factor [RF]), and seronegative spondyloarthropathies (eg, human leukocyte antigen [HLA] B-27, erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]).
Imaging Studies
- Plain radiographs of the calcaneus may reveal a Haglund deformity (increased prominence of the posterosuperior aspect of the calcaneus). However, on weight-bearing lateral radiographs, the retrocalcaneal recess often appears normal even in patients with retrocalcaneal bursitis, limiting its usefulness in making this diagnosis.[6]
- Imaging of patients with retrocalcaneal bursitis may have an absence of the normal radiolucency that is seen in the posteroinferior corner of Kager's fat pad. This may occur with or without an associated erosion of the calcaneus.[7]
- Plain radiographs can be used to evaluate for stress fracture of the calcaneus. If the studies are negative for a stress fracture, but a stress fracture remains a significant diagnostic consideration, the clinician may wish to pursue 3-phase bone scanning or computed tomography (CT) scanning of the calcaneus.
- Magnetic resonance imaging (MRI) may demonstrate bursal inflammation, but this modality probably does not offer much more information than that found by careful physical examination. Theoretically, MRI could help the physician to determine whether the inflammation is within the subcutaneous bursa, the subtendinous bursa, or even within the tendon itself; however, such testing is generally not necessary.
- Ultrasonography may be a potentially useful tool for diagnosing pathologies of the Achilles tendon.[8] (See the Procedures section below.)
- Some clinicians have suggested that ultrasonography can be used in place of MRI in cases in which imaging is desired to investigate pathology at the posterior heel. One study concluded that extended field-of-view sonography (EFOVS) when combined with traditional gray-scale sonography has similar sensitivity and specificity to MRI for diagnosing calcaneal bursitis in addition to more rapid results, lower cost, and lack of contraindications.[9]
Procedures
- Many clinicians advocate the use of corticosteroid injection(s) into the affected bursa, with particular care to avoid injection within the Achilles tendon. Although there is a theoretical risk of tendon rupture, prospective, randomized studies have not been performed to definitively establish a causal relationship between steroid injections and such tendon ruptures. Instead, the association between steroid injections and subsequent tendon ruptures is mostly based on retrospective case reports. Thus, the cases that were more likely to go on to rupture were potentially those in which a more severe presentation prompted the steroid injections in the first place.A case report by Sofka et al demonstrated that retrocalcaneal bursitis can be diagnosed and treated with ultrasonography.[10] This modality can be used to guide injection into the retrocalcaneal bursa with a combination of local anesthetic (eg, lidocaine, with relief within minutes and duration of several hours) and corticosteroid (eg, triamcinolone [Kenalog; Bristol-Myers Squibb Company, Princeton, NJ], with anti-inflammatory effect within 24-48 hours and a relief duration of weeks to months). In contrast, in an animal study, Hugate et al demonstrated the adverse effects of local corticosteroid injections (both within the tendon substance and into the retrocalcaneal bursa) on the biomechanical properties of the Achilles tendon.[11] The authors stressed that ultrasonographic guidance helps to ensure reliable and accurate delivery of medication into the bursa, while concurrently avoiding intratendinous injection.
McGee DJ. Lower leg, ankle, and foot. Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1992:448-515.
Snider RK, ed. Foot and ankle. Essentials of Musculoskeletal Care. 2nd ed. Rosemont, Ill: American Academy of Orthopedic Surgeons; 1997:366-489.
Young JL, Olsen NK, Press JM. Musculoskeletal disorders of the lower limbs. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996:783-812.
Brinker MR, Miller MD. The adult foot. Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders Co; 1999:342-63.
Teebagy AK. Leg and ankle. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999:241-7.
van Sterkenburg MN, Muller B, Maas M, Sierevelt IN, van Dijk CN. Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis. Acta Orthop. Jun 2010;81(3):387-90. [Medline].
Ly JQ, Bui-Mansfield LT. Anatomy of and abnormalities associated with Kager's fat Pad. AJR Am J Roentgenol. Jan 2004;182(1):147-54. [Medline]. [Full Text].
Blankstein A, Cohen I, Diamant L, et al. Achilles tendon pain and related pathologies: diagnosis by ultrasonography. Isr Med Assoc J. Aug 2001;3(8):575-8. [Medline].
Reiter M, Ulreich N, Dirisamer A, Tscholakoff D, Bucek RA. [Extended field-of-view sonography in Achilles tendon disease: a comparison with MR imaging]. Rofo. May 2004;176(5):704-8. [Medline].
Sofka CM, Adler RS, Positano R, Pavlov H, Luchs JS. Haglund's syndrome: diagnosis and treatment using sonography. HSS J. Feb 2006;2(1):27-9. [Medline]. [Full Text].
Hugate R, Pennypacker J, Saunders M, Juliano P. The effects of intratendinous and retrocalcaneal intrabursal injections of corticosteroid on the biomechanical properties of rabbit Achilles tendons. J Bone Joint Surg Am. Apr 2004;86-A(4):794-801. [Medline].
Anderson JA, Suero E, O'Loughlin PF, Kennedy JG. Surgery for retrocalcaneal bursitis: a tendon-splitting versus a lateral approach. Clin Orthop Relat Res. Jul 2008;466(7):1678-82. [Medline]. [Full Text].
Ortmann FW, McBryde AM. Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis. Foot Ankle Int. Feb 2007;28(2):149-53. [Medline].
Anderson JA, Suero E, O'Loughlin PF, Kennedy JG. Surgery for retrocalcaneal bursitis: a tendon-splitting versus a lateral approach. Clin Orthop Relat Res. Jul 2008;466(7):1678-82. [Medline]. [Full Text].
Green SM, ed. Nonsteroidal anti-inflammatories. Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon Publishing; 2000:11-2.
Kachlik D, Baca V, Cepelik M, et al. Clinical anatomy of the retrocalcaneal bursa. Surg Radiol Anat. Jun 2008;30(4):347-53. [Medline].
Mutlu H, Sildiroglu H, Pekkafali Z, Kizilkaya E, Cermik H. MRI appearance of retrocalcaneal bursitis and rheumatoid nodule in a patient with rheumatoid arthritis. Clin Rheumatol. Sep 2006;25(5):734-6. [Medline].
Olsen NK, Press JM, Young JL. Bursal injections. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:36-43.
Suzuki T, Tohda E, Ishihara K. Power Doppler ultrasonography of symptomatic rheumatoid arthritis ankles revealed a positive association between tenosynovitis and rheumatoid factor. Mod Rheumatol. 2009;19(3):235-44. [Medline].
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