Patient's complain: Retrocalcaneal pain and swelling persisting for weeks, months and some time for years. Insidious in onset. Pain varies in intensity and swelling varies in size depending on patient's day to day activities. patient finds difficulty in squatting and climbing up & down stairs. High heel shoes or walking on toes somewhat relieves pain.
On examination: retrocalcaneal swelling is localized at the level of superior third of the posterior tuberosity of the calcaneus. As swelling is deeper to the TENDO-ACHALIS it is prominent on the sides of tendon and is not seen over it. Swelling is less obvious when ankle is planter flexed / patient stands on toes and it becomes prominent when ankle is dorsiflexed. In acute onset , swelling is somewhat warm and tender even over the tendoachalis more so when tendon is relaxed.
Pathological anatomy: Due to some odd process natural anatomy of the posterior surface of the calcaneus changes and develops a bony protuberance at its superior angle. It may be natural or due to infection, trauma, benign growth etc. (shown with red marker in Fig.2) so much so it starts rubbing and pinching the anterior surface of the TA irritating the in between bursa which becomes inflamed i.e. bursitis leading to bursal swelling due to its thickened wall distended with inflammatory fluid causing pain and swelling which pops on both medial and lateral sides of the tendon. The swelling becomes more prominent whenever TA tendon tightens on weight bearing more so with dorsiflexion of the ankle while squatting, walking, climbing up down stairs, going uphill etc.
Treatment of the Haglund's syndrome: temporarily pain and inflammation can be reduced with rest and patient is asked to use high-heel footwear while weight bearing. To cure the condition the bony protuberance has to be surgically excised without damaging TA insertion and avoid wait bearing till the surgical wound has healed properly.
Insertion of Achilles tendon: -As the tendo-Achilles approaches its insertion the tendon flattens to expand horizontally, and become thick aponeurotic to insert to the whole width of the ridged middle surface. The flattened tendon at its insertion forms an acute angle with the proximal smooth surface and the triangular space thus formed is lined with a synovial sheath. This arrangement facilitates smooth sliding of flattened end of TA over the proximal part of calcaneus during the dorsiflexion of the ankle joint. During active planter flexion the acute angle between flattened TA and the proximal part of calcaneus somewhat opens up and in dorsiflexion the space gets almost totally reduced so much so the tendon almost rubs against the smooth superior part of the posterior surface of calcaneus. Thus, presence of any bony protuberance and or roughness in the superior part of posterior surface pinches the anterior surface of flattened TA when ankle is dorsiflexed irritating the bursa between the bone and the tendon. This repeated movements of the ankle causes inflammation of the retrocalcaneal bursa which gets filled with synovial fluid causing pain and swelling. As the bursa is deeper to the TA, the swelling pouches of synovial fluid are formed on either sides of the tense TA and not over it giving a dumb-bell appearance just proximal to insertion of TA. The pain gets aggravated and the dumb-bell swelling on the sides of TA becomes tense and prominent on dorsiflexion and is relieved partially or fully with planter flexion of the ankle joint.(Fig.2)
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