You are shown six images of a 58-year-old male athlete with persistent heel pain for two years. The case seems simple, but have a look at the images, and see how many conditions or abnormalities you can find.
With arrows now highlighting the key areas (images 7 to 12), see if you can answer the following questions.
Q1 – On images 7, 8 and 9, what does the pink arrow point to? If you think “pump bump”, you might come up with the right answer.
Q2 – The blue arrow on image 9 points to what?
Q3 – The green arrows on images 10, 11 and 12 point to what?
Q4 – The yellow arrow points to an abnormality in the calcaneus itself on images 10, 11 and 12. How would you describe this abnormality?
Q5 – A series of orange arrows are seen on image 12. How would you describe this abnormality?
A1 – A Haglund deformity, also known as a “pump-bump” in honor of high-heel wearers, is an exacerbating morphologic problem in this patient.
A2 – Delamination and/or separation of the footprint of the Achilles. These deeper fibers tend to have more of a soleal than a gastrocnemius contribution.
A3 – Supracalcaneal bursitis. But, there is more. A focal “spot” of hypointensity is seen on image 11. The findings represent a coalescent area of calcium pyrophosphate deposition disease (CPPD).
A4 – An erosion from traction enthesopathy. Erosions in the heel and plantar fascia may sometimes conjure up visions of seronegative spondyloarthropathies. However, in this case, the abnormality was mechanical due to exercise, overuse, and alteration in bone morphology. Erosion represents the inflammatory sequela of mechanical irritation and CPPD.
A5 – Any of the below would do:
- Undersurface delamination as a partial thickness tear
- 50% depth partial thickness undersurface tear (concealed from the superficial surface) associated with a hypertrophied tendon
- Moderate depth fraying and delamination in a hypertrophic tendon
A cocktail of these adjectives would do just fine.
1 – Delamination partial thickness tear
2 – Hypertrophic tendinopathy
3 – Bursitis
4 – Calcium Pyrophosphate Deposition (CPPD)
5 – “Pump-bump” or Haglund deformity
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