Fig 1 - uploaded by Priya Sundararajan
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(A) Chauveaux-Liet angle: subtracting the angulation between the posterior superior surface of the calcaneus and the vertical pull of the Achilles tendon (C) from the calcaneal inclination angle (A): Chauveaux-Liet angle ¼ angle A À angle C. Between these angles is the Fowler-Philip angle (B). The total angle is the sum of angles A and B. (B) Positive parallel pitch lines in a patient with Haglund's syndrome.
Source publication
The surgical correction of insertional Achilles tendinopathy (IAT) repair typically involves tendon debridement, osteophyte removal, lengthening of the gastroc-soleus complex, and resection of the posterior superior calcaneal eminence. Limited evidence has supported decompression of the superior calcaneal prominence, because this step has had a pro...
Context in source publication
Context 1
... 20 lateral foot, weightbearing radiographs on file were evaluated. No bilateral radiographs were taken from group 2. The following radiographic notations were taken from all lateral weightbearing foot radiographs: calcaneal inclination angle, Fowler-Philip angle (20), total angle (21), parallel pitch lines (22), Chauveaux-Liet angle (23), and the presence or absence of retrocalcaneal enthesiophytes (24) ( Figs. 1 and 2). All patients in group 1 had undergone ankle MRI of the affected site. ...
Similar publications
Background:
Surgical treatment of insertional Achilles tendinopathy often involves detachment and debridement of the Achilles tendon insertion. A recent study has shown that knotted suture bridge fixation of the Achilles to the calcaneus is biomechanically superior to single-row fixation, but there is an absence of literature on the use of differe...
Citations
... Insertional Achilles tendinopathy presents various radiographic characteristics, including exostosis and intra-tendon calcification. However, there is limited research on the radiographic evaluation of this condition [3,4]. ...
... In studies comparing an asymptomatic control group with patients experiencing insertional Achilles tendinopathy, Haglund's syndrome, or posterior heel pain, the Fowler-Phillip angle in the symptomatic and asymptomatic groups was 62.3 and 60. [3,4,7,11,32]. ...
... This suggests that calcaneal posterior tilt alone has little association with the onset of insertional Achilles tendinopathy, but a combination of calcaneal posterior tilt and the specific shape of the calcaneus may be well associated with disease onset. In the literature, the values of the calcaneal pitch angle in the Haglund syndrome/ insertional Achilles tendinopathy group and the control group were 22.1 and 20.3 according to Bulstra, 21.6 and 18.4 according to Sundararajan,19.9 and 19.7 according to Singh, and 25.5 and 21.7 according to Tourné, respectively [4,5,11,30], with each study demonstrating no significant differences between the groups. Meanwhile, the Chauveau-Liet angle values were 3.7 and − 4.4 according to Sundararajan and 19.1 and 11.5 according to Tourné, for each heel, respectively [4,11]. ...
Purpose
This retrospective study aimed to investigate whether the standard radiographic indicators for Haglund's syndrome are applicable to insertional Achilles tendinopathy.
Methods
Patients who underwent surgery for insertional Achilles tendinopathy in one heel and experienced no pain in the other heel were enrolled in this study. Preoperative calibrated radiographs of the lateral view of the calcaneus were assessed using (1) calcaneal pitch angle, (2) Fowler-Phillip angle, (3) posterior calcaneal angle, (4) Chauveau-Liet angle, (5) X/Y ratio, (6) Haglund’s deformity height, (7) Haglund’s deformity peak angle, (8) calcification length, (9) calcification width, (10) parallel pitch test, and (11) presence of free body. The Wilcoxon signed rank test and McNemar’s test were used for statistical analyses.
Results
Seventy-one patients (52 males; mean age, 57.2; mean body mass index, 27.1) were included. Mean values for each index in the symptomatic and asymptomatic heels were as follows, respectively: (1) 23.5, 23.0 (p = 0.30); (2) 58.9, 57.8 (p < 0.05); (3) 7.6, 9.2 (p < 0.05); (4) 15.8, 13.9 (p < 0.05); (5) 2.8, 2.8 (p = 0.87); (6) 5.4, 5.0 (p < 0.05); (7) 99.6, 99.0 (p = 0.44); (8) 10.5, 7.6 (p < 0.001); and (9) 5.1, 4.4 (p < 0.05). The sensitivity, specificity, and area under curve of significant indicators were as follows, respectively: (2) 0.78, 0.37, 0.55; (3) 0.45, 0.72, 0.58; (4) 0.63, 0.54, 0.57; (6) 0.45, 0.69, 0.59; (8) 0.48, 0.80, 0.66; and (9) 0.63, 0.54, 0.59. The presence of free body also showed a significant difference between both heels (p < 0.05).
Conclusion
Some radiographic indicators for Haglund's syndrome are applicable to the diagnosis of insertional Achilles tendinopathy. A comparison of the parameters of Haglund’s syndrome with those of insertional Achilles tendinopathy may illuminate the etiology and pathology of insertional Achilles tendinopathy and lead to novel treatments.
... En pacientes con pies cavos, calcáneos verticalizados o deformidad de Haglund, ante un aumento de las solicitaciones (como en casos de sobreuso, carrera, etc.) en portadores de calzados inadecuados con contrafuertes rígidos, se puede producir el denominado síndrome de Haglund, caracterizado por la tríada: deformidad de Haglund, bursitis retroaquílea y tendinopatía aquílea insercional (calcificada o no). Estas nomenclaturas se entremezclan en ocasiones y generalmente se asocian, aunque algunos autores marcan diferencias entre ellas (25) . Puede darse degeneración del tendón de Aquiles aislada en su zona de inserción, aunque resulta menos frecuente (26) . ...
... El tratamiento quirúrgico de las tendinopatías insercionales aquíleas suele incluir diferentes gestos quirúrgicos, aunque estos deben personalizarse en cada caso: desbridamiento de bursas inflamadas y tejido hipertrófico, exéresis de calcificaciones bursales e intratendinosas, resección de tejido degenerativo intratendinoso y de prominencias óseas (gesto constante si existe deformidad de Haglund), sin que exista consenso respecto al tamaño de la resección (25) . ...
... More recently, the Chauveaux-Liet angle has been used to determine whether a Zadek osteotomy is indicated. The Chauveaux-Liet angle is represented by the difference between the calcaneal pitch angle or angle of verticalization and the angle formed by the vertical line tangent to the most posterior point of the greater tuberosity and the straight line joining this point to the apex of the posterosuperior crest [34]. Jerosch considers a Chauveaux-Liet angle that is greater than 30° to be a good indication for a dorsal closing wedge osteotomy [35]. ...
Background: The Zadek osteotomy, a dorsal closing wedge osteotomy of the calcaneus, has been described as a treatment option in patients with Insertional Achilles Tendinopathy (IAT) that have failed conservative management. The aim of this study was to evaluate the clinical outcomes and the complications of the Zadek for the management of IAT.
Methods: PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were searched for all studies to November 2022. PRISMA guidelines were followed. The overall estimates of effect were presented as Weighted Mean Difference (WMD) and 95% confidence intervals (CIs). Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4).
Results: Ten studies with 232 patients were included. Functional scores and pain levels were significantly improved after the Zadek osteotomy (p<0.00001). There were a total of 22 complications reported in the included studies and they were all considered minor. The most common complications were superficial wound infection and sural nerve paraesthesia.
Conclusions: The Zadek osteotomy is a safe and effective procedure for patients with IAT. There are no well-designed randomized controlled trials in the literature assessing the outcomes of a Zadek osteotomy against alternate surgical treatments and future research should focus on this.
Level of Evidence II
... However, based on the Sundararajan study, there is a 25% chance of having insertional Achilles tendinopathy, with or without retrocalcaneal bursitis (Haglund syndrome). 12 In this case, a better surgical outcome is achieved with debridement on their degenerative Achilles tendon and/or retrocalcaneal bursa. 10 The surgery options for Haglund deformity include open resection of the exostosis and inflamed bursa (with retrocalcaneal bursitis), endoscopic calcaneoplasty, and calcaneal osteotomy. ...
p>Deformitas Haglund adalah kelainan anatomi tulang kalkaneus berupa eksostosis di bagian posterosuperior, merupakan penyebab kedua tersering keluhan nyeri tumit sisi belakang pada atlet profesional dan amatir. Patogenesisnya masih belum diketahui; pada fase kronis, bursa retrokalkaneal dan tendon insersi Achilles akan ikut meradang. Kombinasi ini disebut dengan sindrom Haglund. Diagnosis ditegakkan dengan anamnesis komprehensif, pemeriksaan klinis, dan pencitraan diagnostik (X-ray, ultrasonografi, dan Magnetic Resonance Imaging) secara cermat. Tata laksana lini pertama adalah terapi konservatif untuk mengurangi tekanan pada eksostosis. Lini kedua adalah pembedahan untuk menghilangkan eksostosis dengan atau tanpa debridemen bursa retrokalkaneal yang meradang dan/atau tendinopati Achilles.
Haglund deformity is an exostosis of the posterosuperior calcaneus. It is the second most common cause of posterior heel pain in professional and amateur athletes. The pathogenesis is still unknown; in chronic phase, retrocalcaneal bursa and Achilles insertional tendon will be inflamed. This condition is also known as Haglund syndrome. Diagnosis required comprehensive history-taking, clinical examination, and diagnostic imaging (X-ray, ultrasound, and Magnetic Resonance Imaging). First-line treatment is conservative therapy to reduce pressure on the exostosis. The second-line is surgery to remove the exostosis with or without debridement of the inflamed retrocalcaneal bursa or Achilles tendinopathy.</p
... However, based on the Sundararajan study, there is a 25% chance of having insertional Achilles tendinopathy, with or without retrocalcaneal bursitis (Haglund syndrome). 12 In this case, a better surgical outcome is achieved with debridement on their degenerative Achilles tendon and/or retrocalcaneal bursa. 10 The surgery options for Haglund deformity include open resection of the exostosis and inflamed bursa (with retrocalcaneal bursitis), endoscopic calcaneoplasty, and calcaneal osteotomy. ...
Deformitas Haglund adalah kelainan anatomi tulang kalkaneus berupa eksostosis di bagian posterosuperior, merupakan penyebab kedua tersering keluhan nyeri tumit sisi belakang pada atlet profesional dan amatir. Patogenesisnya masih belum diketahui; pada fase kronis, bursa retrokalkaneal dan tendon insersi Achilles akan ikut meradang. Kombinasi ini disebut dengan sindrom Haglund. Diagnosis ditegakkan dengan anamnesis komprehensif, pemeriksaan klinis, dan pencitraan diagnostik (X-ray, ultrasonografi, dan magnetic resonance imaging) secara cermat. Tata laksana lini pertama adalah terapi konservatif untuk mengurangi tekanan pada eksostosis. Lini kedua adalah pembedahan untuk menghilangkan eksostosis dengan atau tanpa debridemen bursa retrokalkaneal yang meradang dan/atau tendinopati Achilles. Haglund deformity is an exostosis of the posterosuperior calcaneus. It is the second most common cause of posterior heel pain in professional and amateur athletes. The pathogenesis is still unknown; in the chronic phase, the retrocalcaneal bursa and Achilles insertional tendon will be inflamed. This condition is also known as Haglund syndrome. Diagnosis required comprehensive history-taking, clinical examination, and diagnostic imaging (X-ray, ultrasound, and magnetic resonance imaging). First-line treatment is conservative therapy to reduce pressure on the exostosis. The second line is surgery to remove the exostosis with or without debridement of the inflamed retrocalcaneal bursa or Achilles tendinopathy.
... A normal Fowler-Philip angle ranges from 44-69 degrees. 19 Figure 1a had an angle of 70.7 degrees, 1b had an angle of 72.2 degrees and 1c had an angle of 66.9 degrees. Furthermore, posterior calcaneal enthesophytes were present on imaging (Figure 1a-c). ...
Accessory muscles in the posterior leg compartment are commonly encountered. Although accessory muscles are usually asymptomatic, they can lead to symptomatology. Three patients who underwent surgery for Achilles tendon pathology had accessory muscles encountered. Two patients had a flexor digitorum accessorius longus muscle and one had an accessory soleus muscle. Magnetic resonance imaging is a useful resource to assess tendinopathies. If an accessory muscle is present and identified on mangnetic resonance imaging, the surgeon can tailor their surgical plan accordingly.
... Radiographic imaging may be initially useful in determining the presence of enthesophytes at the tendon insertion site on the calcaneus, calcifications within the Achilles tendon, or presence of Haglund's deformity (Fig. 1). 10,35 Additionally, the Chauveaux-Liet angle may be used to help determine presence of a Haglund's deformity, and if the calcaneus may need to be altered in the vertical angle/posterior-superior aspect, or corrected by a horizontalization osteotomy. 36,37 Magnetic resonance imaging (MRI) is capable of identifying chronic degenerative changes in the tendon, partial tearing in the tendon, and may also be useful in recognizing edema at the tendon insertion or calcaneal protuberance (Fig. 2). 10 MRI is also helpful in planning surgical treatment of the Achilles tendon insertion by giving a more robust picture of the condition of the tendon. ...
... 36,37 Magnetic resonance imaging (MRI) is capable of identifying chronic degenerative changes in the tendon, partial tearing in the tendon, and may also be useful in recognizing edema at the tendon insertion or calcaneal protuberance (Fig. 2). 10 MRI is also helpful in planning surgical treatment of the Achilles tendon insertion by giving a more robust picture of the condition of the tendon. 35 Ultrasound imaging may be useful in visualizing tendon ruptures or overall tendon thickness, and allow for dynamic evaluation of the structure, but is less dependable on identifying Figure 1 Preoperative lateral radiographs in a patient with symptomatic IAT demonstrating intratendinous calcification along with a prominent superior posterior calcaneal tuberosity. ...
Insertional Achilles tendinopathy (IAT) is a degenerative process at the insertion of the Achilles tendon onto the calcaneus. Many possible reasons for why this condition develops exist, and is likely due to a combination of factors, but an abnormal, bony prominence at the posterior-superior aspect of the calcaneus, known as a Haglund's deformity, may play a role in the development of IAT. This exostosis may cause increased compressive forces and irritation of the tendon at the calcaneal insertion, leading to pain and degenerative changes within the tendon. Non-operative treatments, including activity modification, eccentric exercise training, extracorporeal shock wave therapy, shoe wear modifications and orthotic inserts, and injection therapies, are the first line of treatment, but have shown varying levels of success in treating IAT. Operative treatments may be indicated after 3-6 months of failed non-operative treatment. In the case of IAT with Haglund's deformity, we describe the procedure of removing the exostosis, debriding the tendon, and reattaching the tendon to the calcaneus, with the use of the flexor hallucis longus tendon, when indicated. Return to sport timeline may be dependent upon severity of tendon damage pre-injury, but care should be taken to monitor load and pain management in a return to run progression program.
... Although most studies comparing radiologic parameters in symptomatic to asymptomatic patients have been retrospective, it is one of very few studies that not only assessed radiographic and MRI parameters but also assessed the outcome by standardized patient-reported outcome scores. Second, due to the retrospective design of the study, complete imaging sets (radiographs and MRI) were not available for all patients [7,21,23,24,26,33,36]. In addition, the MRI protocol was not standardized. ...
... Therefore, the study might have been underpowered. But again, the number of patients included compares favorably to most previous studies assessing patient-reported outcome scores in IAT [23,26,33,36]. The next limitation could be the extensile surgical treatment approach. ...
Introduction
Diagnosis and treatment of insertional tendinopathy of the Achilles tendon (IAT) remains a challenge. The aim of this study was to assess the influence of pre-operative radiological pathologies on the patient-reported outcomes following open debridement of all pathologies for IAT.
Materials and methods
In this IRB-approved retrospective correlation and comparative study, patients with pre-operative imaging were identified from the authors’ retrospective IAT database comprising of 118 patients. All were treated by a standardized surgical treatment strategy utilizing a midline, transachillary approach and debridement of all pathologies. A total of fifteen radiologic parameters were measured on radiographs (RX) and MRI. The patient-reported outcomes were assessed using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A-G) and the general health questionnaire SF-12 at a minimum follow-up of 12 months. The data are presented as mean ± SD (95% CI).
Results
88 patients (74.6%) with an average age of 50 ± 12 (47–52) years were included. Radiographs were available in 68 patients and MRI in 53. The mean follow-up was 3.8 ± 1.9 (3.4–4.3) years. The overall VISA-A-G was 81 ± 22 (77–86), the SF-12 PCS 54 ± 7 (52–55), and the SF-12 MCS 52 ± 9 (50–54) points. None of the assessed radiological parameters had a significant influence on the patient-reported outcome following surgical treatment for IAT.
Conclusion
In this retrospective correlation study, no significant association was found between preoperative radiographic and MRI radiologic parameters for IAT and postoperative patient-reported outcomes (VISA-A-G and SF-12).
... A total of 74 patients with Haglund syndrome who had calcaneoplasty from June 2015 to June 2019 were included in this retrospective study. The inclusion criteria were posterior heel pain and swelling, as well as the following characteristics shown on magnetic resonance imaging (MRI) 19,22,23 : retrocalcaneal exudation or bursitis, heterogeneous intratendinous hyperintensity <50% (grade 0, 1a, or 1b according to the Pomranz classification 15 ), bone marrow edema in the posterosuperior calcaneal tuberosity, bony spurs on the Achilles insertion, and anteroposterior Achilles tendon thickness of 2 cm above the insertion measured in the horizontal view. 14,22 In addition, the MRI had to be at least 6 months after the failed nonoperative treatment. ...
... Radiographic parameters were measured on lateral ankle radiographs taken preoperatively to determine the characteristics of Haglund deformity in each group, including the pitch line, Haglund height, Chauveaux-Liet angle, and Fowler-Philip angle 8,23 (Figure 4). ...
Background
Although endoscopic calcaneoplasty and retrocalcaneal debridement have been extensively applied to treat Haglund syndrome, evidence of the value of the endoscopic procedure remains to be fully established.
Purpose/Hypothesis
The purpose of this study was to compare the postoperative outcomes and the amount of osteotomy between open and endoscopic surgery for the treatment of Haglund syndrome. It was hypothesized that endoscopic calcaneoplasty would lead to higher patient satisfaction and lower complication rates compared with open surgical techniques.
Study Design
Cohort study; Level of evidence, 3.
Methods
The following postoperative outcomes were compared between the open surgery group (n = 20) and the endoscopic surgery group (n = 27): visual analog scale for pain, American Orthopaedic Foot & Ankle Society ankle-hindfoot scale, Foot Function Index, Tegner score, Ankle Activity Score, and 36-Item Short Form Health Survey; postoperative complications; and duration of surgery. To determine the extent of resection, the authors compared the calcaneal height ratio, calcaneal resection ratio, calcaneal resection angle, pitch line, and Haglund deformity height between groups. The learning curve for endoscopic calcaneoplasty was also calculated.
Results
There were no significant differences between the open and endoscopic groups on any outcome score. Two patients in the open group reported temporary paresthesia around the incisional site, indicating sural nerve injuries; no complication was reported in the endoscopy group. None of the parameters for extent of resection were statistically significant between the groups. The duration of surgery was 44.90 ± 10.52 and 65.39 ± 11.12 minutes in the open and endoscopy groups, respectively ( P = .001). Regarding the learning curve for endoscopic calcaneoplasty (6 surgeons; 27 follow-up patients; 9 patients lost to follow-up), the duration of surgery reached a steady point of 55.68 ± 4.19 minutes after the fourth operation.
Conclusion
The results of this study indicated that the endoscopy procedure was as effective as the open procedure. The endoscopic procedure required significantly more time than the open procedure, and the duration of the endoscopic procedure was shortened only after the fourth operation, suggesting that it requires high technical skills and familiarity with the anatomic relationships.
... According to some sources, the co-occurrence of a bigger eminence of the calcaneal tuberosity and the inflammation of the retrocalcaneal bursa, related to its insertion into the bone, is 25% [18]. There are no reports of any anatomical variations in the surface shape of the calcaneal tuberosity, nor of any other possible associations with the occurrence of retrocalcaneal bursitis. ...
Purpose:
The aim of the study was to establish the relationship between the shape of the calcaneal tuberosity (flat, stepped, rounded, normal) and the probability that retrocalcaneal bursitis among people who train running regularly.
Methods:
The study included a group of 30 runners who suffered from retrocalcaneal bursitis in the past, and 30 people who never had symptoms of this disease. The study was based on a diagnostic survey, as well as on clinical examination. The surface of the calcaneal tuberosity and the slope of the calcaneus were assessed using X-rays. The mobility of the bursa, its surface size, the thickness of the Achilles tendon and its attachment rate were established during an ultrasound examination.
Results:
Flat surface of the calcaneal tuberosity increases fourfold the risk of suffering from retrocalcaneal bursitis (OR = 4.3). The people whose calcaneus slope is above 25° are at increased risk of suffering from such an inflammation compared with the people whose calcaneus bone is more horizontal (OR = 2.8). The analysis shows that the thickness of the Achilles tendon (p = 0.001), the surface size of the bursa (p = 0.009), as well as the flat surface of the calcaneal tuberosity (p = 0.008) are strongly associated with the occurrence of retrocalcaneal bursitis.
Conclusions:
The flat shape of the calcaneal tuberosity increases the risk of bursitis. The risk of inflammation is higher when the Achilles tendon is thicker and the surface of the bursa is smaller than normal.
