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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 12
| Issue : 1 | Page : 46-49 |
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Haglund's syndrome: Radiographical evaluation and its clinical relevance
Aradhana Sanga1, Rajesh K Kushwaha2, Rakesh K Vidrohi3, Prerna Sanga4, Saikat Kumar Dey5
1 Assistant Professor, Department of Anatomy, RIMS, Ranchi, Jharkhand, India
2 Medical Officer, CHC, Hariharganj, Jharkhand, India
3 Specialist Medical Officer, Department of Radiology MRMCH, Palamu, Jharkhand, India
4 Development Research Professional, Department of Social Research Development, TISS, Mumbai, India
5 Assistant Professor, Department of Anatomy, Burdwan Medical College, Purba Bardhaman, West Bengal, India
| Date of Submission | 23-Nov-2022 |
| Date of Decision | 27-Jan-2023 |
| Date of Acceptance | 30-Jan-2023 |
| Date of Web Publication | 21-Feb-2023 |
Correspondence Address:
Saikat Kumar Dey
206, Moran Road, P.O. Gondalpara, P.S. Chandannagar, Hooghly - 712 137, West Bengal
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/NJCA.NJCA_228_22
Background: Haglund's syndrome an important cause of posterior heel pain presents with a prominent bony contour, a retrocalcaneal bursitis or achillis tendinitis these can also occur in isolation hence for the diagnosis of etiology of Haglund's disease certain radiological parameters and soft tissue parameters have been created to evaluate the anatomical variations which will assist in its exact diagnosis. Study aims to distinguish between the bony and soft tissue causes of Haglund's disease radiologically. Methodology: After Institutional ethical committee clearance an observational cross-sectional study was conducted with subjects coming to radiology OPD for X-ray foot with complains of posterior heel pain fulfilling inclusion and exclusion criteria were examined for X-ray lateral view of foot. Parameters like calcaneal inclination angle (CIA), Fowler Philip angle (FPA), parallel pitch line (PPL), Steffenson & Evenson angle (SEA) measured, posterior/calcaneal spur and posterior calcaneal step were noted. The data obtained was analyzed for mean, Standard deviation, sensitivity % and false negative %. Result: Sensitivity of the parameters were analyzed to find CIA, SEA &PPL to be 63.3%, 55% and 55% sensitive respectively. CIA could be assigned most sensitive but regarding soft tissue parameters none were sensitive. Conclusion: CIA, SEA & PPL were found to be sensitive among bony parameters. But none of the soft tissue parameters were sensitive radiologically highlighting a need for its correlation with clinical symptom in peripheral health centers where MRI is not available. Sensitivity of bony and soft tissue parameters were analyzed to find CIA, SEA & PPL to be sensitive. CIA could be assigned most sensitive among bony parameter but with regards to soft tissue parameters none were sensitive.
Keywords: Bony and soft tissue parameters, calcaneal inclination angle, Haglund's syndrome, radiological evaluation
How to cite this article:
Sanga A, Kushwaha RK, Vidrohi RK, Sanga P, Dey SK. Haglund's syndrome: Radiographical evaluation and its clinical relevance. Natl J Clin Anat 2023;12:46-9 |
How to cite this URL:
Sanga A, Kushwaha RK, Vidrohi RK, Sanga P, Dey SK. Haglund's syndrome: Radiographical evaluation and its clinical relevance. Natl J Clin Anat [serial online] 2023 [cited 2023 Mar 20];12:46-9. Available from: http://www.njca.info/text.asp?2023/12/1/46/370139 |
| Introduction | |  |
Haglund's syndrome named after Haugland P who first attributed the deformity of the posterior-superior portion of the calcaneus as an important cause of posterior heel pain is a collection of bony as well as soft tissue abnormality of the posterior calcaneus which presents with a prominent bony contour, a retrocalcaneal bursitis, or Achilles tendinitis.[1],[2],[3] According to Jukes et al.,[4] this problem was most common among two groups: one being middle-aged overweight and the other being young and active runners. These can also occur in isolation; hence, for the diagnosis of etiology of Haglund's disease, certain radiological parameters (angles or lines) and soft tissue abnormality depicting parameters (spur or steps) have been developed to evaluate the anatomical variations which will assist in its exact diagnosis.[5],[6],[7]
The study aimed to estimate the most sensitive radiological parameter among bony and soft tissue parameters to diagnose Haglund's disease.
| Materials and Methods | | |
After obtaining permission from the institutional ethical committee, subjects between 18 and 60 years of age (18–30 years susceptible to soft tissue abnormality and 30–80 years susceptible to bony abnormality) coming to the radiology outpatient department for X-ray foot and having complaints of posterior heel pain due to causes other than arthritis, injury, neurological cause, or pregnancy were approached. A brief history of those giving consent was taken, and those fulfilling inclusion and exclusion criteria (pathological diseases of foot, history of injury foot, neurological causes, and pregnancy) were examined by weight-bearing X-ray foot lateral view. Fifty subjects were included in the study with total 60 heels (10 bilateral), there were 21 males and 39 females, with an average age of 39 years. Among 31 subjects who had pain in the right foot, 21 were female and 10 were male, and out of 29 subjects who had pain in the left foot, 18 were female and 11 were male.
With the help of white marker pencil, protractor and scale lines and angles were drawn on X-ray plate against the view box and measured.
Parameters such as calcaneal inclination angle (CIA), Fowler–Philip angle (FPA), Stevenson and Evenson angle (SEA), parallel pitch line (PPL), planter/calcaneal spur, and posterior calcaneal step were measured.[8]
Working definitions
- Calcaneal inclination angle: Intersection of the tangent along horizontal surface and another tangent drawn joining the medial tuberosity and the anterior tubercle.[8] Normal range = 15°–17°, symptomatic >19° [Figure 1]
- Fowler–Philip angle: The angles created by a line perpendicular to both the inferior border of the calcaneus and the posterosuperior surface of the greater tuberosity.[8] Normal range of angle = 44°–69°, angle >75 is considered to cause symptoms [Figure 1]
- Steffenson and Evenson angle: At the point where a line tangential to the greater tuberosity meets another line parallel to the long axis of the calcaneus.[9] Normal value = <60°, symptomatic = >65° [Figure 1]
- Parallel pitch line: The calcaneal pitch angle baseline is the lower PPL (a tangent to the anterior tubercle and the medial tuberosity).[9] A perpendicular is created between the baseline and the posterior lip of the talus articular facet. At a distance d from the baseline, the upper PPL is drawn parallel to it. The posterosuperior crest should typically continue to extend below the upper PPL, i.e. PPL−. It is regarded abnormal if it is over this line, or PPL+ [Figure 1]
- Calcaneal spur: A pointed projection of calcification at the tendo-Achilles insertion[9] [Figure 2]
- Posterior calcaneal step: The middle of the posterior surface of the calcaneus develops a calcaneal step as a result of calcification of the Achilles tendon[9] [Figure 3].
 | Figure 1: Lateral view X-ray plate showing measurement of various angles. Angle a = Fowler–Philip angle, Angle b = calcaneal inclination angle, Angle c = Steffensen and Evensen angle, Line A = line tangential to the posterosuperior surface of the greater tuberosity, Line B = intersection of the baseline tangent to the anterior tubercle and medial tuberosity. Line C = line along the horizontal surface. Line D = line along the long axis of the calcaneus. Line F = upper PPL. PPL: Parallel pitch line
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 | Figure 2: Calcaneal spur: Calcification at the insertion of tendo-Achilles in the form of a pointed projection[9]
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 | Figure 3: Posterior calcaneal step: Calcification of Achilles tendon produces a calcaneal step in the middle of the posterior surface of the calcaneus[9]
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| Results | | |
The studied parameters are tabulated in [Table 1]. | Table 1: Comparison of sensitivity percentage and false-negative percentage of various parameters
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The sensitivity of all the parameters was analyzed to find CIA, SEA, and PPL to be 63.3%, 55%, and 55%, respectively. CIA could be assigned most sensitive, but with regard to soft tissue parameters, none were sensitive. The radiological measurements of a few patients are shown in [Figure 4], [Figure 5], [Figure 6], [Figure 7]. | Figure 4: Graphical representation showing the sensitivity of various parameters in %
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 | Figure 5: Angle a = FP angle positive measuring 75°and Angle b = CIA positive measuring 27°. The rest parameters are normal
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 | Figure 6: (a) PPL positive, other parameters being normal. (b) C. spur as well as C. step in the same patient. PPL: Parallel pitch line
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 | Figure 7: (a) Angle b = CIA positive measuring 22°and PPL positive. (b) C. spur in the same patient. CIA: Calcaneal inclination angle, PPL: Parallel pitch line
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| Discussion | | |
This study was conducted to examine the diagnostic value of various radiological parameters described in the literature for diagnosis of posterior heel pain. Fifty subjects were included in the study with total 60 heels (10 bilateral). There were 21 males and 39 females, with an average age of 39 years. Out of these, 31 had pain in the right foot and 29 in the left foot. Among 31 subjects who had pain in the right foot, 21 were female and 10 were male, and out of 29 subjects who had pain in the left foot, 18 were female and 11 were male [Figure 8].
According to Shah and Wong[10] and Vyce et al.,[11] Haglund's disease though common in both genders has a female preponderance which is also evident from our study with 39 females and 21 males showing the symptoms. Among females, it is more common on the right side, while in males, it is slightly more on left.
A comparison of the study done by various authors, as shown in [Table 2], shows CIA to be the most reliable parameter compared to FPA found to be most reliable by other authors.
CIA, the most significant bony parameter, compared to the rest three parameters is important as calcaneus is more vertical in cavus deformity, which affects the prominence of the posterosuperior aspect of the calcaneus and predisposes to bursitis. Fuglsang and Troup and R Singh found CIA to be 57% and 29.6%, respectively. Both had found Fowler and Philip angle to be most significant. For CIA, Sharma SC found only 3 heels out of 59, thus showing only 5% affected. In our study, 41 out of 60 heels had more than 17°, thus amounting to 68%.
Soft tissue parameter, calcaneal spur, and calcaneal spur were found very less sensitive compared to all the other studies.
| Conclusion | | |
Although three bony parameters appear to be reliable in distinguishing Haglund's disease due to bony causes compared with soft tissue parameters, a need for its correlation with clinical symptom is found to play a role if soft tissue investigation like magnetic resonance imaging (MRI) is not done routinely for diagnosis of posterior heel pain. The causes of posterior heel pain due to combination of changes in shape and inclination around the calcaneus can, to some extent, be calculated by the above angles and could be managed nonoperatively.
Recommendations
- Calcaneal axial view/modified calcaneal axial view could be used for better analysis of the middle and superior third of the calcaneus
- Advanced radiological techniques such as computed tomography scan and MRI could be used for additional visualization of the calcaneus and Achilles tendon pathology[16]
- Exact documentation of distribution of body weight equally on two limbs during taking standing X-ray could not be done due to lack of proper instruments
- New parameters such as X-Y ratio and angle of BRINK can also be studied in future studies.[17]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 14. | Fiamengo SA, Warren RF, Marshall JL, Vigorita VT, Hersh A. Posterior heel pain associated with a calcaneal step and Achilles tendon calcification. Clin Orthop Relat Res 1982;(167):203-11. |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]
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