0:01

So here we've got our pump bump or haglin deformity.

0:04

This is a posterior superior calcaneus deformity.

0:07

And I have to admit, in a lot of cases

0:09

where I've got secondary findings that suggest

0:12

that I've got a haglin syndrome, don't

0:15

to me look like there's an amazingly

0:18

prominent posterior superior bump,

0:20

but it doesn't take a whole lot.

0:22

So as you look at this very subtle prominence

0:25

of the posterior superior aspect of the calcaneus,

0:28

but you certainly have changes in the soft tissues,

0:31

those nicely characterized on the mr.

0:33

There's the retrocalcaneal bursa.

0:36

Reactive marrow change in the bone tend tendinosis

0:39

of the Achilles altered signal intensity

0:41

and CAGR fat pad, high signal intensity here.

0:45

And what you will come to know is the superficial tendon

0:48

achilles bursa, all those things going along

0:50

with the Haglin syndrome.

0:52

So when we're thinking about how we identify,

0:56

if we're doing it in a very systematic fashion, according

0:59

to the literature, these are all the lines

1:01

and things that you can draw to identify it.

1:03

And if you've got bone that extends superficial to this line

1:07

that you've drawn, that qualifies to be called

1:11

a haglin deformity.

1:13

But really, again, these look very subtle in some cases.

1:16

And of course the soft tissue findings really be lie.

1:20

What's really happening at the poster aspect

1:22

of the calcaneus.

1:23

These are the easy ones.

1:24

Huge enthesophyte, definitely you've got this spur formation

1:28

or proliferative bone formation.

1:30

We talked about the constellation of findings

1:32

that give you the syndrome.

1:34

The achilles tendinosis,

1:35

the superficial TenDot achilles bursa that's here.

1:40

Sometimes people call this a pre achilles bursa.

1:44

The real name is superficial tend achilles bursa.

1:48

I call it what you want. Bursa superficial two.

1:52

Um, you know, the poster margin of the calcaneus,

1:54

the name is not really so super, super important,

1:58

but really describing the findings.

2:00

The retrocalcaneal bur is that shown in the illustration?

2:04

Of course, that abnormality of the poster superior aspect

2:07

of the calcaneus.

2:10

Here's the mr showing all of those things.

2:14

And another example, I like this one

2:16

because it really shows nicely the superficial

2:18

tend achilles bursa.

2:20

You know, these don't have to just be filled with fluid

2:23

because it starts to have this irritation.

2:25

Sometimes you'll see that it's intermediate

2:27

and sometimes even low signal intensity there, um,

2:30

because of the kind of friction or mass effect chronically.

2:34

Um, here you're seeing the achilles tendon cagr fat pad

2:37

and retrocalcaneal bursal findings as well.

2:40

Another example, same thing here

2:42

with a very prominent posterior superior bump.

2:45

So looking for that whole constellation of findings

2:49

with respect to the Hagman syndrome.

2:52

So enthesitis can clearly happen.

2:55

And there's a whole concept

2:57

that was introduced several years

2:59

Ago, uh, by Michael Benjamin, uh, who is, uh, a very, uh,

3:03

well-known pathologist who went over, um,

3:06

the detailed anatomy of the tendon attachment, um,

3:10

of the Achilles to the calcaneus,

3:12

calling it a synovial sial complex.

3:15

So he talked about the fibro cartilaginous nodules

3:18

that exist in the distal Achilles at the ende attachment,

3:22

the presence of synovium here, uh, with respect

3:25

to the retrocalcaneal bursa and,

3:27

and how that can really manifest

3:29

with different types of pathology.

3:31

And so we can see findings here,

3:33

both in synovial inflammatory processes like rheumatoid

3:36

arthritis as well as the seronegative spondyloarthropathies.

3:40

And remember that inflammatory mediators as well

3:43

as immune targets are present in those

3:46

seronegative spondyloarthropathies.

3:48

Sometimes as imagers,

3:49

because we really dealt with standard clinical MR sequences,

3:54

it's not apparent to us

3:55

that these fibro cartilaginous nodules exist at

3:58

the emphasis of tendons.

4:00

But in the majority of tendons,

4:02

we have a transitional tissue of fibrocartilage

4:05

between the tensile tendon and the bone.

4:08

And so that's why those serve as an immune target

4:12

and we get enthesitis

4:13

with those sero negative spondyloarthropathies.

4:17

An example here showing enal disease, really

4:21

prominent retrocalcaneal bursal changes reactive merit

4:24

change, uh, even erosion here at the emphasis

4:27

and in a patient with rheumatoid arthritis.

4:30

And so our take home points, uh, from our discussion

4:33

of metatarsal and heel pain is that these

4:37

clinical entities have broad differential considerations.

4:40

Uh, an understanding of complex anatomy is really crucial

4:45

for, um, diagnosis

4:46

and characterization of the pathology

4:49

that occurs in these different entities.

4:51

So thanks so much for your time

4:53

and it's always an honor to share the virtual podium

4:56

with Don and the rest of the UCSD group.