Endoscopic Procedures for Retrocalcaneal Bursitis, Achilles Tendon, Posterior Tibial Tendon, Peroneal Tendons, and Flexor Hallucis Longus Tendon

Endoscopic Procedures for Retrocalcaneal Bursitis, Achilles Tendon, Posterior Tibial Tendon, Peroneal Tendons, and Flexor Hallucis Longus Tendon






Arthroscopic surgery is regarded as one of the three greatest improvements in the diagnosis and treatment of musculoskeletal disorders.1 Ankle arthroscopy experienced major technological advancements in the 20th century. In 1930, the American physician, Michael S. Burman, MD, a resident at the Hospital for Joint Disease in New York, went to Germany for a fellowship in endoscopy.1 Shortly after, he published his results on three endoscopically examined cadaveric ankles.2 Tagaki and later Watanabe made considerable contributions to arthroscopic surgery. Watanabe developed the first fiberoptic scope, the “#22,” in 1967 and later published a series of 28 ankle arthroscopies in 1972 (see Chap. 1).3

Over the last few decades, ankle arthroscopy has become an important procedure with numerous indications. Both anterior and posterior pathology as well as tendon pathology can be addressed. Endoscopic approaches offer multiple advantages over open procedures; among others, it provides a direct visualization of structures without the need of an extensive surgical approach; improved assessment of articular cartilage; less postoperative morbidity; faster and functional rehabilitation; and earlier resumption of sports, and treatment can be offered at an outpatient clinic.1, 4, 5, 6 Posterior ankle problems pose a diagnostic and therapeutic challenge, based on their nature, but also due to the deep location of hindfoot structures.

Historically, the ankle joint was approached by a three-portal technique, the anteromedial, anterolateral, and posterolateral portals. Using this technique, the patient is placed in the supine position.7, 8, 9 The traditional posteromedial portal has been associated with potential damage to the tibial nerve, the posterior tibial artery, and local tendons.10

In 2000, the senior author introduced a two-portal endoscopic approach to the hindfoot with the patient in the prone position.11 This technique has shown to provide an excellent access to the posterior ankle compartment, the subtalar joint, and extra-articular structures.11, 12, 13, 14 Later, he introduced an endoscopic approach to the peroneal tendons, posterior tibial tendon, and the Achilles tendon.15, 16, 17 This chapter provides up-to-date information on posterior ankle arthroscopy and tendoscopy with a wide variety of indications highlighted.



Achilles tendon pathology can be divided into two separate entities, noninsertional and insertional.18, 19 The first can present as a local degeneration of the tendon, which most often occurs in combination with paratendinopathy. Most patients present with a nodular thickening of the Achilles tendon. The pain is predominantly located at the medial side.20 Insertional pathology is related to abnormalities at the insertion of the Achilles tendon, including the posterior aspect of the calcaneus and the retrocalcaneal bursa. This section describes the noninsertional tendinopathies, which can be divided into three entities: tendinopathy, paratendinopathy, or a combination.


The Achilles tendon is the distal tendinous extension of the medial and lateral heads of the gastrocnemius and soleus muscle. The tendon inserts distally on the mid-posterior aspect of the calcaneus. The plantaris tendon is the distal part of a biarticular plantaris muscle. It inserts proximally on the lateral femoral condyle and distally on the calcaneus at the medial side of the Achilles tendon. Simultaneous knee and ankle movements result in a different pull of the soleus and plantaris tendons. A combined tendinopathy and paratendinopathy is typically located 5 to 7 cm proximal of the insertion of the Achilles tendon into the calcaneus. In the healthy patient, the plantaris tendon moves separately from the Achilles tendon. In case of a chronic paratendinopathy, the plantaris tendon gets more or less fixed to the Achilles tendon at the level of the nodule. Hence, separate tendon movements are restricted. This might provide an explanation for the medially located pain.16

Diagnostic Imaging

Magnetic resonance imaging (MRI) and ultrasonography (US) can provide useful information to differentiate between the various forms of tendinopathy.24



In 1928, Patrick Haglund described a patient with a painful hindfoot. He interpreted this pain being caused by a prominent posterosuperior aspect of the calcaneus, in conjunction with a sharp rigid heel counter.45 Retrocalcaneal bursitis is caused by repetitive impingement of the retrocalcaneal bursa between the posterior aspect of the calcaneus and the anterior aspect of the Achilles tendon. A swelling is present at the level of the posterosuperior calcaneal prominence along both sides of the Achilles tendon. Although it may occur in both sexes and at any age, females at the end of their second or third decade are most often affected. It frequently presents itself bilaterally.


The retrocalcaneal (subtendinous) bursa is located between the anterior site of the Achilles tendon and the posterosuperior aspect of the calcaneus.

Superior of the calcaneus, we find Kager fat pad or the pre-Achilles fat pad, a lipomatous structure located anterior to the Achilles tendon and superior to the calcaneus. Kager triangle is bordered anteriorly by the flexor hallucis longus, inferiorly by the calcaneus, and posteriorly by the Achilles tendon.46

FIGURE 20-4. Preoperative lateral radiograph of a right foot and ankle with retrocalcaneal bursitis and prominence of the posterosuperior part of the calcaneus. To compare, the symptomless left foot is also shown. Note the diminished radiolucency at the lower portion of Kager triangle in the right foot.

Diagnostic Imaging

The previously mentioned, Kager triangle is important in diagnosing retrocalcaneal bursitis using conventional radiographs. A hypertrophy of the posterosuperior aspect of the calcaneus can be seen on conventional lateral radiographs. Adjacent to it, a diminished radiolucency of the retrocalcaneal recess and the lower portion of Kager triangle can be found (Fig. 20-4). This is a sign of deep retrocalcaneal bursitis. US is a cost-effective method that can provide useful information on Kager triangle as well as the retrocalcaneal bursa and Achilles tendon.47, 48 MRI is known to be both accurate and precise regarding evaluation of possible pathology and size of the retrocalcaneal bursa.46, 49

Sep 25, 2018 | Posted by in RHEUMATOLOGY | Comments Off on Endoscopic Procedures for Retrocalcaneal Bursitis, Achilles Tendon, Posterior Tibial Tendon, Peroneal Tendons, and Flexor Hallucis Longus Tendon
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