Insertional Achilles tendinopathy is an umbrella medical term referring to pain and swelling on the posterior aspect of the calcaneus. High-resolution ultrasound imaging is commonly used in daily practice to assess the pathological changes of the Achilles tendon, cortical bone of the calcaneus, and soft tissues located inside the retrocalcaneal space to optimize the management of relevant patients. To the best of our knowledge, a standardized ultrasound protocol to evaluate the retrocalcaneal bursal complex is lacking in the pertinent literature. In this sense, our step-by-step sonographic approach is intended to be an easy and ready-to-use guide for sonographers/physicians in daily practice to assess this anatomical complex in patients with Achilles tendinopathy. Needless to say, the peculiar histological features of this V-shaped synovial/fibrocartilaginous bursa surrounding the posteroinferior wedge of the Kager's fat pad and the retrocalcaneal space make the examination challenging.

Department of Neuroscience Imaging and Clinical Sciences Gabriele d'Annunzio University of Chieti and Pescara Chieti Italy

Department of Physical and Rehabilitation Medicine Hacettepe University Medical School Ankara Turkey

Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center National Taiwan University Hospital Taipei City Taiwan

Department of Rehabilitation Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague Czech Republic

Institute of Anatomy 1st Faculty of Medicine Charles University Prague Czech Republic

Physical and Rehabilitation Medicine Unit Luigi Sacco University Hospital ASST Fatebenefratelli Sacco Milan Italy

Rheumatology Clinic University Hospital of Basel Basel Switzerland

UZR Ultraschallzentrum und Institut für Rheumatologie Basel Switzerland

Zobrazit více v PubMed

Krishna Sayana M, Maffulli N. Insertional achilles tendinopathy. Foot Ankle Clin 2005; 10:309–320. https://doi.org/10.1016/j.fcl.2005.01.010.

van Dijk CN, van Sterkenburg MN, Wiegerinck JI, Karlsson J, Maffulli N. Terminology for achilles tendon related disorders. Knee Surg Sports Traumatol Arthrosc 2011; 19:835–841. https://doi.org/10.1007/s00167-010-1374-z.

Shaw HM, Vázquez OT, McGonagle D, Bydder G, Santer RM, Benjamin M. Development of the human Achilles tendon enthesis organ. J Anat 2008; 213:718–724. https://doi.org/10.1111/j.1469-7580.2008.00997.x.

Tamborrini G, Bruyn GA. CME‐Sonografie 93: Ultraschall der enthese – nicht jede «enthesitis» bedeutet eine spondyloarthritis [CME sonography 93: ultrasound of the enthesis – not every “enthesitis” signals a spondyloarthritis]. Praxis 2020; 109:888–896. [German]. https://doi.org/10.1024/1661-8157/a003566.

Theobald P, Bydder G, Dent C, Nokes L, Pugh N, Benjamin M. The functional anatomy of Kager's fat pad in relation to retrocalcaneal problems and other hindfoot disorders. J Anat 2006; 208:91–97. https://doi.org/10.1111/j.1469-7580.2006.00510.x.

Malagelada F, Stephen J, Dalmau‐Pastor M, et al. Pressure changes in the Kager fat pad at the extremes of ankle motion suggest a potential role in achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 2020; 28:148–154. https://doi.org/10.1007/s00167-019-05585-1.

Ferreira GF, Caruccio FRC, Guerrero Bou Assi JR, et al. Ultrasound‐guided hyaluronic acid injection for the treatment of insertional achilles tendinopathy: a prospective case series. Foot Ankle Surg 2022; 28:879–882. https://doi.org/10.1016/j.fas.2021.12.004.

Chimenti RL, Stover DW, Fick BS, Hall MM. Percutaneous ultrasonic tenotomy reduces insertional achilles tendinopathy pain with high patient satisfaction and a low complication rate. J Ultrasound Med 2019; 38:1629–1635. https://doi.org/10.1002/jum.14835.

Boone SL, Uzor R, Walter E, et al. Safety and efficacy of image‐guided retrocalcaneal bursa corticosteroid injection for the treatment of retrocalcaneal bursitis. Skelet Radiol 2021; 50:2471–2482. https://doi.org/10.1007/s00256-021-03783-y.

Srivastava P, Aggarwal A. Ultrasound‐guided retro‐calcaneal bursa corticosteroid injection for refractory Achilles tendinitis in patients with seronegative spondyloarthropathy: efficacy and follow‐up study. Rheumatol Int 2016; 36:875–880. https://doi.org/10.1007/s00296-016-3440-4.

Kachlik D, Baca V, Cepelik M, et al. Clinical anatomy of the retrocalcaneal bursa. Surg Radiol Anat 2008; 30:347–353. https://doi.org/10.1007/s00276-008-0335-4.

Benjamin M, McGonagle D. The anatomical basis for disease localisation in seronegative spondyloarthropathy at entheses and related sites. J Anat 2001; 199:503–526. https://doi.org/10.1046/j.1469-7580.2001.19950503.x.

Benjamin M, Moriggl B, Brenner E, Emery P, McGonagle D, Redman S. The “enthesis organ” concept: why enthesopathies may not present as focal insertional disorders. Arthritis Rheum 2004; 50:3306–3313. https://doi.org/10.1002/art.20566.

Canoso JJ, Liu N, Traill MR, Runge VM. Physiology of the retrocalcaneal bursa. Ann Rheum Dis 1988; 47:910–912. https://doi.org/10.1136/ard.47.11.910.

Ricci V, Ricci C, Gervasoni F, et al. From physical to ultrasound examination in lymphedema: a novel dynamic approach. J Ultrasound 2022; 25:757–763. https://doi.org/10.1007/s40477-021-00633-4.

Ricci V, Abdulsalam AJ, Özçakar L. Ultrasound imaging for dummies: getting oriented among the planes. J Rehabil Med 2019; 51:624–625. https://doi.org/10.2340/16501977-2581.

Ballal MS, Walker CR, Molloy AP. The anatomical footprint of the achilles tendon: a cadaveric study. Bone Joint J 2014; 96:1344–1348. https://doi.org/10.1302/0301-620X.96B10.33771.

Pirri C, Stecco C, Güvener O, et al. EURO‐MUSCULUS/USPRM dynamic ultrasound protocols for ankle/foot. Am J Phys Med Rehabil 2024; 103:e29–e34. https://doi.org/10.1097/PHM.0000000000002349.

Ricci V, Soylu AR, Özçakar L. Artifacts and artistic facts: a visual simulation for ultrasound training. Am J Phys Med Rehabil 2019; 98:521–525. https://doi.org/10.1097/PHM.0000000000001134.

Ricci V, Ricci C, Tamborrini G, et al. From histology to sonography in synovitis: EURO‐MUSCULUS/USPRM approach. Pathol Res Pract 2023; 241:154273. https://doi.org/10.1016/j.prp.2022.154273.

Cocco G, Ricci V, Corvino A, et al. Musculoskeletal disorders in padel: from biomechanics to sonography. J Ultrasound 2024; 27:335–354. https://doi.org/10.1007/s40477-023-00869-2.

Turmo‐Garuz A, Rodas G, Balius R, et al. Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the achilles tendon and the medial head of the gastrocnemius muscle? Musculoskelet Surg 2014; 98:121–126. https://doi.org/10.1007/s12306-013-0305-9.

Pękala PA, Henry BM, Pękala JR, Piska K, Tomaszewski KA. The Achilles tendon and the retrocalcaneal bursa: an anatomical and radiological study. Bone Joint Res 2017; 6:446–451. https://doi.org/10.1302/2046-3758.67.BJR-2016-0340.R1 [Erratum in: Bone Joint Res 2019;8(9):437].

Cocco G, Ricci V. Dynamic ultrasound assessment for insertional achilles tendinopathy: the COcco‐RIcci (CORI) sign. Skelet Radiol 2024. https://doi.org/10.1007/s00256-024-04746-9.

Ricci V, Chang KV, Naňka O, Özçakar L. Superficial retrocalcaneal bursae and nerves: from anatomy to ultrasound‐guided procedures. Clin Anat 2024. https://doi.org/10.1002/ca.24193.

Ricci V, Mezian K, Chang KV, et al. Ultrasound‐guided injection of the achilles paratenon: a cadaveric investigation. Foot Ankle Surg 2024; 30:313–318. https://doi.org/10.1016/j.fas.2024.01.005.

D'Agostino MA, Terslev L, Aegerter P, et al. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR‐OMERACT ultrasound taskforce—Part 1: definition and development of a standardized, consensus‐based scoring system. RMD Open 2017; 3:e000428. https://doi.org/10.1136/rmdopen-2016-000428.

Rufai A, Ralphs JR, Benjamin M. Structure and histopathology of the insertional region of the human Achilles tendon. J Orthop Res 1996; 13:585–593. https://doi.org/10.1002/jor.1100130414.