Shaheed Ziaur Rahman Medical College Hospital, Orthopedic department

Scientific seminar on Rational use of antibiotic

Scientific seminar on pain management

Training Program on Management of Clubfoot by Ponseti Method

Tenotomy done by Dr Rezaul Alam Jewel sir

scientific seminar on osteoporosis

Gastrocnemius muscle flap done by Dr Rezaul Alam Jewel sir

15th August

Scientific seminar on malignant bone tumor

Orthopaedic department থেকে ডা: রেজাউল আলম জুয়েল স্যারকে শুভেচ্ছা

Congratulations respected Dr Rezaul Alam Jewel sir for being elected as organizing secretary ( Rajshahi division) of Bangladesh Orthopaedic Society.

http://www.orthobullets.com/trauma/1024/monteggia-fractures

Monteggia Fractures - Trauma - Orthobullets.com Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (70 to 80% of adult Monteggia fractures)

http://www.orthobullets.com/approaches/12020/hip-anterior-approach-smith-petersen

Hip Anterior Approach (Smith-Petersen) - Approaches - Orthobullets.com

Introduction
Bursitis is the inflammation of a bursa. Retrocalcaneal bursitis is in
inflammation of the bursa located between the calcaneus and the anterior
surface of the Achilles tendon[1] .There are two bursae located just superior
to the insertion of the Achilles (calcaneal) tendon. [2]
Anterior or deep to the tendon is the retrocalcaneal (subtendinous) bursa ,
which is located between the Achilles tendon and the calcaneus [2] .
Posterior or superficial to the Achilles tendon is the subcutaneous calcaneal
bursa, also called the Achilles bursa. This bursa is located between the skin
and posterior aspect of the distal Achilles tendon.Inflammation of either or
both of these bursa can cause pain at the posterior heel and ankle region. [3]
[4][5]
It is also known as Achille tendon bursitis. It can often be mistaken for
Achilles tendonitis or can also occur in conjunction with Achilles
tendonitis.
Clinical Anatomy and pathogenesis
The Achilles tendon insertion, the fibrocartilagios walls of the retrocalcaneal
burse that extends into the tendon and the adjacent calcaneum form an
"ENTHESIS ORGAN". The key concept is that at this site the tendon
insertion, the bursa and the bone are so intimately related that a prominence
of the calcaneum will greatly predispose to mechanical irritation of the bursa
and the tendon. Also, ther is significant strain on the tendon insertion on the
posterior aspect of the tendon with dorsiflexion. [6][7]
Epidemiology
Its fairly comman in normal population as campared to athlets in whom this
is quiet comman. In normal population its incidence is high in individuals
who are accustomed to wearing high-heeled shoes on a long-term basis
may experience increased stretch and irritation of the Achilles tendon and its
associated bursae when switching to flat shoes.
Causes
Overtraining in an athlete
Tight or poorly fitting shoes that produce excessive pressure at the posterior
heel
Haglund deformity
Altered joint axis
Inflammation of the calcaneal bursae is most commonly caused by
repetitive (cumulative) trauma or overuse, and the condition is aggravated
by pressure, such as when athletes wear tight-fitting shoes. Retrocalcaneal
bursitis may also be associated with conditions such as gout, rheumatoid
arthritis, and seronegative spondyloarthropathies. In some cases,
retrocalcaneal bursitis may be caused by bursal impingement between the
Achilles tendon and an excessively prominent posterosuperior aspect of the
calcaneus (Haglund deformity) . In Haglund disease, impingement occurs
during ankle dorsiflexion. [2]
Sign and Symptoms
Pain at the back of the heel, especially when running uphill.
Pain may get worse when rising on the toes (standing on tiptoes)
Tenderness at the back of heel
Swelling at the back of heel.
Clinical Assesment
A good clinical practise includes evaluation of the tendon, bursa and
calcaneum by, careful history, inspection of the region for bony prominence
and local swelling as well as palpation of the area of maximal tenderness.
Biomechanical abnormalities, joint stiffness and proximal soft tissue
tightening can exacerbate an anatomical predisposition to retrocalcaneal
bursitis, they warrant correction when present [7] .
Plain radiographs of the calcaneus may reveal a Haglund deformity
(increased prominence of the posterosuperior aspect of the calcaneus).
However, on weight-bearing lateral radiographs, the retrocalcaneal recess
often appears normal even in patients with retrocalcaneal bursitis, limiting
its usefulness in making this diagnosis.Radiographs may be used as a
diagnostic measure to support a clinician’s diagnosis of retrocalcaneal
bursitis. Individuals with retrocalcaneal bursitis may have an absence of the
normal radiolucency (ie, blunting) that is seen in the posteroinferior corner of
the Kager fat pad, known as the retrocalcaneal recess or bursal wedge. This
may occur with or without an associated erosion of the calcaneus. [8][9]
Magnetic resonance imaging (MRI) may demonstrate bursal inflammation,
but this modality probably does not offer much more information than that
found by careful physical examination. Theoretically, MRI could help the
physician to determine whether the inflammation is within the subcutaneous
bursa, the subtendinous bursa, or even within the tendon itself; however,
such testing is generally not necessary.
Ultrasonography may be a potentially useful tool for diagnosing pathologies
of the Achilles tendon. [10]
Differential Diagnosis [11]
Posterior ankle impingment
Haglund deformity
Achilles tendonitis
partial rupture achilles tendon
Plantarfasicitis
Treatment
Conservation
Physical Therapy
The patient with retrocalcaneal bursitis should be instructed to apply ice to
the posterior heel and ankle in the acute period of the bursitis. Icing can be
performed several times a day, for 15-20 minutes each. Some clinicians
also advocate the use of contrast baths.
Gradual progressive stretching of the Achilles tendon may help relieve
impingement on the subtendinous bursa and can be performed in the
following manner:
Stand in front of a wall, with the affected foot flat on the floor. Lean forward
toward the wall until a gentle stretching is felt within the ipsilateral Achilles
tendon.
Maintain the stretch for 20-60 seconds and then relax.
Perform the stretches with the knee extended and then again with the knee
flexed.
To maximize the benefit of the stretching program, repeat the above steps
for several stretches per set, several times daily. Avoid ballistic (ie, abrupt,
jerking) stretches.
Other treatment options are microcurrent therapy and corticosteriod
injection into the retrocalcaneal bursa
Surgical
If conservation treatment fails then surgery is indicated.