Does Painful Heels in Ankylosing Spondylitis Demonstrate Distinctive Features on Plain Radiographs: A Study of 104 Cases

Tae-Hwan Kim; Seunghun Lee; Il-Hoon Sung; Sung-Jae Kim; Hyo-Kyung Sung; Jae-Seung Hur

doi:10.4078/jrd.2017.24.2.93

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Kim, Lee, Sung, Kim, Sung, and Hur: Does Painful Heels in Ankylosing Spondylitis Demonstrate Distinctive Features on Plain Radiographs: A Study of 104 Cases

Original Article

J Rheum Dis 2017;24(2):93-98.

Published online: 31 October 2017

DOI: https://doi.org/10.4078/jrd.2017.24.2.93

Does Painful Heels in Ankylosing Spondylitis Demonstrate Distinctive Features on Plain Radiographs: A Study of 104 Cases

Tae-Hwan Kim¹, Seunghun Lee², Il-Hoon Sung³, Sung-Jae Kim³, Hyo-Kyung Sung¹, Jae-Seung Hur³

¹Hanyang University Hospital for Rheumatic Disease, Seoul, Korea

²Department of Radiology, Hanyang University College of Medicine, Seoul, Korea

³Department of Orthopedic Surgery, Hanyang University College of Medicine, Seoul, Korea

Corresponding to: Il-Hoon Sung, Department of Orthopedic Surgery, Hanyang University College of Medicine, 222-1 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea. E-mail: sungih@hanyang.ac.kr

Received 13 February 201712 March 2017 Accepted 10 April 2017

This is a Free Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

To investigate simple radiographic findings on painful heels in ankylosing spondylitis (AS). Heel radiography in most studies was from AS patients' non-painful heel.

Methods

Seventy AS patients (34 bilateral cases) with heel pain at the time digital radiographs were taken were studied. Standing lateral views (104 radiographs) of the heel were reviewed. Associations between radiologic abnormalities and disease duration and among various abnormal findings were analyzed.

Results

Ninety-six (93.4%) had radiographic abnormalities (82.7% in soft tissues/61.5% in bone). Abnormalities of bone only were observed in 9.6%, of the soft tissues only in 30.8%, and of both were 51.9%. These included Kager's triangle's blurring (77.9%), posterior soft tissue swellings near the Achilles tendon insertion (65.4%), obliterations of the retrocalcaneal recess (65.4%), erosions of the superior pole of the posterior calcaneus (31.7%), subplantar irregular spurs (20.2%), posterior traction spurs (16.3%), subplantar erosions (14.4%) and cortical thickenings of the inferior calcaneal body (5.8%). There was a significant association between swelling in the posterior soft tissue and obliteration of the retrocalcaneal recess (p<0.001).

Conclusion

Digital radiography in AS is useful for observing not only bony lesions but also soft tissue abnormalities of the heel, particularly of the posterior heel. For assessing the symptomatic enthesitis of the Achilles, this simple and quick diagnostic tool is valuable when examining for soft tissues' alterations of the posterior heel.

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Keywords: Ankylosing spondylitis, Heel pain, Enthesitis of heel, Radiography

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Figure 1.

Lateral plain foot radiographs. (A) Subplantar erosion with an irregular spur (small arrow) in the inferior calcaneal tuberosity without any involvement soft tissue and bone of the posterior heel. (B) Focal involvement of soft tissues of the posterior heel such as blurred Kager's triangle (large arrows), swelling of the posterior soft tissue shadow (small arrows) and obliteration of the retrocalcaneal recess (arrowhead), which are distinctively comparable to posterior heel of (A). (C) Concomitant involvement of bone and soft tissue of the posterior heel such as blurred Kager's triangle, erosion of the posterior calcaneal tuberosity (large arrow), swelling of the posterior soft tissue shadow (small arrow) and obliteration of the retrocalcaneal recess (arrowhead).

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Table 1.

Clinical characteristics of the patients (n=70)

Variable	Data
Gender (male:female)	60:10
Age (yr)	30.7±10.9 (range, 15∼59)
ESR (mm/h)	45±37.3 (range, 2∼140)
CRP (mg/dL)	2.7±3 (range, 0∼11.3)
HLA-B27 positivity (%)	97.1

ESR: erythrocyte sedimentation rate, CRP: C-reactive protein, HLA: human leukocyte antigen.

Table 2.

Number of abnormalities in ankylosing spondylitis and the inter-and intra-observer reliability in 104 lateral foot X-rays

Variable	Location	Lesion	Incidence	Interobserver reliability	Intra-observer reliability
Bony abnormalities	Inferior calcaneal tuberosity	Spur	21 (20.2)	0.92	0.86
		Erosion	15 (14.4)	0.76	0.78
	Calcaneal body	Proliferation	n 6 (5.8)	0.92	0.76
	Posterior calcaneal tuberosity	Spur	17 (16.3)	0.92	0.93
		Erosion	33 (31.7)	0.85	0.85
Soft tissue changes	Retrocalcaneal recess	Obliteration	n 68 (65.4)	0.88	0.91
	Posterior soft tissue	Swelling	68 (65.4)	0.76	0.92
	Kager's triangle	Blurring	81 (77.9)	0.63	0.72
Others	Talonavicular joint	Arthritis	2 (1.9)	NA	NA
	Calcaneonavicular joint	Arthritis	1 (1)	NA	NA
		Coalition	2 (1.9)	NA	NA

Values are presented as number (%). NA: not available.

Table 3.

Correlations between radiographic abnormalities of bone and soft tissues and disease duration

Variable	Location	Lesion C	Correlation coefficient	p-value
Bony abnormality	Inferior calcaneal tuberosity	Spur	0.231	0.018
		Erosion	0.073	0.461
	Calcaneal body	Proliferation	0.084	0.397
	Posterior calcaneal tuberosity	Spur	0.281	0.004
		Erosion	−0.028	0.776
	Total		0.265	0.007
Soft tissue abnormality	Retrocalcaneal recess	Obliteration	−0.123	0.773
	Posterior soft tissue	Swelling	−0.029	0.13
	Kager's triangle	Blurring	−0.149	0.215
	Total		−0.124	0.210
Total number of abnormalities			0.714	0.036

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