Morbo di Haglund

Il morbo di Haglund è un’infiammazione della regione retrocalcaneare in prossimità dell’inserzione del tendine d’Achille che interessa i tessuti molli peritendinei e la porzione ossea calcaneare posteriore, spesso sede di particolare conformazione caratterizzata da prominenza dell’angolo postero-superiore.

Fu descritta per la prima volta nel 1928 da Haglund; si presenta fondamentalmente in giovani tra 15 e 30 anni.

CAUSE E SINTOMI DEL MORBO DI HAGLUND

Le cause che determinano il morbo di Haglund possono essere anatomiche o funzionali.
Nelle prime si osserva un aumento della tuberosità postero superiore o postero esterna del calcagno; a volte l’esistenza di un varismo del calcagno può determinare la prominenza della porzione postero-laterale pur non essendo presente una tuberosità ossea evidente. La calzatura inadeguata, usata durante l’attività sportiva o le normali attività lavorative, possono determinare compressione del tendine contro il calcagno sporgente causando forte dolore.

Tra le cause funzionali l’aumento dell’attività fisica, sportiva o lavorativa, può favorire l’insorgere di processi infiammatori che possono evolvere in una situazione cronica associata ad ipercheratosi, eritema ed aumento della sensibilità dolorosa. In altre occasioni, molto meno frequenti, si può osservare un quadro infiammatorio acuto della borsa retro calcaneare, con sintomatologia caratteristica della borsite acuta.

La clinica è rappresentata da dolore in sede calcaneare posteriore, zoppia, e difficoltà a calzare scarpe chiuse, iperemia della borsa retrocalcaneare, algia acuta alla digitopressione, tumefazione ossea in sede retrocalcaneare.

La diagnosi è facile e si avvale di uno studio radiografico e di una RM per valutare l’integrità morfologica e funzionale del tendine d’Achille; infatti assai frequentemente la patologia si associa ad una sofferenza inserzionale del tendine stesso.

RADIOGRAFIE
Esse sono evidentemente indispensabili. Devono essere realizzate in flessione dorsale e plantare per permettere lo studio dinamico. Lo studio morfologico del bordo postero-superiore del calcagno viene fatto su dei criteri radiologici tra cui quelli descritti da Fowler, Philip e Denis.
Per Fowler l’angolo disegnato dalle tangenti al bordo inferiore e al bordo posteriore dell’osso è normalmente di 60°.
Qualsiasi aumento comporta una salienza anomala del angolo postero-superiore del calcagno. Per Denis la tangente alla parte più posteriore della grossa tuberosità sfiora il cono postero-superiore o resta dietro di esso. Tutti i debordamenti sono legati ad una salienza anomala. L’esame radiografico deve essere completato con delle misure degli angoli del piede secondo i criteri abituali per identificare eventuali problemi statici.

L’angolo di Fowler-Philip  può essere indicativo per deformità di Haglund; è formato dalla congiunzione delle linee tangente al tubercolo posteriore  ed al punto d’inserzione del tendine d’Achille e la  linea che unisce il tubercolo anteriore con il processo mediale del tubercolo plantare del calcagno. L’angolo maggiore di 75 gradi è indicativo per sindrome di Haglund.

Nella sottostante diapositiva nelle prima immagine è rappresentato un profilo calcaneare posteriore regolare mentre nella seconda immagine viene presentato un profilo calcaneare prominente (frecce rosse) causa di conflitto con il tendine d’Achille.

L’ecografia documenta con accuratezza tutte le alterazioni del tendine e dei tessuti molli peritendinei e delinea il profilo osseo calcaneare. Con L’esame doppler si visualizza ancor più lo stato di sofferenza peritendinea, causa del dolore, rappresentato da presa di colore rosso nei tessuti interessati da tale infiammazione.

La Risonanza Magnetica (RM) è la metodica più completa perchè in più dell’ecografia evidenzia lo stato di sofferenza dell’osso calcaneare, ben evidenziato nelle immagini STIR (T2 con soppressione del grasso) vera prova del conflitto osteo-tendineo.

In questo caso la RM evidenzia il conflitto osteo-tendineo pur in assenza di un vero sperone calcaneare. Si riscontra inoltre una piccola lesione della porzione profonda del tendine.

DIAGNOSI DIFFERENZIALE
Tra le malattie generali già largamente citate bisogna menzionare la bursite preachillea. E’ spesso dovuta a delle anomalie del angolo postero-superiore del calcagno o a turbe della statica, in generale un piede cavo. Si manifesta clinicamente con dolori e all’esame con una tumefazione della regione del tallone. Ma al contrario della forma precedente questa tumefazione non è direttamente posteriore ma laterale, apparendo da ciascun lato del tendine come una bisaccia. Si riscontra una piccola fluttuazione che si sente sotto le dita palpando ciascuna faccia della zona tumefatta. La puntura della tumefazione permette di confermare la diagnosi e nello stesso tempo costituisce un gesto terapeutico efficace senza pregiudicare eventuali recidive.

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