Schinz's disease (osteochondropathy of the apophysis of the calcaneal bone, osteochondropathy of the calcaneal tuberosity, osteochondropathy of the heel bone, Haglund-Schinz disease)

Osteochondropathy

name a group of chronic diseases of the musculoskeletal system, characterized by necrotic changes in the apophysis, spongy substance of short and epiphyses of long tubular bones. They appear as a result of excessive mechanical load of a point nature, which causes a malnutrition of the bone tissue.

At the initial stage, especially at a young age, there are no obvious clinical manifestations. This prevents the timely diagnosis of osteochondropathy of bones and the prescription of treatment, which is fraught with microfractures and the development of arthrosis. But, with a competent approach to treatment, the prognosis is generally favorable. Osteochondropathy does not pose a threat to human life. With properly selected therapy, deformation and contracture do not occur.

What is osteochondropathy of bones?

This disease is the result of embolism or thrombosis, leading to impaired blood circulation and the development of aseptic necrosis. As it progresses, the strength of the damaged bone tissue decreases - the slightest load, cramps, muscle strain intensifies the pathology. Pain sensations appear, mobility of the affected area is limited, joints lose their healthy configuration, which leads to deforming arthrosis. With aseptic necrosis, which occurs with osteochondropathy of the joint, bone cells are destroyed and die, while the intercellular substance is preserved.

The first description of osteochondropathy of the joints appeared at the beginning of the twentieth century. In terms of clinical manifestations, it resembles osteoarticular tuberculosis, but is distinguished by a benign course with the absence of such somatic manifestations as inflammation, fever, and exhaustion. According to the International Classification of Diseases (ICD-10), osteochondropathy is assigned the code M93.9; it is classified as a disease of the musculoskeletal system and connective tissues.

In most cases, osteochondropathy is diagnosed in children and adolescents (3-18 years old) - during the period of active growth. Each nosological form is characterized by development within certain age limits and distribution by gender.

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Symptoms of osteochondropathy

It is characterized by long-term development. At the initial stage, there is no clinical picture. The gradual and slow development of pathology leads to changes in the joint structures, which is manifested by the following signs.

• Painful sensations, especially with mechanical stress or injury to the affected area;
• Edema not accompanied by inflammatory processes;
• Frequent fractures;
• Muscle contracture with osteochondropathy of the joint;
• Change in shape: superficially located apophyses are thickened;
• Functional disorders: motor activity is limited; with calcaneal osteochondropathy, lameness appears;
• Shortening of limbs.

If the spine is affected, posture is disturbed; with pathology in the lower extremities, including osteochondropathy of the calcaneus, the gait changes and lameness develops.

Ignoring the problem, incorrect diagnosis and delayed treatment leads to the following consequences:

• contracture – complete or partial loss of joint mobility, its fixation in a forced position;
• muscular dystrophy due to metabolic disorders, leading to a deficiency of nutrients in bone tissue and a decrease in muscle mass;
• arthrosis – degenerative-dystrophic changes in the joints, leading to the gradual destruction of cartilage tissue.

If you do not see a doctor in a timely manner, 27% of patients become disabled.

Pathogenesis of Haglund's deformity

During constant friction of the Achilles tendon, inflammation of the mucous membrane of the bursa begins. This chronic multi-month impact is transmitted to the posterior calcaneal tubercle and pathological cartilage slowly begins to form, changed, often with sharp spines. This can even be seen on an x-ray. The formation of this cartilage occurs due to the body’s protective reaction. The desire to strengthen the area of ​​constant irritation and improve tendon gliding. But, unfortunately, pathological cartilage is not capable of this. It turns out to be a vicious circle.

The pressure on the bursa and Achilles tendon increases even more, which increases inflammation, pain and swelling. Inflammation of the mucous bursa and Achilles tendon without bone deformation is called achillobursitis (posterior calcaneal bursitis). Typically, bursitis precedes Haglund's deformity.

Patients do not pay much attention to the “bump,” thinking that it is a callus until it hurts. And as a rule, this condition is quite difficult to treat conservatively. This is why it is so important to see an orthopedist in the early stages of Haglund's disease.

Reasons for appearance

Ostechondropathy is a consequence of one or more of the pathologies described below.

• Genetic predisposition - the disease is more often diagnosed in patients whose parents are susceptible to the same pathology;
• Circulatory disorders - its nature can be congenital, traumatic, or be a consequence of metabolic disorders;
• Metabolic disorders, including carbohydrate, fat, purine;
• Irrational or malnutrition, causing a deficiency of vitamins, micro-, macroelements (calcium, phosphorus, magnesium, etc.);
• Long-term eating disorders: bulimia, anorexia;
• Alimentary (nutritional) or hormonal obesity, overdeveloped muscle mass;
• Bacterial, viral infections;
• Traumatic injuries;
• Endocrine pathologies;
• Neurotrophic disorders;
• Long-term use of corticosteroid hormones.

The cause of the most commonly diagnosed osteochondropathy of the calcaneus is chronic microtrauma. They appear, for example, as a result of prolonged exposure to a forced unnatural position or regular high loads placed on the same joint. Osteochondropathy of the calcaneus is diagnosed in professional athletes: gymnasts, acrobats, figure skaters, fencers.

Survey

• Pain and tenderness on palpation (before the insertion of the Achilles tendon and along the posterior border of the calcaneus).
• Passive ankle dorsiflexion test: a decrease in amplitude will be detected. In addition, this test may cause pain.
• Compression test: Mediolateral compression of the calcaneal growth plate will provoke pain in Sever's disease. The manipulation is performed on the lower third of the heel bone. This test is the most important for diagnosing calcaneal apophysitis.

Compression test

• Standing on your toes increases the pain in your heels.
• Biomechanical disorders: pes planovalgus, forefoot varus, hindfoot varus, pes cavus, pes planus and forefoot valgus.
• The appearance of edema and other changes in the skin are not characteristic of Sever's disease and indicate other pathological conditions. However, slight swelling may also be present with Sever's disease.
• Gait may remain normal. The patient may also limp or stomp loudly with the heel.
• Overweight.

Stages of the disease

In its development, osteochondropathy of bones goes through several stages.

1. The first stage of aseptic necrosis lasts from 1 to 12 months. During this period, subchondral necrosis of cancellous bones forms and manifests itself while maintaining the viability of hyaline cartilage. The bone becomes less strong and more vulnerable.
2. The second stage lasts about six months. During this period, primary deformation of the articular surface is detected. It takes on a wavy, scalloped outline. There is flattening and compression of damaged bone tissue, expansion of the joint space.
3. This stage can last up to 3 years. It is characterized by the resorption of necrotic lesions and the replacement of diseased bone tissue with granulation tissue containing newly formed blood vessels. The height of the bone decreases; on x-rays, the necrotic area is represented by separate small fragments.
4. At this stage, which lasts 2-3 years, the strength characteristics and shape of the bone are restored. The diseased fragments and the tissues that replace them are replaced by a newly formed spongy substance.
5. At the final stage, two options are possible. With timely and adequate treatment of osteochondropathy, the anatomical structure of the bone, its structure and functionality are restored up to 85% - the patient actually recovers. Otherwise, the disease leads to persistent deformation and the development of secondary osteoarthritis with significant limitation of mobility.

There are no clear distinctions between the stages described above. Pathological processes are characterized by gradual development.

Which bones and joints are susceptible to osteochondropathy?

pathological processes can develop in various bone structures. Osteochondropathies are susceptible to:

1. Long tubular bones (epiphyses):

   femur (head), II-III metatarsal bones, clavicle (sternal end), fingers (phalanx);

2. Short tubular bones:

   navicular bone of the foot, lunate carpal, patella, vertebral body, talus, sesamoid bones, tarsus.

3. Apophyses:

   tibia, apophyseal rings of the vertebrae, humerus, pubis. Osteochondropathy of the calcaneal tuber is often diagnosed.

Depending on the location of the lesion, several types of disease are distinguished - Legg-Calvé-Perthes disease, Keller-I and II, Scheuermann-Mau, Calve, partial osteochondropathy, damage to the knee, elbow joint, calcaneus, etc.

Prevention of Hoogland's deformity

• Wearing shoes with soft backs.
• Use shoes with 2-4 cm heels for high arches.
• If you have flat feet or planovalgus deformity, you need to wear custom orthopedic insoles every day.

Don't self-medicate!

Only a doctor can determine the diagnosis and prescribe the correct treatment. If you have any questions, you can call or ask a question by email.

Diagnostics

Diagnostic measures for suspected bone osteochondropathy begin with an analysis of complaints and collection of anamnesis.
Clinical examination reveals characteristic signs of the disease. Usually they are not accompanied by deterioration in general condition, laboratory parameters and obvious inflammation (hyperemia, hyperthermia). Subsequently, the patient is prescribed:

1. Ultrasonography. With its help, the condition of the bone surface is assessed.
2. X-ray.
3. Computed tomography. It is effective from the 2nd stage of osteochondropathy. The use of multispiral tomography with 3D modeling allows one to obtain a three-dimensional image of the affected segment. The method is the only possible alternative to MRI when locating metal structures in the patient’s body.
4. Magnetic resonance imaging. It is used to evaluate the hard and soft structures of the affected area and the efficiency of the blood supply to the bones.

If osteochondropathy of the joint is suspected, arthroscopy is recommended - a minimally invasive video-endoscopic manipulation to assess the surface of the joint, cartilaginous covering, and identify areas of dead tissue. The technique is used not only for diagnosis, but also for treatment.

Differential diagnosis

1. Musculoskeletal disorders: Achilles bursitis, tenosynovitis, ankle sprain or peritendinitis, retrocalcaneal exostosis or bursitis, plantar fasciitis. In all of these conditions, the apophyseal region compression test will be negative.
2. Infectious diseases or endogenous causes: tuberculosis, rheumatoid arthritis, rheumatic fever, cysts, tumors, osteomyelitis. These diseases also involve other parts of the body, so recognizing them is not difficult.
3. Injuries: foreign bodies, inferior calcaneal nerve entrapment, tendon or ligament ruptures, fractures and stress fractures, tarsal tunnel syndrome, contusions.
4. Other causes: tarsal coalition. Decreased subtalar joint range of motion and negative compression test.

Treatment methods

For osteochondropathy, treatment is complex, along with eliminating the root cause.

Mode

Treatment measures begin with compliance with the orthopedic regimen to eliminate stress on the affected area. Depending on the location of the pathology, it is possible to use bandages, knee pads, plaster splints, rigid reclining corsets, etc. For osteochondropathy of the calcaneal tuber or femur, it is recommended to use crutches or a cane.

Diet

With osteochondropathy of bones, the patient’s diet should be dominated by foods saturated with Omega-3 fatty acids, vitamins A, E, C, zinc, magnesium, selenium, and copper.

Recommended use:

• seafood (especially salmon, mackerel, etc.);
• nuts;
• poultry meat;
• chicken eggs;
• legumes, soy products.

It is advisable to avoid canned meat, fatty dairy products, animal fats, and smoked meats.

Drug therapy

When treating osteochondropathy, it is advisable to prescribe the following medications:

• analgesics to eliminate pain;
• chondroprotectors - they prevent the development of degenerative changes in bone tissue, restore its structure, and reduce pain.
• osteoprotectors – vitamin and mineral complexes for restoring bone and cartilage tissue and maintaining their health;
• disaggregants to prevent thrombosis.

Artracam, a drug with chondo- and osteoprotective effects, has proven to be highly effective. It not only relieves pain and inflammation, but also restores cartilage and joint tissue, preventing their destruction. The convenient form and dosage make the treatment comfortable, effective, and with prolonged results. Remember that all drugs must be prescribed by a doctor - even Artracam has contraindications. Self-medication is unacceptable.

The effectiveness of exercise therapy and massage

The main goal of physical therapy is to strengthen joints, bone and muscle tissue, and restore physical activity. Exercise therapy is prescribed at any stage of the disease and includes two types of exercises:

• active – performed by the patient independently;
• passive - performed by a specialist.

A set of exercises is developed by the doctor depending on the stage of the disease and the patient’s condition.

The effect of the massage is aimed at relieving pain, contractures, improving the nutrition of bone tissue, and correcting blood circulation.

Physiotherapy

Physiotherapeutic effects allow:

• improve blood circulation;
• reduce pain;
• increase regeneration of the affected area;
• reduce the severity of dystrophic changes;
• restore joint function.

In the treatment of osteochondropathy, it is advisable to prescribe: electro-, phonophoresis, heliotherapy, thalassotrapy, air baths, ultrasound, peloid therapy, radon and sodium chloride baths, etc.

After operation

As a rule, during the first week after surgery for Hoogland's deformity, patients move independently, limiting the load on the operated leg, but sometimes crutches are required. In the early postoperative period, anti-inflammatory painkillers and antibiotics are prescribed. Dressings are carried out until the wound heals. Physiotherapy can be performed from the first day after surgery. These methods can reduce swelling and pain after surgery. Typically, 10 sessions of magnetic therapy and laser therapy are prescribed. Stitches are usually removed between 10 and 14 days. Sometimes the suture is removed intradermally with absorbable sutures. In this case, there is no need to remove anything. Complete rehabilitation takes place in 4-6 weeks with the first type of operation (removal of exomtosis). For the other two types of surgery, recovery may take 2-3 months. While the heel bone is healing.