Knee Surg Sports Traumatol Arthrosc (2017) 25:1873–1877

DOI 10.1007/s00167-017-4434-9

ANKLE

Endoscopic surgery in athletes with a symptomatic calcaneal

lipoma
P. D’Hooghe1 · B. Krivokapic1 · P. Dzendrowskyj1 · K. Hassoun1 · B. Bukva1 ·
P. Landreau1 

Received: 13 September 2016 / Accepted: 16 January 2017 / Published online: 22 February 2017
© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017

Abstract  Keywords  Calcaneus · Lipoma · Athlete · Endoscopy ·

Purpose  This study shows that endoscopy is an effective
treatment modality for athletes with a symptomatic calca-
neal lipoma.
Methods  Between 2013 and 2016, five professional ath-
letes with symptomatic calcaneal lipoma underwent endo-
scopic-assisted curettage and bone graft treatment. Lipoma
size was measured by magnetic resonance imaging (MRI)
and rated using the American Orthopaedic Foot and Ankle
Society Ankle-Hindfoot Scale (AOFAS). All athletes were
followed up for 12 months postoperatively and monitored
on return to previous activity level.
Results  The mean ankle-hindfoot scale score improved
from a preoperative 71.3 +/−3.9 points (median 67–81)
to a postoperative 97.8 +/−3.4 points (median 89–100).
Radiological assessment revealed no recurrence or patho-
logic fracture, with adequate bone fill-up in all 5 cases. All
athletes returned to their previous level of activity within
8 weeks of surgery (mean period 7.2 weeks, median 5–8
weeks).
Conclusion  Endoscopic surgery can be used as a valid
treatment tool for athletes with a calcaneal lipoma. It allows
for a safe and early return to sports activities and minimises
risk for recurrence and pathological fracture after initial
return to play.
Level of Evidence IV.
* P. D’Hooghe
pieter.dhooghe@aspetar.com; pieter.orthopedie@gmail.com
1 bearing and heel support for more than three months, (4)
Department of Orthopaedic Surgery, Aspetar Orthopaedic
and Sportsmedicine Hospital, Aspire Zone, Sportscity Street
1, PoBox 29222, Doha, Qatar
Magnetic resonance imaging
Introduction
Intraosseous lipoma is a rare lesion, making up less than
0.1% of all bone tumours. This low incidence may be
because it is often asymptomatic and therefore seldomly
recognised at an early stage. Intraosseous lipomas are
benign tumours that are radiographically similar to bone
cysts. The most common differential diagnoses for symp-
tomatic calcaneal lipoma are: Achilles tendinopathy, retro-
calcaneal bursitis, gout and plantar fasciitis. This paper
evaluates the feasibility, effectiveness and clinical out-
comes of an endoscopically-assisted technique in athletes
with symptomatic calcaneal lipoma.
Materials and methods
Between 2013 and 2016, five professional athletes with
symptomatic calcaneal lipoma were seen at our Orthopae-
dic Department. All athletes were referred for heel pain that
had prevented them for participating in sports activities for
at least three months. The diagnosis of calcaneal lipoma
was radiologically made in all cases by plain lateral and
axial radiographs, and also MRI. This was subsequently
confirmed by histological examination. Surgery was indi-
cated due to: (1) persistent heel pain for more than three
months (2) inability to engage in normal sports activities,
(3) non-responsiveness to sports restriction, partial weight
risk of impending fracture. This risk was defined as a

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1874 Knee Surg Sports Traumatol Arthrosc (2017) 25:1873–1877

destruction of the calcaneal trabecular bone by more than

50% of the lipoma’s thickness.

Surgical technique

Surgery was performed under spinal anesthesia with the

patient in semi-lateral position. A radiologically-guided
spinal needle was centred at the lipoma with the lipoma-
tous contours marked over the hindfoot. Two portals were
made—anteriorily and posteriorily—over the lipoma. The
lateral calcaneal wall was defenestrated with a 5-mm can-
nulated drill. The lipoma was then removed via the portals,
with samples taken for histological investigation (Fig.  1).
After curettage and irrigation, the existing space was filled
with allogenic bone graft chips (Fig.  2). Postoperative
protocol included immediate partial weight-bearing with
walker boot and crutches for two weeks. Return to impact
sports was allowed 4  weeks after surgery, with athletes
returning to full athletic sports activities by individual
choice. Fig. 2  Lateral postoperative X-ray of a calcaneal lipoma that is
debrided endoscopically and filled up with bone chips

Evaluation No IRB approval request was deemed necessary for this

All athletes were assessed by the AOFAS (American
Orthopaedic Foot and Ankle Society Ankle-Hindfoot
Scale) scores—both preoperatively and at final follow up
of 12 months. Lateral and axial radiographs were used for
radiological assessment preoperatively, at 3 months and at
final follow up. All radiographs were evaluated for recur-
rence, bone fill and pathological fractures by an independ-
ent radiologist who was not involved in the treatment of
the athletes. Time to return to full sports participation was
monitored during the 3  month postoperative evaluation.
evaluation.
Results
Mean follow-up period after surgery was 18.3 months
(median 12–33 months). Mean ankle-hindfoot scale score
improved from a preoperative 71.3 +/−3.9 points (median
67–81) to a postoperative 97.8 +/−3.4 points (median
89–100). Functional scores and pain scores improved sig-
nificantly postoperatively. At 12  months postoperatively,
all radiographs showed no lipoma recurrence, adequate
bone fill-up and no pathological fractures. Potential sur-
gical complications such as infection, sural nerve injury
or delayed wound healing did not occur. All five athletes
returned to full sports participation within 8 weeks of sur-
gery—mean 7.2 weeks (median 5–8 weeks).

Discussion

The most important finding and clinical relevance of this

Fig. 1  Endoscopic image of a calcaneal lipoma
case series is that endoscopy for symptomatic calcaneal
lipoma is a valid treatment option—especially in athletes—
allowing for a safe and rapid return to play.
Calcaneal intraosseous lipoma was first described in
1976 [28]. A larger series of 66 intraosseous lipomas was
published by Milgram in 1988 [21, 22]—who proposed a
three-stage classification for intraosseous lipoma based on

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Knee Surg Sports Traumatol Arthrosc (2017) 25:1873–1877 1875

histological characteristics [5, 21]. Appearances of lipo-

mas on radiographs, CT and MRI (Table  1) correspond
to the histological staging system [5, 21]. Milgram states
that stage 1 lesions are purely radiolucent with resorption
of pre-existing bone and expansion or remodelling in half
of all cases. In stage 2 lesions, localised areas of calcifi-
cation may be seen and are typically central—only occa-
sionally peripheral. At stage 3, reactive ossification around
the calcified fat in the outer rim of the lesion is prominent.
Peripheral or central calcification fills much of the lesion,
with expansion present in a minority of cases [5, 18, 21].
It is usually located between the anterior and middle
third of the calcaneus (Fig. 3) and is derived from lipocytes
and mostly seen at the metaphysis of long bones [31] (prox-
imal femur) and os calcis. Symptoms may be very non-
specific and are often misdiagnosed as plantar fasciitis [11,
17, 19, 20]. Soft tissue lipomas are more predominant in
females, but males and females are affected almost equally Fig. 3  Lateral X-ray of a calcaneal lipoma
if they present in the calcaneus [5, 33].
Radiographically, an intraosseous lipoma presents as an
osteolytic, well-circumscribed lesion with a thin sclerotic Literature is sparse on the natural history of intraosseous
rim and most authors suggest that imaging alone can pro- lipomas- [12, 23, 25, 27, 30, 34] they are considered to rep-
vide a definitive diagnosis [5, 29]. This radiographic find- resent true benign tumours of fat—although this view has
ing is non-specific and is sometimes difficult to distinguish been challenged [3–6, 16, 32]. Lipomas present across a
from a non-ossifying fibroma, simple bone cyst, aneurys- very wide age spectrum (Table 1) and previous events such
mal bone cyst, giant cell tumour, fibrous dysplasia, bone as trauma may leave permanent features of deformity and
infarct, chondroid tumour or fungal bone infection [1, 2, 5, porosis [14, 21, 24, 28].
9, 10, 16, 18, 29]. There are different radiographic appear- In all five cases the lipoma occurred in the same calcaneal
ances between lipomas in the os calcis and simple bone area: the “critical angle” (Figs. 3, 4). It is a recognised area
cysts, including: the presence of calcification (Fig.  3) and of normal porosity that may be very pronounced—even in
the lack of bony expansion [5]. A biopsy to histologically the young. This area of porosity occurs because of two lines
identify a calcaneal lipoma is ideal, but invasive. Identifica- of biomechanical stress that are manifest by prominent tra-
tion of fat density on CT [15] is usually considered diag- beculae, leaving a triangular area in which there are relatively
nostic of an intraosseous lipoma [2, 5, 7, 8, 13, 26, 31]
while the fat component of the intraosseous lipoma is easily
recognised on MRI (Fig. 4) by high signal intensity on both
T1-weighted and T2-weighted images, and fat suppression
on STIR or other fat suppression sequences.

Table 1  A summary of clinical and radiological calcaneal lipoma

features, comparing the reported literature with the 5 cases from the
current study

Radiological and clini- Reported literature Current study

cal features

Age range (mean) 12–66 (42 years) 17–27 (22 years)

Size 20–40 mm 24–38 mm (31 mm)
Marginal sclerosis 20/33 (61%) 16 (73%)
Calcification 24 (62%) 13 (67%)
Bone expansion 5 (13%) 2 (7%)

In some literature reports, certain radiological features were not Fig. 4  Sagital T2 MRI image of a calcaneal lipoma in the “critical
recorded angle” area

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1876
fewer trabeculae [5, 35]. Simple cysts of the os calcis also
occur in this critical angle and—like lipomas- contain no epi-
thelial lining [16, 35].
Small cysts that are not located in the pressure-bearing
trabecular area are usually asymptomatic and most lipomas
can be treated conservatively. The main indications for sur-
gical intervention are suspicion or evidence of malignancy
(although this is very rare [22]), and the risk of pathological
fracture (although there are no reports of this complication
[5, 32]). Surgical treatment usually consists of curettage and
packing with bone chips (Fig. 2). Cysts that extend the entire
width of the calcaneus laterally to medially and occupy at
least 30% of the length of calcaneus antero-posteriorly have
been defined as “critical-size cyst”.
The main limitations of this case series are the small
amount of patients (only five), the lack of comparative groups
(e.g. to the open technique) and the absence of a rehabilita-
tion protocol in evaluation. Also, no metabolic testing or
Dexa scan was performed to look for underlying bone dis-
orders. All five patients presented with Stage three “critical
size” lipomas. Further studies are needed to understand the
aetiology and natural history of intraosseous lipomas in the
athlete and identify their optimal treatment options.
Conclusion
This study shows that “critical size” intra-osseous calcaneal
lipomas can be treated endoscopically—allowing a safe and
early return to play in athletes. Surgical intervention in ath-
letes is indicated for these symptomatic lipomas. In conclu-
sion, endoscopic curettage and allogenic bone grafting is
a useful treatment to avoid pathological fracture and allow
early return to play.
Compliance with ethical standards  17. Latham PD, Athanasou NA (1991) Intraosseous lipoma
Conflict of interest  None of the authors have any conflicts of interest
regarding the content of this paper.
Funding  No funding has been received for this study.
Ethical approval  This article does not contain any studies with
human participants or animals performed by any of the authors.
Informed consent  All five patients signed a classic internationally
recognized surgical “informed consent”.
References
1. Appenzeller J, Weitzner S (1974) Intraosseous lipoma of os cal-
cis. Case report and review of literature of intraosseous lipoma
of extremities. Clin Orthop Relat Res 101:171–175
13
Knee Surg Sports Traumatol Arthrosc (2017) 25:1873–1877
2. Barcelo M, Pathria MN, Abdul-Karim FW (1992) Intraosseous
lipoma. A clinico- pathologic study of four cases. Arch Pathol
Lab Med 116:947–950
3. Barker GR, Sloan P (1986) Intraosseous lipomas: clinical fea-
tures of a mandibular case with possible aetiology. Br J Oral
Maxillofac Surg 24:459–463
4. Boylan J, Springer K, Halpern F (1991) Intra-osseous lipoma
of the calcaneus. A case report. J Am Podiatr Med Assoc
81:502–505
5. Campbell R, Grainger A, Mangham D, Beggs I, Teh J, Davies
A (2003) Intraosseous lipoma: a report of 35 new cases and a
review of the literature. Skeletal Radiol 32:209–222
6. Coquerelle P, Cotten A, Flipo RM, Chastanet P, Duquesnoy
B, Delcambre B (1995) Intraosseous lipoma: role and limi-
tations of modern imaging techniques. Rev Rhum Engl Ed
62:147–150
7. Dickson A, Ayres W, Mason M, Miller W (1951) Lipoma of
bone of intraosseous origin. J Bone Joint Surg Am 33:257–259
8. Gero MJ, Kahn LB (1988) Case report 498: Intraosseous
lipoma of the distal end of the fibula with focal infarction.
Skeletal Radiol 17:443–446
9. Goldenhar AS, Maloney JP, Helff JR (1993) Negative bone
scan in the diagnosis of calcaneal intraosseous lipoma. J Am
Podiatr Med Assoc 83:600–602
10. Goldman A, Marcove R, Huvos A, Smith J (1984) Case report:
Intraosseous lipoma of the tibia. Skeletal Radiol 12:209–212
11. Gonzalez JV, Stuck RM, Streit N (1997) Intraosseous lipoma
of the calcaneus: a clinicopathologic study of three cases. J
Foot Ankle Surg 36:306–310 (discussion 329)
12. Hall FM, Cohen RB, Grumbach K (1986) Case report 377:
Intraosseous lipoma (angiolipoma) of right third rib. Skeletal
Radiol 15:401–403
13. Hanelin LG, Sclamberg EL, Bardsley JL (1975) Intraos-
seous lipoma of the coccyx. Report of a case. Radiology
114:343–344
14. Hart JA (1973) Intraosseous lipoma. J Bone Joint Surg Br
55:624–632
15. Ketyer S, Brownstein S, Cholankeril J (1983) CT diagnosis of
intraosseous lipoma of the calcaneus. J Comput Assist Tomogr
7:546–547
16. Lagier R (1980) Case report: lipoma of the calcaneus with bone
infarct. Skeletal Radiol 5:267–269
within the femoral head. A case report. Clin Orthop Relat Res
265:228–232
18. Lauf E, Mullen BR, Ragsdale BD, Kanat IO (1984) Intraosseous
lipoma of distal fibula. Biomechanical considerations for suc-
cessful treatment. J Am Podiatr Med Assoc 74:434–440
19. Leeson M, Kay D, Smith B (1983) Intraosseous lipoma. Clin
Orthop 181:186–190
20. Levin MF, Vellet AD, Munk PL, McLean CA (1996) Intraosse-
ous lipoma of the distal femur: MRI appearance. Skeletal Radiol
25:82–84
21. Milgram JW (1988) Intraosseous lipomas. A clinicopathologic
study of 66 cases. Clin Orthop Rel Res 231:277–302.
22. Milgram JW (1990) Malignant transformation in bone lipomas.
Skeletal Radiol 19:347–352
23. Miller WB, Ausich JE, McDaniel RK, Longo JJ (1982) Mandib-
ular intraosseous lipoma. J Oral Maxillofac Surg 40:594–596
24. Mueller MC, Robbins JL (1960) Intramedullary lipoma of bone.
J Bone Joint Surg Am 42:517–520
25. Newman CW (1957) Fibrolipoma of the mandible. J Oral Surg
15:251–252
26. Pande KC, Ceccherini AF, Webb JK, Preston BJ (1998) Intra-
osseous lipomata of adjacent vertebral bodies. Eur Spine J
7:344–347
Knee Surg Sports Traumatol Arthrosc (2017) 25:1873–1877 1877
27. Polte HW, Kolodny SC, Hooker SP (1976) Intraosseous angi-
olipoma of the mandible. Oral Surg Oral Med Oral Pathol
41:637–643
28. Poussa M, Holmstrom T (1976) Intraosseous lipoma of the cal-
caneus. Report of a case and a short review of the literature. Acta
Orthop Scand 47:570–574
29. Propeck T, Bullard MA, Lin J, Doi K, Martel W (2000) Radi-
ologic-pathologic correlation of intraosseous lipomas. Am J
Roentgenol 175:673–678
30. Ragsdale BD (1993) Polymorphic fibro- osseous lesions of bone:
an almost site-specific diagnostic problem of the proximal femur.
Hum Pathol 24:505–512
31. Ramos A, Castello J, Sartoris DJ, Greenway GD, Resnick D,
Haghighi P (1985) Osseous lipoma: CT appearance. Radiology
157:615–619
32. Richardson AA, Erdmann BB, Beier-Hanratty S et  al (1995)
Magnetic resonance imagery of a calcaneal lipoma. J Am Podiatr
Med Assoc 85:493–496
33. Schatz SG, Dipaola JD, D’ A gostino A, Hanna R, Quinn
SF (1992) Intraosseous lipoma of the calcaneus. J Foot Surg
31:381–384
34. Smith WE, Fienberg R (1957) Intraosseous lipoma of bone. Can-
cer 10:1151–1152
35. Van Linthoudt D, Lagier R (1978) Calcaneal cysts. A radio-
logical and anatomico- pathological study. Acta Orthop Scand
49:310–316
13
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