Haglund’s deformity is an abnormality of the bone and soft tissues in the foot. An enlargement of the bony section of the heel (where the Achilles tendon is inserted) triggers this condition. The soft tissue near the back of the heel can become irritated when the large, bony lump rubs against rigid shoes.
Pathophysiology
- General
- Typically affects middle aged females
- Often bilateral
- Diagnosis is a combination of clinical and radiographic assessment
- Haglund’s Deformity
- Defined as a bony enlargement of the posterosuperior part of the Calcaneus at the attachment site of the Achilles Tendon
- Haglund’s Syndrome
- Posterior heel pain, characterized by a painful soft tissue swelling at the level of the Achilles tendon insertion
- Pump Bump
- Visible and palpable thickening of the soft tissues at the Achilles Tendon insertion
Causes
It is mostly an idiopathic condition, but several contributory factors like over-practice in runners, tight or poorly fitting shoes, or altered biomechanics of foot joints because of the dealigned subtalar joint may play a role [rx].
- Pathophysiology is poorly understood
- Generally considered to be an idiopathic condition
- General
- Achilles tendon attaches to the back of the heel bone
- The uppermost portion of the back of the heel bone can rub against the tendon
- Soft tissues can get irritated when the posterior calcaneus rubs against the shoe
- This can lead to retrocalcaneal bursitis, Achilles tendonitis and subsequent thickening of the tendon
- Runners
- Tight or poorly fitting shoes
- Altered biomechanics
- Tight Achilles Tendon or Posterior chain
- Walking on outside of heels
Differential Diagnosis
- Fractures & Dislocations
- Distal Tibia Fracture
- Distal Fibular Fracture
- Talus Fracture
- Calcaneus Fracture
- Subtalar Dislocation
- Ankle Fracture (& Dislocation)
- Peroneal Subluxation
- Muscle and Tendon Injuries
- Peroneal Tendon Injuries
- Achilles Tendonitis
- Achilles Tendon Rupture
- Posterior Tibial Tendon Dysfunction
- Flexor Hallucis Longus Tendinopathy
- Ligament Injuries
- Lateral Ankle Sprain
- Medial Ankle Sprain
- Syndesmotic Sprain
- Chronic Ankle Instability
- Intersection Syndrome Foot
- Bursopathies
- Retrocalcaneal Bursitis
- Nerve Injuries
- Peroneal Nerve Injury
- Tarsal Tunnel Syndrome
- Arthropathies
- Osteoarthritis of the Ankle
- Osteochondral Defect Talus
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin’s Disease)
- Calcaneal Apophysitis (Sever’s Disease)
- Other
- Haglunds Deformity
- Posterior Ankle Impingement Syndrome
- Sinus Tarsi Syndrome
Diagnosis
Clinical example of Haglund’s Deformity
- History
- Characterized by retrocalcaneal heel or ankle pain
- Limping swelling may be present
- Pain worse at the initiation of walking or unning
- Physical Exam: Physical Exam Ankle
- Prominent swelling and bump is noted over the back of both heels
- Warmth, redness, and tenderness may be present over the posterior heel
- Plantarflexion should be intact
- Special Tests
- Thompson Test: should be normal
Radiographs
- Standard Radiographs Ankle
- Sufficient to make the diagnosis
- Potential Findings
- Haglund’s lesion: prominent calcaneal projection at posterosuperior part of the calcaneal tuberosity
- Calcaneal bursal swelling
- Increased density in pre-Achilles bursae
- Heterotopic bone formation at the insertion of or within the Achilles tendon
- Fowler’s Angle: needs update
MRI
- Not routinely required
- Can be obtained in equivocal cases
- Potential findings
- Posterosuperior calcaneal spurring with impingement on the Achilles tendon
- Synovial thickening and collection in the retrocalcaneal bursa
- Thickening and high signal in the insertional fibers of Achilles tendon and
- Edema in the adjoining retro-Achilles fat pad
![Cause It is mostly an idiopathic condition, but several contributory factors like over-practice in runners, tight or poorly fitting shoes, or altered biomechanics of foot joints because of the dealigned subtalar joint may play a role [4].](https://rxharun.com/rxharun/wp-content/uploads/2022/04/cureus-0008-00000000820-i02.jpg)
Treatment
Nonoperative
- Indications
- Vast majority of patients
- Goal
- Reduce symptoms, treat soft tissue swelling and pain
- This approach will not shrink the bony protrusion
- Shoe inserts
- Altering heel height in shoe wear can offload the achilles
- Consider heel pads, lifts or wedges
- Open heel shoes
- Wearing shoes that are backless or have soft backs will avoid or minimize irritation
- Orthosis
- Physical Therapy
- Stretching of posterior chain
- NSAIDS
- Topical Analgesics
- Ice therapy
- Corticosteroid Injection
- In select cases with ultrasound guidance to avoid injecting in Achilles Tendon
- Additional therapies to consider (note: no current evidence to support)
- Therapeutic Ultrasound
- TENS
Operative
- Indications
- Failure of conservative management
- Technique
- Retrocalcaneal decompression
- Calcaneal ostectomy or osteotomy
- Calcaneoplasty
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