Haglund's Deformity: Understanding Causes, Symptoms, and Treatment

What is a Haglund Lesion?

A Haglund lesion, more commonly referred to as Haglund's Deformity, is a bony enlargement on the back of the heel bone (calcaneus) at the insertion point of the Achilles tendon, often leading to painful inflammation of the surrounding soft tissues.

Understanding Haglund's Deformity

Haglund's Deformity, sometimes called "pump bump" due to its association with rigid-backed shoes, is a structural anomaly of the calcaneus. The "lesion" in this context refers to the prominent bony spur or enlargement that develops on the posterolateral aspect of the heel bone. This enlargement can impinge upon the Achilles tendon and the bursa located between the tendon and the bone (retrocalcaneal bursa), leading to significant pain and inflammation.

Key Anatomical Structures Involved:

• Calcaneus: The heel bone, where the bony enlargement forms.
• Achilles Tendon: The large tendon connecting the calf muscles to the calcaneus. The bony prominence can rub against this tendon, causing tendinopathy.
• Retrocalcaneal Bursa: A small, fluid-filled sac located between the Achilles tendon and the calcaneus. This bursa reduces friction, but Haglund's deformity can compress and inflame it, leading to retrocalcaneal bursitis.
• Superficial Calcaneal Bursa: Located between the Achilles tendon and the skin, this bursa can also become inflamed.

The chronic irritation from the bony spur can lead to a cascade of issues, including bursitis, Achilles tendinopathy (inflammation or degeneration of the Achilles tendon), and in severe cases, even partial tearing of the Achilles tendon.

Causes and Risk Factors

While the exact cause of Haglund's Deformity is multifactorial, it primarily arises from repetitive friction and pressure on the back of the heel.

Primary Contributing Factors:

• Footwear: The most commonly cited cause. Shoes with rigid, unyielding backs, such as dress shoes, ice skates, or running shoes with stiff heel counters, can repeatedly rub against the heel, particularly in individuals with a prominent calcaneal bone.
• Foot Mechanics: Certain foot types and biomechanical patterns increase susceptibility:
  • High Arches (Pes Cavus): Individuals with high arches tend to walk with their heel tilted inward (varus heel), which can cause the heel bone to rub against the Achilles tendon.
  • Tight Achilles Tendon: A tight Achilles tendon can increase pressure on the retrocalcaneal bursa and the posterior calcaneus during ankle dorsiflexion (e.g., walking, running).
  • Supinated Foot Type: Feet that tend to roll outward during gait (supination) can put increased stress on the outer aspect of the heel.
• Genetics: There may be a genetic predisposition to developing a prominent calcaneal bone.
• Activity Level: High-impact activities, especially those involving repetitive ankle movements or uphill running, can exacerbate the condition.

Common Symptoms

The symptoms of Haglund's Deformity typically develop gradually and worsen over time with continued irritation.

Characteristic Symptoms Include:

• Pain at the back of the heel: Often worse with activity, especially when wearing shoes with stiff backs, or at the beginning of exercise.
• Visible bony bump: A noticeable enlargement on the back of the heel, just above the Achilles tendon insertion.
• Swelling: Localized swelling around the bony prominence.
• Redness: Inflammation of the skin over the affected area.
• Tenderness to touch: Pain upon palpation of the bony bump and the surrounding soft tissues.
• Difficulty wearing certain shoes: Due to pain and pressure.
• Limping: In more severe cases, pain may alter gait.

Diagnosis

Diagnosis of Haglund's Deformity typically involves a combination of clinical examination and imaging studies.

Diagnostic Process:

• Physical Examination: A healthcare professional will examine the foot and ankle, looking for the characteristic bony prominence, swelling, redness, and tenderness. They will also assess range of motion and evaluate gait.
• Medical History: Discussing symptoms, activity levels, and footwear choices provides crucial information.
• X-rays: Lateral X-rays of the foot are the primary imaging tool. They clearly show the bony enlargement of the calcaneus and can help differentiate Haglund's deformity from other heel pain causes. Specific measurements, such as the parallel pitch lines, can help confirm the diagnosis.
• MRI (Magnetic Resonance Imaging): While not always necessary, an MRI may be used to assess the soft tissues (Achilles tendon, bursa) for inflammation, degeneration, or tears, especially if surgical intervention is being considered.

Conservative Management Strategies

The initial approach to managing Haglund's Deformity is almost always conservative, focusing on reducing inflammation, alleviating pain, and modifying contributing factors.

Key Conservative Treatments:

• Rest and Activity Modification: Reducing or temporarily stopping activities that aggravate the heel pain is crucial. This includes avoiding uphill running or excessive jumping.
• Ice Therapy: Applying ice packs to the affected area for 15-20 minutes several times a day can help reduce pain and inflammation.
• Footwear Modifications: This is paramount.
  • Avoid stiff-backed shoes: Opt for open-backed shoes, soft-backed shoes, or sandals.
  • Heel lifts: Placing a heel lift inside the shoe can slightly elevate the heel, reducing pressure on the back of the calcaneus and easing tension on the Achilles tendon.
  • Padding: Soft pads placed around the bony prominence inside the shoe can reduce friction.
• Orthotics: Custom or over-the-counter orthotic inserts can help correct biomechanical imbalances, such as excessive pronation or supination, and support the arch, which can reduce stress on the heel.
• Physical Therapy and Rehabilitation: A targeted exercise program is essential.
  • Stretching: Gentle stretching of the calf muscles (gastrocnemius and soleus) and Achilles tendon can improve flexibility and reduce tension.
  • Eccentric Exercises: For associated Achilles tendinopathy, eccentric heel drops can be beneficial, strengthening the tendon while elongating it.
  • Manual Therapy: Techniques to improve ankle mobility and soft tissue extensibility.
  • Gait Analysis and Retraining: To identify and correct problematic movement patterns.
• Medications:
  • NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Over-the-counter or prescription NSAIDs can help manage pain and inflammation.
  • Corticosteroid Injections: While effective for bursitis, injections directly into the Achilles tendon are generally avoided due to the risk of tendon weakening or rupture.

Surgical Intervention

Surgical intervention is typically considered only after a prolonged course (at least 6-12 months) of conservative treatment has failed to provide adequate relief. The goal of surgery is to remove the bony prominence and any inflamed soft tissue.

Common Surgical Procedures:

• Calcaneal Osteotomy: Removal of the bony spur (exostectomy) and sometimes a wedge of the calcaneus to reshape the bone and reduce impingement.
• Retrocalcaneal Bursa Excision: Removal of the inflamed bursa.
• Achilles Tendon Debridement: If the Achilles tendon is significantly damaged, debridement (removal of damaged tissue) may be performed.

Recovery from surgery involves a period of immobilization, followed by a structured rehabilitation program to restore strength, flexibility, and function.

Prevention Strategies

Preventing Haglund's Deformity often involves careful attention to footwear and addressing underlying biomechanical factors.

Preventative Measures:

• Choose Appropriate Footwear:
  • Avoid shoes with rigid or narrow heel counters.
  • Opt for shoes with soft, flexible heel sections.
  • Ensure shoes fit properly and do not rub or cause pressure points on the heel.
• Address Biomechanical Issues:
  • Stretching: Regularly stretch calf muscles and the Achilles tendon, especially if you have naturally tight hamstrings or calves.
  • Strengthening: Maintain strong calf muscles and intrinsic foot muscles to support proper foot mechanics.
  • Orthotics: If you have high arches or a tendency to excessively supinate, custom or over-the-counter orthotics can help distribute pressure evenly and support the foot.
• Gradual Increase in Activity: When starting new exercise programs or increasing intensity, do so gradually to allow your body to adapt.
• Listen to Your Body: Pay attention to early signs of heel pain and address them promptly before they escalate into a chronic condition.

Conclusion

Haglund's Deformity, or a Haglund lesion, is a painful condition resulting from a bony enlargement on the heel that irritates surrounding soft tissues. While it can be debilitating, a comprehensive approach involving appropriate footwear, activity modification, targeted physical therapy, and sometimes orthotics, can effectively manage symptoms in the vast majority of cases. Understanding the underlying causes and committing to preventative strategies are key to avoiding recurrence and maintaining an active, pain-free lifestyle. If you suspect you have Haglund's Deformity, consulting with a healthcare professional, such as a podiatrist or orthopedic specialist, is crucial for accurate diagnosis and a personalized treatment plan.