Haglund's Disease: Understanding the 'Pump Bump,' Causes, Symptoms, Diagnosis, and Treatment

What is a Haglund's disease?

Haglund's disease, also known as Haglund's deformity or "pump bump," is a condition characterized by a bony enlargement on the back of the heel bone (calcaneus) at the insertion of the Achilles tendon, often leading to painful inflammation of the surrounding soft tissues.

Understanding Haglund's Deformity

Haglund's deformity is a structural abnormality involving the calcaneus, the largest bone in the foot, forming the heel. Specifically, it refers to an abnormal bony prominence or spur that develops on the posterosuperior aspect of the calcaneus, where the Achilles tendon attaches. This bony overgrowth can rub against the Achilles tendon and the retrocalcaneal bursa (a fluid-filled sac located between the Achilles tendon and the heel bone), leading to chronic irritation, inflammation, and pain. The term "pump bump" is a common colloquialism, referring to the condition's frequent association with rigid-backed high-heeled shoes, which can exacerbate the irritation.

Anatomy Involved

To understand Haglund's deformity, it's crucial to identify the key anatomical structures in the posterior ankle and heel:

• Calcaneus: The heel bone, which forms the foundation of the rearfoot.
• Achilles Tendon: The largest and strongest tendon in the body, connecting the calf muscles (gastrocnemius and soleus) to the calcaneus. It is critical for plantarflexion of the foot (pointing the toes down) and push-off during walking, running, and jumping.
• Retrocalcaneal Bursa: A small, fluid-filled sac positioned between the Achilles tendon and the superior posterior aspect of the calcaneus. Its primary function is to reduce friction between these structures during movement.
• Skin: The skin overlying the heel can also become irritated and inflamed due to constant friction from footwear.

The bony prominence of Haglund's deformity causes a "pinching" or "impingement" effect on the retrocalcaneal bursa and the Achilles tendon against the rigid heel counter of shoes, leading to bursitis (inflammation of the bursa) and/or Achilles tendinopathy (degeneration and inflammation of the Achilles tendon).

Causes and Risk Factors

While the exact cause can be multifactorial, Haglund's deformity is primarily an overuse injury exacerbated by specific anatomical and environmental factors:

• Genetic Predisposition and Foot Biomechanics:
  • High Arches (Pes Cavus): Individuals with high arches tend to walk with their weight on the outside of their heel, which can cause the heel bone to tilt backward and lead to increased pressure on the Achilles insertion.
  • Tight Achilles Tendon: A tight Achilles tendon can increase tension and friction at its insertion point, contributing to irritation against the bony prominence.
  • Rigid Foot Structure: A less flexible foot may be less able to absorb shock, leading to increased stress on the heel.
• Footwear:
  • Rigid Heel Counters: Shoes with stiff, unyielding material at the back of the heel (common in dress shoes, ice skates, or high heels, hence "pump bump") can constantly rub against the prominent bony area, causing inflammation and pain.
  • Lack of Proper Support: Poorly fitting or unsupportive shoes can alter gait mechanics and increase stress on the heel.
• Repetitive Stress:
  • Running and Jumping: Athletes, particularly runners, are at higher risk due to the repetitive impact and strain on the Achilles tendon and heel.
  • Sudden Increase in Activity: Rapidly increasing the intensity or duration of physical activity can overload the structures around the heel.

Common Symptoms

The symptoms of Haglund's deformity typically develop gradually and can range from mild discomfort to severe pain, impacting daily activities and athletic performance:

• Pain at the back of the heel: This is the hallmark symptom, often exacerbated by activity, especially running uphill or walking in certain shoes.
• Visible bony bump: A noticeable enlargement on the posterior aspect of the calcaneus.
• Tenderness to touch: The area around the bony prominence, particularly the retrocalcaneal bursa, is often very sensitive to palpation.
• Redness and swelling: Inflammation of the bursa and surrounding soft tissues can cause visible swelling and redness.
• Pain with shoe wear: Discomfort or pain when wearing shoes with rigid heel counters.
• Stiffness in the Achilles tendon: Particularly noticeable in the morning or after periods of rest.

Diagnosis

A thorough clinical evaluation is essential for diagnosing Haglund's deformity, often involving:

• Physical Examination: The healthcare provider will visually inspect the heel for a bony prominence, swelling, and redness. They will palpate the area to identify tenderness, particularly over the retrocalcaneal bursa and Achilles tendon insertion. They may also assess foot structure, range of motion, and gait.
• Imaging Studies:
  • X-rays: Lateral X-rays of the foot are typically performed to confirm the presence and size of the bony prominence on the calcaneus. They can also reveal signs of associated Achilles tendinopathy or bursitis.
  • MRI (Magnetic Resonance Imaging): While not always necessary, an MRI can provide detailed images of the soft tissues, revealing inflammation of the retrocalcaneal bursa, degeneration or tearing of the Achilles tendon, and fluid accumulation.
• Differential Diagnosis: It's important to differentiate Haglund's deformity from other conditions that cause heel pain, such as isolated Achilles tendinopathy, retrocalcaneal bursitis without a significant bony spur, plantar fasciitis, or stress fractures of the calcaneus.

Treatment and Management Strategies

Treatment for Haglund's deformity typically begins with conservative (non-surgical) methods aimed at reducing inflammation, relieving pain, and addressing biomechanical factors. Surgical intervention is usually considered only after conservative measures have failed.

Non-Surgical Approaches

• Rest and Activity Modification: Reducing activities that aggravate the heel pain, such as running or wearing specific shoes.
• Ice Application: Applying ice packs to the affected area for 15-20 minutes several times a day to reduce inflammation and pain.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Oral medications like ibuprofen or naproxen can help manage pain and inflammation.
• Proper Footwear:
  • Wearing shoes with soft, pliable heel counters or open-backed shoes to eliminate pressure on the bony prominence.
  • Using heel pads or lifts to elevate the heel slightly, which can reduce pressure on the Achilles tendon.
• Physical Therapy:
  • Stretching: Specific exercises to stretch the Achilles tendon and calf muscles can help reduce tension.
  • Strengthening: Exercises to strengthen the surrounding muscles to improve foot and ankle mechanics.
  • Gait Analysis: Addressing any gait abnormalities that contribute to the condition.
• Orthotic Devices: Custom or over-the-counter orthotics can help control foot motion, provide arch support, and reduce stress on the heel.
• Corticosteroid Injections: Injections into the retrocalcaneal bursa can reduce inflammation and pain. However, injections directly into the Achilles tendon are generally avoided due to the risk of tendon rupture.
• Immobilization: In severe cases, a walking boot or cast may be used for a short period to immobilize the foot and allow tissues to heal.

Surgical Intervention

Surgery is considered when conservative treatments have failed to provide significant relief after several months. The goal of surgery is to remove the bony prominence and any inflamed soft tissue.

• Calcaneal Osteotomy: This involves removing the bony spur from the calcaneus. In some cases, a wedge of bone may also be removed to alter the angle of the heel bone and reduce impingement.
• Bursectomy: Removal of the inflamed retrocalcaneal bursa.
• Achilles Tendon Debridement/Repair: If the Achilles tendon is significantly damaged, debridement (removal of damaged tissue) or repair may be performed concurrently.

Post-surgical recovery typically involves a period of immobilization, followed by physical therapy to restore strength, flexibility, and function.

Prevention

While not all cases are preventable, certain measures can reduce the risk of developing Haglund's deformity:

• Wear Appropriate Footwear: Choose shoes with soft, flexible heel counters that do not rub or irritate the back of the heel. Avoid high heels and shoes with rigid backs for extended periods.
• Stretch Regularly: Incorporate regular calf and Achilles tendon stretches into your routine, especially before and after physical activity.
• Gradual Increase in Activity: When starting a new exercise program or increasing intensity, do so gradually to allow your body to adapt.
• Address Biomechanical Issues: If you have high arches or a rigid foot, consider consulting a podiatrist or physical therapist for advice on orthotics or specific exercises.

When to See a Professional

It is advisable to consult a healthcare professional, such as a podiatrist, orthopedic surgeon, or sports medicine physician, if you experience:

• Persistent heel pain that does not improve with rest or home remedies.
• A visible lump or swelling on the back of your heel.
• Pain that interferes with your daily activities or ability to exercise.
• Signs of infection, such as fever, redness, or warmth around the heel.

Early diagnosis and intervention can help prevent the condition from worsening and improve the chances of successful non-surgical management.