A contribution by Nick Despeghel, Jonathan Hooft, Gertjan Pauwels and Wout Lippens
• Clinically Relevant Anatomy
• Epidemiology /Etiology
• Characteristics/Clinical Presentation
• Medical Management
• Physical Therapy Management
• Key Evidence
Haglund’s deformity is a symtomatic osseous prominence of the posterosuperior corner of the calcaneus creating posterior heel pain and swelling around the insertion of the Achilles tendon (Hong-Geun Jung et al. 2010). It is associated with retrocalcaneal bursitis (Stephens M.M. 1994). Cavo varus deformities exacerbate this problem.
It was first described by Patrick Haglund as early as 1928 (Haglund P. 1928), and until that time numerous other descriptions were used, such as: “pump bump”, because the rigid backs of pump-style shoes can create pressure that aggravates the posterior heel pain and swelling, and winter heel (Stephens M.M. 1994).
The occurrence of Haglund deformity is more characteristic of younger patients, aged 15 – 30. Symptoms of the accompanying bursitis, such as: a noticeable bump on the back of the heel; pain in the area where the Achilles tendon attaches to the heel; swelling in the back of the heel; redness near the inflamed tissue, are intensified by wearing footwear with hard heel edges, which impinge on the bursa and the Achilles tendon on the calcaneal bone (Lesic & Bumbasirevic 2004).
Clinically Relevant Anatomy
The Achilles tendon originates from the aponeurosis of both gastrocnemius and soleus muscles. It inserts into the middle third of the posterior surface of the calcaneus (Mayerson & Mandelbaum 2000). Near the Achilles tendon insertion, there are two bursae. One bursae is located deeply – the retrocaneal bursae, and the other one is superficial below the skin. These can be the sites of inflammation processes or can develop non-inflammatory, inflammatory suppurative or calcified retrocalcaneal bursitis (Lesic & Bumbasirevic 2004).
In some cases heredity can play a role in this deformity. You can inherit the bone structure that makes them prone to developing Haglund’s Deformity.
The major factor of Haglund’s Deformity are high arches. When you have high arches, the heel is tilted backward into the Achilles tendon because the Achilles tendon is attached to the back of the heel bone. A bony protrusion develops and the bursa becomes inflamed due to the constant irritation of the back of the heel bone to rub against the tendon.
Another cause of Haglund’s Deformity can be a tight Achilles tendon, it causes pain by compressing the tender and the inflamed bursa.
Or a tendency to walk on the outside of the heel. it produces wear on the outer edge of the sole of the shoe which will rotate the heel inward. That will result in a grinding of the heel bone against the tendon. There will be formed a bursa, which eventually becomes inflamed and tender.
Haglund’s Deformity can also be caused by an increase in weight, injury, improper shoes, or tight shoes who will not counter the bump but cause symptoms and which maybe lead to a bursitis.
The main symptom of Haglund’s Deformity is the enlargement of the bone on the back of the heel. There is a bump visible in the area where the Achilles tendon attaches to the heel. This bump can be very painful when it’s pressed or when the person wears tight shoes. It often becomes swollen and red and also the bursae can become inflamed, due to the soft tissue in the back of the heel that rubs against the shoe. Offcours persons with Haglund’s Deformity feel pain in the back of the heel. Most patients who suffer from Haglund’s syndrome are women between 15 to 35 years old, because they regularly wear high heels. Haglunds syndrome is also very common in runners and is frequently misdiagnosed as Achilles tendonitis.
Haglund’s deformity itself cannot be resolved by non-operative treatment. After all the calcified parts can only be removed by surgery.
Surgical treatment specific for Haglund’s deformity consists either of bump removal or a closing wedge calcaneal osteotomy. A recent article is published about a closing wedge osteotomy witch is called the Keck and Kelly closing wedge osteotomy. It can be of great importance as a physiotherapist to know witch operative treatment the patient underwent. The crucial difference between the two kinds of operation is the state of the Achilles tendon. When there is a bump removal, there is a bone resection adjacent to the Achilles tendon. The other form, which is implied in the technique of the article avoids this. The goal of the technique is that there is a limited opportunity for intraoperative or postoperative complications. In another article they talk about a partial excision ant the risk of avulsion of the tendon afterward. As conclusion we can say that depending on the kind of operative treatment, the physiotherapist can adapt his treatment taking into account whether the insertion of the Achilles tendon is intact or not or if there is a risk of avulsion of the tendon.
Physical Therapy Management
Non-operative treatment can be helpful in prevention and in curing the bursitis who is often the cause of this deformity.
As the deformity is caused by inflammation of the achilles’ tendon or of the bursa nearby prevention is based on minimizing the friction between these structures and the calcaneus. Wearing backless shoes or shoes with a soft backside is the first step. Also pads who are placed under the calcaneus can help to reduce irritation when walking. If the patient has a high arch a heel lift could be helpful to decrease pressure on the heel.
Both bursitis and tendinitis are inflammations which means the pain can be reduced with ant-inflammatory medication, rest, immobilization and ice. Corticoid injection are NOT recommended because their use can cause tendon ruptures. Excentric exercises has proven to be a good asset to the therapy in treating an inflammation of the Achilles’ tendon.
We have given some evidence levels of the most important articles.
• Troy J. Boffeli, DPM, FACFAS, Matthew C. Peterson, DPM, The Keck and Kelly Wedge Calcaneal Osteotomy for Haglund's Deformity: A Technique for Reproducible Results, The Journal of Foot and Ankle Surgery, Available online 23 March 2012. (2C)
• Kolodziej P, Glisson RR, Nunley JA., Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund's deformity: a biomechanical study., juli 1999. (2C)
• Pradeep Alexander, MD. Haglund deformity. Orthopaedia. (http://www.orthopaedia.com/display/Main/Haglund+deformity), 2012. (2C)
• Stephens M.M. (1994). Haglund’s deformity and retrocalcaneal bursitis. Orthop Clin North Am. 25: 41 – 46
• Hong-Geun Jung M.D., Ph.D., John Alistair Carag M.D., Jae-Yong Park M.D., Eui-Jung Bae M.D., So-Dug Lim M.D., Ph.D., Han-Soo Kim M.D., Ph.D. (2010). Osteochondroma of the calcaneus presenting as Haglund’s deformity. Foot and Ankle Surgery. 17: 20 – 22
• Mayerson M.S & Mandelbaum B. (2000). Disorders of the Achilles tendon and the retrocalcaneal region. Foot and ankle disorders. 1367 – 1398
• Lesic A. & Bumbasirevic M. (2004). Disorders of the Achilles tendon. Current Orthopaedics. 18: 63 – 75
• Haglund P. (1928). Beitrag zur uliwik der Achilesse have. Z Orthop Chir. 49
• Neuhaus and Know, Matthew D. and Jason R.. Neuhaus foot and ankle, Geraadpleegd op 26 april 2012, http://www.neufoot.com/haglunds-deformity.html
• Foot Associates of central Texas ,Geraadpleegd op 26 april 2012, http://www.whymyfoothurts.com/aboutus/
• Haglund’s Deformity Symptoms And 4 Ways Of Treatment, geraadpleegd op 10 mei 2012, http://haglundsdeformity.net/
• YourFootHealth, Haglund's Foot Deformity, geraadpleegd op 10 mei 2012, http://www.yourfoothealth.com/haglunds-deformity.html
• Stephens, MM. , Haglund's deformity and retrocalcaneal bursitis, Cappagh Orthopaedic Hospital, Dublin, Ireland, 1994
• Troy J. Boffeli, DPM, FACFAS, Matthew C. Peterson, DPM, The Keck and Kelly Wedge Calcaneal Osteotomy for Haglund's Deformity: A Technique for Reproducible Results, The Journal of Foot and Ankle Surgery, Available online 23 March 2012,
• Kolodziej P, Glisson RR, Nunley JA., Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund's deformity: a biomechanical study., juli 1999.
• Pradeep Alexander, MD. Haglund deformity. Orthopaedia. (http://www.orthopaedia.com/display/Main/Haglund+deformity), 2012.