Haglund's deformity: Difference between revisions
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== '''Definition/Description ''' == | == '''Definition/Description ''' == | ||
Haglund’s deformity is a symptomatic osseous prominence of the posterosuperior corner of the calcaneus resulting in posterior heel pain and swelling around the insertion of the [[Achilles tendon]].<ref>Jung H, Carag JA, Park J, Bae E, Lim S, Kim H. [https://www.sciencedirect.com/science/article/abs/pii/S126877311000113X Osteochondroma of the calcaneus presenting as Haglund’s deformity.] Foot and Ankle Surgery 2010;17:20–22.</ref> It is associated with retrocalcaneal bursitis.<ref name=":0">Stephens MM. [https://europepmc.org/abstract/med/8290230 Haglund's deformity and retrocalcaneal bursitis.] The Orthopedic clinics of North America 1994;25(1):41-6.</ref> Cavo varus deformities exacerbate this problem. | Haglund’s deformity is a symptomatic osseous prominence of the posterosuperior corner of the calcaneus resulting in posterior heel pain and swelling around the insertion of the [[Achilles tendon]].<ref>Jung H, Carag JA, Park J, Bae E, Lim S, Kim H. [https://www.sciencedirect.com/science/article/abs/pii/S126877311000113X Osteochondroma of the calcaneus presenting as Haglund’s deformity.] Foot and Ankle Surgery 2010;17:20–22.</ref> It is associated with [[Retrocalcaneal Bursitis|retrocalcaneal bursitis]].<ref name=":0">Stephens MM. [https://europepmc.org/abstract/med/8290230 Haglund's deformity and retrocalcaneal bursitis.] The Orthopedic clinics of North America 1994;25(1):41-6.</ref> Cavo varus deformities exacerbate this problem. | ||
<br>It was first described by Patrick Haglund as early as 1928<ref>Haglund P. Beitrag zur uliwik der Achilesse have. Z Orthop Chir 1928;49.</ref>. Prior to that 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".<ref name=":0" /> | <br>It was first described by Patrick Haglund as early as 1928<ref>Haglund P. Beitrag zur uliwik der Achilesse have. Z Orthop Chir 1928;49.</ref>. Prior to that 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".<ref name=":0" /> | ||
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=== Epidemiology === | === Epidemiology === | ||
Hugland's Deformity are most common in the female population between the ages of 15 and 35, especially in woman who regularly wear heels. It is also common in runners.<ref name=":1" /> | |||
=== Etiology === | === Etiology === | ||
Predisposing factors: | Predisposing factors:<ref name=":1" /> | ||
* '''Genetics''' (hereditary): Patients can have a bone structure that makes them prone to developing Haglund’s Deformity. | * '''Genetics''' (hereditary): Patients can have a bone structure that makes them prone to developing Haglund’s Deformity. | ||
* '''High foot arches''': With high arches, the heel is tilted backward into the [[Achilles tendon]] (due to the insertion on the calcaneus). | * '''High foot arches''': With high arches, the heel is tilted backward into the [[Achilles tendon]] (due to the insertion on the calcaneus). | ||
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** '''Injury''' | ** '''Injury''' | ||
** '''Improper/tight shoes''': Does not counter the bump but cause symptoms and which maybe lead to [[bursitis]]. | ** '''Improper/tight shoes''': Does not counter the bump but cause symptoms and which maybe lead to [[bursitis]]. | ||
== '''Characteristics/Clinical presentation''' == | |||
== | === Symptoms === | ||
* Enlargement of the bone on the back of the heel: | |||
** Protrusion visible in the area where the [[Achilles tendon]] attaches to the calcaneus | |||
* Pain at back of heel: | |||
** On palpation, or when tight shoes are worn. | |||
* Redness and swelling: | |||
** The friction between the soft tissue at the back of the heel and the shoe, can cause the bursae can become inflamed. | |||
Symptoms are aggravated by wearing footwear with hard heel edges, as this impinge on the bursa and the [[Achilles tendon]] on the calcaneas.<ref name=":1" /> | |||
== Differential diagnosis == | |||
* [[Achilles Tendinopathy|Achilles tendinitis]]<ref name=":1" /> | |||
== '''Medical management''' == | == '''Medical management''' == | ||
=== Conservative management === | |||
Conservative management of Hugland's deformity used to relieve the associated symptoms, but are not able to resolve the problem. Anti-inflammatory medication are recommended for pain relief, but corticosteriod injections are best avoided, as it can lead to [[Achilles Rupture|rupture of the Achilles tendon]]. | |||
< | === Surgery === | ||
* Removal of bony protrusion: | |||
** Possible complication of injury to the [[Achilles tendon]] | |||
* Partial removal of bony protrusion: | |||
** High risk of Achilles tendon avulsion<ref>Kolodziej P, Glisson RR, Nunley JA. [https://journals.sagepub.com/doi/abs/10.1177/107110079902000707 Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund's deformity: a biomechanical study.] Foot & ankle international 1999;20(7):433-7.</ref> | |||
* Closing wedge calcaneal osteotomy (Keck & Kelly technique)<ref>Boffeli TJ, Peterson MC. [https://www.sciencedirect.com/science/article/pii/S1067251612001044 The Keck and Kelly wedge calcaneal osteotomy for Haglund's deformity: a technique for reproducible results.] The Journal of Foot and Ankle Surgery 2012;51(3):398-401.</ref> | |||
== '''Physiotherapy management''' == | == '''Physiotherapy management''' == | ||
Physiotherapists can play a big role in the conservative management of Hugland's Deformity, especially with the management of the [[bursitis]] associated with this deformity. | |||
=== Prevention === | |||
* Education and advice: | |||
** Educate patient about pathology | |||
** Modification of aggravating factors to minimize friction between [[Achilles tendon]] and bursa: | |||
*** Advice regarding shoes (start with backless shoes with a soft backside) | |||
*** Pads under calaneus reduce irritation when walking | |||
*** Referral to podiatry | |||
** Heel lift in patients with high foot arches will decrease pressure on the heel | |||
** Advice regarding weight loss (where applicable) | |||
=== Management of [[bursitis]]/[[Achilles Tendinopathy|tendinitis]] === | |||
* Management of inflammation: | |||
** Rest | |||
** Immobilization | |||
** Ice | |||
** Eccentric [[gastrocnemius]] and [[soleus]] exercises | |||
<br>More information about how to treat [[Achilles tendonitis]] or [[Retrocalcaneal bursitis]] can be found on other physiopedia pages. | Also see the pages for [[Achilles tendinosis]] and [[Retrocalcaneal Bursitis|retrocacaneal bursitis]] for more information on the management thereof.<br> | ||
=== Post-operative management === | |||
It is important to take the risks of Achilles tendon rupture and injury after removal of the bony protrusion into consideration when managing these patients post-operatively. | |||
<br>More information about how to treat [[Achilles tendonitis]] or [[Retrocalcaneal bursitis]] can be found on other physiopedia pages.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. | |||
<br><u>'''Key Evidence '''</u><br>We have given some evidence levels of the most important articles.<br>• 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)<br>• 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)<br>• Pradeep Alexander, MD. Haglund deformity. Orthopaedia. (http://www.orthopaedia.com/display/Main/Haglund+deformity), 2012. (2C) | <br><u>'''Key Evidence '''</u><br>We have given some evidence levels of the most important articles.<br>• 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)<br>• 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)<br>• Pradeep Alexander, MD. Haglund deformity. Orthopaedia. (http://www.orthopaedia.com/display/Main/Haglund+deformity), 2012. (2C) | ||
== '''References''' == | |||
[[Category:Primary Contact]] | [[Category:Primary Contact]] | ||
<references /> | <references /> | ||
Revision as of 12:01, 5 January 2019
Original Editors - Nick Despeghel, Jonathan Hoof, Gertjan Pauwels and Wout Lippens
Top Contributors - Niha Mulla, Leana Louw, Kim Jackson, Wout Lippens, Kalyani Yajnanarayan and Claire Knott
Definition/Description [edit | edit source]
Haglund’s deformity is a symptomatic osseous prominence of the posterosuperior corner of the calcaneus resulting in posterior heel pain and swelling around the insertion of the Achilles tendon.[1] It is associated with retrocalcaneal bursitis.[2] Cavo varus deformities exacerbate this problem.
It was first described by Patrick Haglund as early as 1928[3]. Prior to that 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".[2]
Clinically relevant anatomy[edit | edit source]
The Achilles tendon originates from the aponeurosis of the gastrocnemius and soleus muscles. It inserts into the middle third of the posterior surface of the calcaneus.[4] Near the Achilles tendon insertion, there are two bursae - the deep retrocaneal bursa, and the o superficial bursa. These can be the sites of inflammation processes or can develop bursitis - non-inflammatory, inflammatory suppurative or calcified retrocalcaneal.[5]
Epidemiology/Etiology[edit | edit source]
Epidemiology[edit | edit source]
Hugland's Deformity are most common in the female population between the ages of 15 and 35, especially in woman who regularly wear heels. It is also common in runners.[5]
Etiology[edit | edit source]
Predisposing factors:[5]
- Genetics (hereditary): Patients can have a bone structure that makes them prone to developing Haglund’s Deformity.
- High foot arches: With high arches, the heel is tilted backward into the Achilles tendon (due to the insertion on the calcaneus).
- 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.
- Tight Achilles tendon: Pain is caused by compressing the tender and the inflamed bursa.
- Tendency to walk on the outside of the heel: This produces wear on the outer edge of the sole of the shoe which will rotate the heel inward.
- This will result in a grinding of the calcaneus against the tendon; a bursa will form, which will eventually becomes inflamed and tender.
- Increase in weight
- Injury
- Improper/tight shoes: Does not counter the bump but cause symptoms and which maybe lead to bursitis.
Characteristics/Clinical presentation[edit | edit source]
Symptoms[edit | edit source]
- Enlargement of the bone on the back of the heel:
- Protrusion visible in the area where the Achilles tendon attaches to the calcaneus
- Pain at back of heel:
- On palpation, or when tight shoes are worn.
- Redness and swelling:
- The friction between the soft tissue at the back of the heel and the shoe, can cause the bursae can become inflamed.
Symptoms are aggravated by wearing footwear with hard heel edges, as this impinge on the bursa and the Achilles tendon on the calcaneas.[5]
Differential diagnosis[edit | edit source]
Medical management[edit | edit source]
Conservative management[edit | edit source]
Conservative management of Hugland's deformity used to relieve the associated symptoms, but are not able to resolve the problem. Anti-inflammatory medication are recommended for pain relief, but corticosteriod injections are best avoided, as it can lead to rupture of the Achilles tendon.
Surgery[edit | edit source]
- Removal of bony protrusion:
- Possible complication of injury to the Achilles tendon
- Partial removal of bony protrusion:
- High risk of Achilles tendon avulsion[6]
- Closing wedge calcaneal osteotomy (Keck & Kelly technique)[7]
Physiotherapy management[edit | edit source]
Physiotherapists can play a big role in the conservative management of Hugland's Deformity, especially with the management of the bursitis associated with this deformity.
Prevention[edit | edit source]
- Education and advice:
- Educate patient about pathology
- Modification of aggravating factors to minimize friction between Achilles tendon and bursa:
- Advice regarding shoes (start with backless shoes with a soft backside)
- Pads under calaneus reduce irritation when walking
- Referral to podiatry
- Heel lift in patients with high foot arches will decrease pressure on the heel
- Advice regarding weight loss (where applicable)
Management of bursitis/tendinitis[edit | edit source]
- Management of inflammation:
- Rest
- Immobilization
- Ice
- Eccentric gastrocnemius and soleus exercises
Also see the pages for Achilles tendinosis and retrocacaneal bursitis for more information on the management thereof.
Post-operative management[edit | edit source]
It is important to take the risks of Achilles tendon rupture and injury after removal of the bony protrusion into consideration when managing these patients post-operatively.
More information about how to treat Achilles tendonitis or Retrocalcaneal bursitis can be found on other physiopedia pages.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.
Key Evidence
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)
References[edit | edit source]
- ↑ Jung H, Carag JA, Park J, Bae E, Lim S, Kim H. Osteochondroma of the calcaneus presenting as Haglund’s deformity. Foot and Ankle Surgery 2010;17:20–22.
- ↑ 2.0 2.1 Stephens MM. Haglund's deformity and retrocalcaneal bursitis. The Orthopedic clinics of North America 1994;25(1):41-6.
- ↑ Haglund P. Beitrag zur uliwik der Achilesse have. Z Orthop Chir 1928;49.
- ↑ Myerson MS, Mandelbaum B. Disorders of the Achilles tendon and the retrocalcaneal region. Foot and ankle disorders. Philadelphia: WB Saunders. 2000:1382-98.
- ↑ 5.0 5.1 5.2 5.3 5.4 Lesic A, Bumbasirevic M. Disorders of the Achilles tendon. Current Orthopaedics 2004;18(1):63-75.
- ↑ 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. Foot & ankle international 1999;20(7):433-7.
- ↑ Boffeli TJ, Peterson MC. The Keck and Kelly wedge calcaneal osteotomy for Haglund's deformity: a technique for reproducible results. The Journal of Foot and Ankle Surgery 2012;51(3):398-401.
